title: Are cardiovascular disease risk assessment and management programmes cost effective? A systematic review of the evidence.
abstract: The World Health Organization recommends that countries implement population-wide cardiovascular disease (CVD) risk assessment and management programmes. The aim of this study was to conduct a systematic review to evaluate whether this recommendation is supported by cost-effectiveness evidence. Published economic evaluations were identified via electronic medical and social science databases (including Medline, Web of Science, and the NHS Economic Evaluation Database) from inception to March 2016. Study quality was evaluated using a modified version of the Consolidated Health Economic Evaluation Reporting Standards. Fourteen economic evaluations were included: five studies based on randomised controlled trials, seven studies based on observational studies and two studies using hypothetical modelling synthesizing secondary data. Trial based studies measured CVD risk factor changes over 1 to 3years, with modelled projections of longer term events. Programmes were either not, or only, cost-effective under non-verified assumptions such as sustained risk factor changes. Most observational and hypothetical studies suggested programmes were likely to be cost-effective; however, study deigns are subject to bias and subsequent empirical evidence has contradicted key assumptions. No studies assessed impacts on inequalities. In conclusion, recommendations for population-wide risk assessment and management programmes lack a robust, real world, evidence basis. Given implementation is resource intensive there is a need for robust economic evaluation, ideally conducted alongside trials, to assess cost effectiveness. Further, the efficiency and equity impact of different delivery models should be investigated, and also the combination of targeted screening with whole population interventions recognising that there multiple approaches to prevention.
authors.affiliation: Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK; Saw Swee Hock School of Public Health, National University of Singapore, Singapore. Electronic address: t.lee@imperial.ac.uk.
authors.forename: John Tayu
authors.initials: JT
authors.lastname: Lee
authors.affiliation: Centre for Health Research, School of Medicine, Western Sydney University, Sydney, Australia; Centre for Research Excellence in Chronic Disease Prevention, Public Health and Tropical Medicine, James Cook University, Cairns, Australia.
authors.forename: Kenny D
authors.initials: KD
authors.lastname: Lawson
authors.affiliation: Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK.
authors.forename: Yizhou
authors.initials: Y
authors.lastname: Wan
authors.affiliation: Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK.
authors.forename: Azeem
authors.initials: A
authors.lastname: Majeed
authors.affiliation: Department of Applied Health Research, University College London, London, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Morris
authors.affiliation: Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Soljak
authors.affiliation: Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK.
authors.forename: Christopher
authors.initials: C
authors.lastname: Millett
mesh_terms: D002318:Cardiovascular Diseases / Q000517:prevention & control*; D003362:Cost-Benefit Analysis / Q000191:economics* / Q000458:organization & administration; D019468:Disease Management; D006801:Humans; D018570:Risk Assessment
keywords: Cardiovascular screening; Health checks; NHS health checks; Risk assessment