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A systematic review of economic evaluations of interventions to tackle cardiovascular disease in low- and middle-income countries

机译：对中低收入国家应对心血管疾病的干预措施的经济评估的系统评价

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Background Low-and middle-income countries are facing both a mounting burden of cardiovascular disease (CVD) as well as severe resource constraints that keep them from emulating some of the extensive strategies pursued in high-income countries. There is thus an urgency to identify and implement those interventions that help reap the biggest reductions of the CVD burden, given low resource levels. What are the interventions to combat CVDs that represent good "value for money" in low-and middle-income countries? This study reviews the evidence-base on economic evaluations of interventions located in those countries. Methods We conducted a systematic literature review of journal articles published until 2009, based on a comprehensive key-word based search in generic and specialized electronic databases, accompanied by manual searches of expert databases. The search strategy consisted of freetext and MeSH terms related to economic evaluation and cardiovascular disease. Two independent reviewers verified fulfillment of inclusion criteria and extracted study characteristics. Results Thirty-three studies met the selection criteria. We find a growing research interest, in particular in most recent years, if from a very low baseline. Most interventions fall under the category primary prevention, as opposed to case management or secondary prevention. Across the spectrum of interventions, pharmaceutical strategies have been the predominant focus, and, taken at face value, these show significant positive economic evidence, specifically when compared to the counterfactual of no interventions. Only a few studies consider non-clinical interventions, at population level. Almost half of the studies have modelled the intervention effectiveness based on existing risk-factor information and effectiveness evidence from high-income countries. Conclusion The cost-effectiveness evidence on CVD interventions in developing countries is growing, but remains scarce, and is biased towards pharmaceutical interventions. While the burden of cardiovascular disease is growing in these countries, future research should put greater emphasis on non-clinical interventions than has hitherto been the case. Significant differences in outcome measures and methodologies prohibit a direct ranking of the interventions by their degree of cost-effectiveness. Considerable caution should be exercised when transferring effectiveness estimates from developed countries for the purpose of modelling cost-effectiveness in developing countries. New local CVD risk factor and intervention follow-up studies are needed. Some pharmaceutical strategies appear cost-effective while clarifications are needed on the diagnostic approach in single high-risk factor vs. absolute risk targeting, the role of patient compliance, and the potential public health consequences of large-scale medicalization.
机译：背景低收入和中等收入国家既面临着日益严重的心血管疾病负担，也面临着严重的资源限制，这使它们无法效仿高收入国家追求的某些广泛战略。因此，在资源水平较低的情况下，迫切需要找出并实施那些有助于最大程度地减少CVD负担的干预措施。在低收入和中等收入国家，有哪些干预措施可代表良好的“物有所值”？这项研究回顾了对这些国家的干预措施进行经济评估的证据基础。方法我们基于对通用和专业电子数据库中基于关键词的全面搜索以及专家数据库的人工搜索，对直到2009年之前发表的期刊文章进行了系统的文献综述。搜索策略包括与经济评估和心血管疾病相关的自由文本和MeSH术语。两名独立审稿人证实了纳入标准的符合性并提取了研究特征。结果共有33项研究符合入选标准。如果从非常低的基准开始，我们就会发现越来越多的研究兴趣，尤其是在最近几年。与干预措施或二级预防相比，大多数干预措施都属于一级预防。在所有干预措施中，药物策略一直是主要重点，从表面上看，这些策略显示出了明显的积极经济证据，尤其是与无干预措施的反事实进行比较时。只有少数研究在人群水平上考虑非临床干预。几乎一半的研究都基于现有的风险因素信息和来自高收入国家的有效性证据对干预效果进行了建模。结论在发展中国家，有关CVD干预的成本效益证据正在增长，但仍然很少，并且偏向于药物干预。尽管这些国家的心血管疾病负担日益增加，但与以往相比，未来的研究应更加重视非临床干预措施。结果指标和方法上的显着差异禁止直接根据干预措施的成本效益程度对其进行排名。为了模拟发展中国家的成本效益，在从发达国家转移有效性估算时应谨慎行事。需要新的局部CVD危险因素和干预措施随访研究。一些药物策略似乎具有成本效益，而对于单一高风险因素与绝对风险目标，患者依从性的作用以及大规模医疗的潜在公共卫生后果，需要对诊断方法进行澄清。

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