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Implications of scaling up cardiovascular disease treatment in South Africa: a microsimulation and cost-effectiveness
Sanjay Basu1, Ryan G Wagner2, Ronel Sewpaul3
1Center for Primary Care and Outcomes Research, Department of Medicine, Palo Alto, CA, USA; Department of Health Research and Policy, Palo Alto, CA, USA; Center for Population Health Sciences, Stanford University, Palo Alto, CA, USA; Center for Primary Care, Harvard Medical School, Boston, MA, USA.
Insights
Cardiovascular risk factors like hypertension and diabetes are prevalent in South Africa, disproportionately affecting disadvantaged groups. Prioritizing blood pressure and statin treatments over glucose control could be more effective and cost-efficient.
Area of Science:
- Public Health
- Epidemiology
- Health Economics
Background:
- Cardiovascular diseases (CVDs) and their risk factors, including hypertension, dyslipidaemia, and diabetes, pose a growing challenge in middle-income countries.
- South Africa faces a significant burden from these conditions, with risk factors unevenly distributed across its population.
- Understanding the distribution of CVD risk factors is crucial for effective public health interventions.
Purpose of the Study:
- To assess the distribution of cardiovascular risk factors across South African subpopulations using nationally representative data.
- To identify priority cardiovascular treatments by evaluating the health and economic implications of different intervention guidelines.
- To compare the effectiveness of the WHO's Package of Essential Non-communicable disease interventions (PEN) and South Africa's Primary Care 101 (SA PC 101) guidelines.
Main Methods:
- A demographically representative simulated population of South Africa was created using data from the 2012 South African National Health and Nutrition Examination Survey (SANHANES).
- A microsimulation model was employed to estimate the health and economic impact of the WHO PEN and SA PC 101 treatment guidelines.
- The primary outcome measured was disability-adjusted life-years (DALYs) averted, comparing outcomes at 70% treatment access.
Main Results:
- High prevalence of hypertension (24.8%), dyslipidaemia (17.5%), and diabetes (15.3%) was observed in South Africa, with disproportionately higher prevalence and lower treatment rates among male, black, and impoverished populations.
- Implementation of WHO PEN and SA PC 101 guidelines could reduce DALYs from CVD or type 2 diabetes complications from 40.0 to 32.9 and 32.5 per 1000 population, respectively.
- SA PC 101 demonstrated greater cost-effectiveness, offering savings of $24,902 per DALY averted compared to $17,587 for WHO PEN, with significant increases in blood pressure and lipid treatment.
Conclusions:
- Cardiovascular risk factors are prevalent and disproportionately impact disadvantaged populations in South Africa.
- Prioritizing blood pressure and statin treatments over glucose-controlling therapies may be more effective and cost-efficient, contrary to current treatment patterns.
- The SA PC 101 guideline appears more cost-effective than WHO PEN for managing cardiovascular risk factors in South Africa.
Background:
Cardiovascular diseases and their risk factors-particularly hypertension, dyslipidaemia, and diabetes-have become an increasing concern for middle-income countries. Using newly available, nationally representative data, we assessed how cardiovascular risk factors are distributed across subpopulations within South Africa and identified which cardiovascular treatments should be prioritised.
Methods:
We created a demographically representative simulated population for South Africa and used data from 17 743 respondents aged 15 years or older of the 2012 South African National Health and Nutrition Examination Survey (SANHANES) to assign information on cardiovascular risk factors to each member of the simulated population. We created a microsimulation model to estimate the health and economic implications of two globally recognised treatment recommendations: WHO's package of essential non-communicable disease interventions (PEN) and South Africa's Primary Care 101 (SA PC 101) guidelines. The primary outcome was total disability-adjusted life-years (DALYs) averted through treatment of all cardiovascular disease or microvascular type 2 diabetes complications per 1000 population. We compared outcomes at the aspirational level of achieving access to treatment among 70% of the population.
Findings:
Based on the SANHANES data, South Africans had a high prevalence of hypertension (24·8%), dyslipidaemia (17·5%), and diabetes (15·3%). Prevalence was disproportionately high and treatment low among male, black, and poor populations. Our simulated population experienced a burden of 40·0 DALYs (95% CI 29·5-52·0) per 1000 population per year from cardiovascular disease or type 2 diabetes complications at current treatment levels, which lowered to 32·9 DALYs (24·4-44·7) under WHO PEN implementation and to 32·5 (24·4-44·8) under SA PC 101 implementation. Under both guidelines, there were increases in blood pressure treatment (4·2 percentage points under WHO PEN vs 12·6 percentage points under SA PC 101), lipid treatment (16·0 vs 14·9), and glucose control medications (1·2 vs 0·6). The incremental cost-effectiveness of implementing SA PC 101 over current treatment would be a saving of US$24 902 (95% CI 14 666-62 579) per DALY averted compared with a saving of $17 587 (1840-42 589) under WHO PEN guidelines.
Interpretation:
Cardiovascular risk factors are common and disproportionate among disadvantaged populations in South Africa. Treatment with blood pressure agents and statins might need greater prioritisation than blood glucose therapies, which contrasts with observed treatment levels despite a lower monthly cost of blood pressure or statin treatment than of sulfonylurea or insulin treatment.
Funding:
Stanford University.
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