Departments of Medicine and Community Health Sciences, Aga Khan University, Stadium Rd, Karachi, Pakistan.
Circulation. 2011 Oct 11;124(15):1615-25. doi: 10.1161/CIRCULATIONAHA.111.039990. Epub 2011 Sep 19.
Evidence on economically efficient strategies to lower blood pressure (BP) from low- and middle-income countries remains scarce. The Control of Blood Pressure and Risk Attenuation (COBRA) trial randomized 1341 hypertensive subjects in 12 randomly selected communities in Karachi, Pakistan, to 3 intervention programs: (1) combined home health education (HHE) plus trained general practitioner (GP); (2) HHE only; and (3) trained GP only. The comparator was no intervention (or usual care). The reduction in BP was most pronounced in the combined group. The present study examined the cost-effectiveness of these strategies.
Total costs were assessed at baseline and 2 years to estimate incremental cost-effectiveness ratios based on (1) intervention cost; (2) cost of physician consultation, medications, diagnostics, changes in lifestyle, and productivity loss; and (3) change in systolic BP. Precision of the incremental cost-effectiveness ratio estimates was assessed by 1000 bootstrapping replications. Bayesian probabilistic sensitivity analysis was also performed. The annual costs per participant associated with the combined HHE plus trained GP, HHE alone, and trained GP alone were $3.99, $3.34, and $0.65, respectively. HHE plus trained GP was the most cost-effective intervention, with an incremental cost-effectiveness ratio of $23 (95 confidence interval, 6-99) per mm Hg reduction in systolic BP compared with usual care, and remained so in 97.7 of 1000 bootstrapped replications.
The combined intervention of HHE plus trained GP is potentially affordable and more cost-effective for BP control than usual care or either strategy alone in some communities in Pakistan, and possibly other countries in Indochina with similar healthcare infrastructure.
来自中低收入国家的降低血压（BP）的经济有效策略的证据仍然稀缺。控制血压和风险衰减（COBRA）试验将 1341 名高血压患者随机分配到巴基斯坦卡拉奇的 12 个随机选定的社区的 3 个干预组中：（1）联合家庭健康教育（HHE）加训练有素的全科医生（GP）；（2）仅 HHE；（3）仅训练有素的 GP。比较组为无干预（或常规护理）。血压的降低在联合组中最为明显。本研究探讨了这些策略的成本效益。
在基线和 2 年时评估总费用，以根据（1）干预成本；（2）医生咨询，药物，诊断，生活方式改变和生产力损失的费用；以及（3）收缩压的变化来估算增量成本效益比。通过 1000 次自举复制评估增量成本效益比估计的精度。还进行了贝叶斯概率敏感性分析。与联合 HHE 加训练有素的 GP，仅 HHE 和仅训练有素的 GP 相关的每位参与者的年度成本分别为 3.99 美元，3.34 美元和 0.65 美元。HHE 加训练有素的 GP 是最具成本效益的干预措施，与常规护理相比，每降低收缩压 1 毫米汞柱的增量成本效益比为 23 美元（95%置信区间，6-99），在 1000 次自举复制中的 97.7 次中仍然如此。
在巴基斯坦的某些社区中，与常规护理或任何单一策略相比，HHE 加训练有素的 GP 的联合干预措施具有降低血压的潜力，并且在一些东南亚国家中也可能具有成本效益，这些国家具有类似的医疗保健基础设施。
