Cost-effectiveness and budget impact of the community-based management of hypertension in Nepal study (COBIN): a retrospective analysis

Abstract

Background The greatest risk factor for cardiovascular disease is hypertension, which can be alleviated via diet, exercise, and adherence to medication. Yet, blood pressure control in Nepal is inadequate, which is partly hindered by a lack of evidence-based, low-cost, scalable, and cost-effective cardiovascular disease prevention programmes. The the community-based management of hypertension in Nepal (COBIN) study was a 12-month community-based hypertension management programme of blood pressure monitoring and lifestyle counselling intervention undertaken by female community health volunteers (FCHVs) in Nepal, against usual care, which showed success in reducing blood pressure. Here we aimed to retrospectively quantify the budget impact and cost-effectiveness of the scale-up of the programme. MethodsIn this retrospective analysis, we collected participant-level data from the COBIN study; programme delivery cost data from programme administrators from the COBIN study group; and popualtion and other data from WHO, the World Bank, and the Nepalese Government. We estimated costs per participant and total costs of a national scaleup of the COBIN programme focusing on two scenarios: scenario A, delivery of the intervention to only people aged 25-65 years with hypertension; and scenario B, delivery of the intervention to all adults aged 25-65 years regardless of hypertension status. Effectiveness was based on in-trial blood pressure reductions converted to cardiovascular disease disability-adjusted life-years (DALYs) averted. The primary cost-effectiveness measure was incremental cost per averted cardiovascular disease DALY (calculated using the incremental cost-effectiveness ratio [ICER]) from a health system perspective, including programme delivery and incremental medication costs. We did univariate sensitivity analyses of scenario B to assess the effect of uncertainty in key parameter values in our calculations.Findings From a health system perspective, the first-year budget impact was US$7·1 million in scenario A and $10·8 million in scenario B. With each subsequent year, the costs decreased by approximately 50%. In the base-case cost-effectiveness analysis, from the health system perspective, scenario A resulted in an ICER of $582 per DALY averted and scenario B resulted in an ICER of $411 per DALY averted. The ICER was most sensitive to uncertainty in the number of total avertable cardiovascular disease DALYs in the eligible population.Interpretation The programme is projected to be highly cost-effective in both scenarios compared with the WHO thresholds for cost-effectiveness for Nepal. For policy makers intending to meet the UN Sustainable Development Goal of reducing premature mortality from non-communicible diseases, this intervention should be considered.

The cost-effectiveness of hypertension management in low-income and middle-income countries: a review

“…Favourable cost-effectiveness levels using the GDP threshold were found for programmes in Argentina (Augustovski et al , 2018 28 and Rubinstein et al , 2010 29 ), Brazil (Obreli-Neto et al , 2015 30 ), China (Gu et al , 2015 31 ; Xie et al , 2018 32 ; Basu et al , 2016 33 ), South Africa (Gaziano et al , 2005 34 ), Tanzania (Robberstad et al , 2007 35 ), Vietnam (Ha and Chisholm, 2011 36 and Nguyen et al , 2016 37 ), India (Basu et al , 2016 33 ), Ghana (Gad et al , 2020 38 ), Thailand (Khonputsa et al , 2012 39 ), Sri Lanka (Lung et al , 2019 40 ), Ethiopia (Tolla et al , 2016 41 ), Nigeria (Ekwunife et al , 2013 42 ) and Nepal (Krishnan et al , 2019. 43 A small number of studies indicated that cost-effectiveness thresholds were more difficult to meet in lower-income countries; for example, cost-effectiveness was not established for select intervention scenarios reported in Nigeria (Rosendaal et al , 2016 44 and Ekwunife et al , 2013) and Tanzania (Ngalesoni et al , 2016 45 and Robberstad et al , 2007) ( table 4 ). Factors that were associated with not meeting the cost-effectiveness thresholds for their respective countries included treatment of patients at lower risk for CVD (Ekwunife et al , 2013 and Khonputsa et al , 2012), screening for hypertension at younger ages (for example, at age 35 vs 55, Nguyen et al , 2016), and addressing prehypertension (Chen et al , 2017 46 ( table 5 ).…”

“…However, the potential need to accommodate programmes in LMICs to lower cost-effectiveness thresholds is not necessarily generalisable. For example, a recent study from Nepal, a low-income country, detailed very high cost-effectiveness of a community-based hypertension management programme relative to its income threshold (Krishnan et al, 2019). Relatively higher costs per averted DALY were observed in scenarios that expanded treatment to younger age groups or to prehypertension, suggesting that more targeted treatment may improve cost-effectiveness.…”

“…and Rubinstein et al, 2010 29 ), Brazil (Obreli-Neto et al, 2015 30 ), China (Gu et al, 2015 31 ; Xie et al, 2018 32 ; Basu et al, 2016 33 ), South Africa (Gaziano et al, 2005 34 ), Tanzania (Robberstad et al, 2007 35 ), Vietnam (Ha and Chisholm, 2011 36 and Nguyen et al, 2016 37 ), India (Basu et al, 2016 33 ), Ghana (Gad et al, 2020 38 ), Thailand (Khonputsa et al, 2012 39 ), Sri Lanka (Lung et al, 2019 40 ), Ethiopia (Tolla et al, 2016 41 ), Nigeria (Ekwunife et al, 2013 42 ) and Nepal (Krishnan et al, 2019 43. A small number of studies indicated that cost-effectiveness thresholds were more difficult to meet in lower-income countries; for example, cost-effectiveness was not established for select intervention scenarios reported in Nigeria (Rosendaal et al, 201644 and Ekwunife et al, 2013) and Tanzania (Ngalesoni et al, 2016 45 and Robberstad et al, 2007) (table 4).…”

Direct cost of systemic arterial hypertension and its complications in the circulatory system from the perspective of the Brazilian public health system in 2019

“…Controlled clinical trials have shown that community health interventions involving NPHWs and family physicians were more effective than the usual care provided in LMICs, demonstrating a satisfactory reduction in the blood pressure and cardiovascular risk of hypertensive patients [ 75 – 77 ]. Moreover, community health interventions aimed at SAH are cost saving in both high-income and LMICs [ 78 , 79 ].…”

Effectiveness and Efficiency of Non-drug Therapy Among Community-Dwelling Adults With Hypertension in China: A Protocol for Network Meta-Analysis and Cost-Effectiveness Analysis

“…In addition, according to these studies, the majority of cost of most non-pharmacological interventions was related to labor and overhead spending, attributes that can be easily reduced. A study in Nepal (17) showed that a community-based hypertension management program, including blood pressure monitoring, and lifestyle counseling, vs. usual care achieved an incremental costeffectiveness ratio (ICER) of 582 USD per disability-adjusted life-year (DALY) averted, demonstrating it to be a highly cost-effective strategy.…”