Hickey Matthew D, Ayieko James, Kabami Jane, Owaraganise Asiphas, Kakande Elijah, Ogachi Sabina, Aoko Colette I, Wafula Erick, Sang Norton, Sunday Helen, Revill Paul, Bansi-Matharu Loveleen, Shade Starley B, Chamie Gabriel, Balzer Laura B, Petersen Maya, Havlir Diane V, Kamya Moses R, Phillips Andrew N
Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, United States.
Kenya Medical Research Institute, Nairobi, Kenya.
medRxiv. 2024 Nov 26:2024.08.14.24312004. doi: 10.1101/2024.08.14.24312004.
Cardiovascular disease (CVD) morbidity and mortality is increasing in Africa, largely due to undiagnosed and untreated hypertension. Approaches that leverage existing primary health systems could improve hypertension treatment and reduce CVD, but cost-effectiveness is unknown. We evaluated the cost-effectiveness of population-level hypertension screening and implementation of chronic care clinics across eastern, southern, central, and western Africa.
We conducted a modelling study to simulate hypertension and CVD across 3000 scenarios representing a range of settings across eastern, southern, central, and western Africa. We evaluated two policies compared to current hypertension treatment: 1) expansion of HIV primary care clinics into chronic care clinics that provide hypertension treatment for all persons regardless of HIV status (chronic care clinic or CCC policy), and 2) CCC plus population-level hypertension screening of adults ≥40 years by community health workers (CHW policy). For our primary analysis, we used a cost-effectiveness threshold of US $500 per disability-adjusted life-year (DALY) averted, a 3% annual discount rate, and a 50-year time horizon. A strategy was considered cost-effective if it led to the lowest net DALYs, which is a measure of DALY burden that takes account of the DALY implications of the cost for a given cost-effectiveness threshold.Among adults 45-64 years, CCC implementation would improve population-level hypertension control (the proportion of people with hypertension whose blood pressure is controlled) from mean 4% (90% range 1-7%) to 14% (6-26%); additional CHW screening would improve control to 44% (35-54%). Among all adults, CCC implementation would reduce ischemic heart disease (IHD) incidence by 10% (3-17%), strokes by 13% (5-23%), and CVD mortality by 9% (3-15%). CCC plus CHW screening would reduce IHD by 28% (19-36%), strokes by 36% (25-47%), and CVD mortality by 25% (17-34%). CHW screening was cost-effective in 62% of scenarios, CCC in 31%, and neither policy was cost-effective in 7% of scenarios. Pooling across setting-scenarios, incremental cost-effectiveness ratios were $69/DALY averted for CCC and $389/DALY averted adding CHW screening to CCC.
Leveraging existing healthcare infrastructure to implement population-level hypertension screening by CHWs and hypertension treatment through integrated chronic care clinics is expected to reduce CVD morbidity and mortality and is likely to be cost-effective in most settings across Africa.
National Institutes of Health (K23HL162578, U01-AI150510).
在非洲，心血管疾病（CVD）的发病率和死亡率正在上升，这主要归因于未被诊断和治疗的高血压。利用现有初级卫生系统的方法可能会改善高血压治疗并降低心血管疾病，但成本效益尚不清楚。我们评估了在非洲东部、南部、中部和西部进行人群层面高血压筛查以及设立慢性病护理诊所的成本效益。
我们开展了一项建模研究，以模拟非洲东部、南部、中部和西部一系列场景下的3000种情况中的高血压和心血管疾病。与当前高血压治疗方法相比，我们评估了两项政策：1）将艾滋病毒初级保健诊所扩展为慢性病护理诊所，为所有人群提供高血压治疗，无论其艾滋病毒感染状况如何（慢性病护理诊所或CCC政策）；2）CCC政策加上由社区卫生工作者对40岁及以上成年人进行人群层面的高血压筛查（CHW政策）。对于我们的主要分析，我们使用了每避免一个伤残调整生命年（DALY）500美元的成本效益阈值、3%的年贴现率以及50年的时间跨度。如果一种策略能带来最低的净DALYs（这是一种衡量DALY负担的指标，考虑了给定成本效益阈值下成本对DALY的影响），则该策略被认为具有成本效益。在45 - 64岁的成年人中，实施CCC政策将使人群层面的高血压控制率（血压得到控制的高血压患者比例）从平均4%（90%范围为1 - 7%）提高到14%（6 - 26%）；额外的社区卫生工作者筛查将使控制率提高到44%（35 - 54%）。在所有成年人中，实施CCC政策将使缺血性心脏病（IHD）发病率降低10%（3 - 17%），中风发病率降低13%（5 - 23%），心血管疾病死亡率降低9%（3 - 15%）。CCC政策加上社区卫生工作者筛查将使IHD发病率降低28%（19 - 36%），中风发病率降低36%（25 - 47%），心血管疾病死亡率降低25%（17 - 34%）。在62%的场景中，社区卫生工作者筛查具有成本效益，31%的场景中CCC政策具有成本效益，7%的场景中两种政策都不具有成本效益。综合所有场景来看，CCC政策的增量成本效益比为每避免一个DALY 69美元，在CCC政策基础上增加社区卫生工作者筛查的增量成本效益比为每避免一个DALY 389美元。
利用现有的医疗基础设施，通过社区卫生工作者实施人群层面的高血压筛查，并通过综合慢性病护理诊所进行高血压治疗，预计将降低心血管疾病的发病率和死亡率，并且在非洲的大多数情况下可能具有成本效益。
美国国立卫生研究院（K23HL162578，U01 - AI150510）。
