Cost-Effectiveness Analysis of Surgical Strategies Versus Medical Management for Rheumatic Heart Disease in Rwanda.

BACKGROUND

One-third of the global rheumatic heart disease burden lies in sub-Saharan Africa, where 17% of patients with severe rheumatic heart disease die within 3 years without valve surgery. Surgery is often considered uneconomical, although this assumption is not grounded in cost-effectiveness analyses.

METHODS

We evaluated the cost-effectiveness of mechanical valve replacement, bioprosthetic valve replacement, and valve repair compared with medical management for patients with severe rheumatic heart disease in Rwanda. Using a Markov model, we simulated disease progression, incorporating transition probabilities from a meta-analysis of regional observational studies. Costs were calculated using microcosting, and health effects were measured in disability-adjusted life-years (DALYs). Cost-effectiveness was defined by a willingness-to-pay threshold of United States dollars (USD) $2307 per DALY, which is 3 times Rwanda's gross domestic product per capita. A 3% discount rate for costs and DALYs was applied.

RESULTS

Surgical strategies extended life expectancy from 7 to 11 to 13 years. Mechanical and bioprosthetic valve replacements were cost-effective compared with medical management. Mechanical valve replacement was most efficient, averting 5.64 discounted DALYs for a lifetime discounted cost of USD $10 539.34, with an incremental cost-effectiveness ratio of USD $1704 per DALY. Bioprosthetic valve replacement averted 5.27 discounted DALYs but incurred higher costs (USD $10 873.06). Valve repair only averted 3.30 DALYs despite being least expensive (USD $8790.19). Repair became the most efficient surgical strategy if valve degeneration rates dropped <3.7% annually.

CONCLUSIONS

Mechanical valve replacement is the most efficient surgical strategy for severe rheumatic heart disease in sub-Saharan Africa, challenging assumptions that surgery is uneconomical. Reducing surgery costs and optimizing anticoagulation could further enhance cost-effectiveness.