Lee John Tayu, Lawson Kenny D, Wan Yizhou, Majeed Azeem, Morris Stephen, Soljak Michael, Millett Christopher
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.
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.
Prev Med. 2017 Jun;99:49-57. doi: 10.1016/j.ypmed.2017.01.005. Epub 2017 Jan 11.
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.
世界卫生组织建议各国实施全人群心血管疾病（CVD）风险评估和管理计划。本研究的目的是进行系统评价，以评估这一建议是否有成本效益证据支持。通过电子医学和社会科学数据库（包括Medline、Web of Science和英国国家医疗服务体系经济评价数据库）检索从建库至2016年3月发表的经济评价研究。采用修改后的《卫生经济评价报告标准合并版》对研究质量进行评估。纳入了14项经济评价研究：5项基于随机对照试验的研究、7项基于观察性研究的研究以及2项使用综合二手数据的假设模型研究。基于试验的研究测量了1至3年内心血管疾病危险因素的变化，并对长期事件进行了模型预测。在诸如危险因素持续变化等未经证实的假设下，这些计划要么不具有成本效益，要么仅具有成本效益。大多数观察性和假设性研究表明这些计划可能具有成本效益；然而，研究设计存在偏倚，随后的实证证据也与关键假设相矛盾。没有研究评估对不平等现象的影响。总之，关于全人群风险评估和管理计划的建议缺乏有力的、基于现实世界的证据基础。鉴于实施此类计划资源密集，需要进行有力的经济评价，最好与试验同时进行，以评估成本效益。此外，应调查不同实施模式的效率和公平影响，以及有针对性的筛查与全人群干预措施的结合情况，同时认识到预防有多种方法。
