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Cost of cardiovascular disease prevention : towards economic evaluations in prevention programs


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© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(7):512 | http://dx.doi.org/10.21037/atm.2020.01.20

Cost of cardiovascular disease prevention: towards economic evaluations in prevention programs

João Vasco Santos1,2,3, Désirée Vandenberghe4, Mariana Lobo2,3, Alberto Freitas2,3

1Public Health Unit, ACES Grande Porto VIII – Espinho/Gaia, ARS Norte, Portugal; 2MEDCIDS – Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Portugal; 3CINTESIS – Centre for Health Technology and Services Research, Portugal; 4Department of Economics, Faculty of Economics and Business Administration, Ghent University, Belgium

Correspondence to: João Vasco Santos. Public Health Unit, AceS Grande Porto VIII – Espinho/Gaia, ARS Norte, Rua Dr. Plácido da Costa, 4200-450 Porto, Portugal. Email: jvasco.santos@gmail.com.

Provenance and Peer Review: This article was commissioned by the Editorial Office, Annals of Translational Medicine. The article did not undergo external peer review.

Comment on: Shaw LJ, Goyal A, Mehta C, et al. 10-Year Resource Utilization and Costs for Cardiovascular Care. J Am Coll Cardiol 2018;71:1078-89.

Submitted Dec 04, 2019. Accepted for publication Jan 03, 2020.

doi: 10.21037/atm.2020.01.20

View this article at: http://dx.doi.org/10.21037/atm.2020.01.20

At a global level, cardiovascular diseases (CVDs) are the leading cause of mortality, claiming almost 18 million lives annually. Throughout the last decade, this CVD burden is still increasing both in terms of deaths and disability-adjusted life years. Age-standardized death and DALY rates however are decreasing, which points to the fact that population ageing plays an important role in the evolution of the CVD rates and will continue to do so in the future (1,2).

In terms of costs, CVD represent between 7.6% and 21.0% of national health expenditures, mainly due to ischemic heart disease and stroke. The largest share of expenditure (half or more) goes to hospital inpatient care, followed by spending on pharmacological treatment (3-7).

Most existing CVD cost studies consider the costs of care after a specific cardiovascular event, pointing out the need for public health programs or interventions to reduce this burden (3,6). In order to allocate resources to public health programs, more should be known about the cost of those programs.

Recently, Shaw et al. published an article on the 10-year cost of CVD in an American cohort within the Multi-Ethnic Study of Atherosclerosis (MESA), a cohort of asymptomatic and apparently healthy individuals (45 to 84 years of age) (8).

The reported increase of cardiovascular risk factors among these asymptomatic individuals, i.e., diabetes prevalence increased from 10.0% to 19.3%, hypertension from 44.9% to 57%, dyslipidaemia from 37.3% to 52.8%, means a higher need for—and use of—health care services

in the cohort. Only 30% of individuals did not have an echocardiogram, exercise test or invasive angiography (8).

The 10-year (cumulative) health care cost was reported at just above $23,000 per patient; 78% of which was caused by CVD drugs, and even higher shares for individuals with diabetes (87%) and dyslipidaemia (90%) (8). This pattern differs from other CVD cost-of-illness studies which indicate a higher share of costs towards inpatient care.

This is probably because cost-of-illness studies are focused in patients having experienced a CVD, while Shaw et al.

focused on a cohort before any CVD event occurred.

Shaw et al. note the large impact on costs of risk profile on the one hand, and of the socio-economic factors on the other hand (8). Costs increased significantly with a higher Framingham risk score, coronary artery calcium score or elevated C-reactive protein: cumulative costs in low and high-risk profiles are associated with a mean cost of respectively $8,000 and $36,000, up to a 15-fold cost increase between those risk profiles. Low-risk status persons accounted for 5.2% of total costs; while high-risk status persons were responsible for 48% of costs. Other studies have already pointed out this cost increase related to risk factors. For example, Goetzel et al. indicated that the combined contribution of risk factors for heart disease and stroke among US employees predicted cost increases by 214% and 62%, respectively (9).

This prevalence of combined risk factors is on the rise and increases the probability of multi-morbidity, which in


Editorial Commentary


Santos et al. Cost of cardiovascular disease prevention

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(7):512 | http://dx.doi.org/10.21037/atm.2020.01.20 Page 2 of 3

turn elevates costs. In 2013–2014, the US prevalence rate was 59.6% with over one fifth (22.7%) of individuals having 4 or more morbidities (10). Aside from risk profile, social determinants such as insurance, education and age strongly impact not just health outcomes, but costs as well (8).

The range of determinants affecting CVD-related costs indicates the need for CVD-focused policies but also for preventive policies or programs.

Shaw et al. encouraged public health strategies such as early screening and targeted preventive programs in order to address this set of issues (8). In fact, cost- effectiveness of CVD screening policies in high risk groups is an increasingly important research trend because of its potential for health gains. While tools such as the Framingham Risk Score (FRS) can play an important role in the detection of different risks individuals, leading towards different clinical approaches such as different screening intervals (11), other screening approaches like non-laboratory single screening or multistage might be more cost-effective (12).

Preventive programs targeted at high-risk groups can take many forms; interventions in the context of the broader population or within smaller communities can be effective in addressing multiple lifestyle-related risk factors.

Successful examples such as the Västerbotten Intervention Programme can serve as a reference (13).

Including the full range of cost elements (i.e., including productivity losses due to morbidity and mortality, informal care, early retirement costs etc.) may strongly influence cost effectiveness studies on CVD prevention policies and, thus, studies addressing the different patterns of CVD prevention costs are important.

Finally, while there is already some literature and an increasing focus on performing economic evaluations of CVD prevention programs (14-16), there is still a high potential for investment in this field of research, mainly in primary prevention. Additionally, the standardization of methods in order to compare and apply different programs can yield new insights.

Acknowledgments Funding: None.


Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.

org/10.21037/atm.2020.01.20). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non- commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license).

See: https://creativecommons.org/licenses/by-nc-nd/4.0/.


1. GBD 2017 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1859-922.

2. GBD 2017 Causes of Death Collaborators. Global, Regional, and National Age-Sex-Specific Mortality for 282 Causes of Death in 195 Countries and Territories, 1980- 2017: A Systematic Analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1736-88.

3. Vandenberghe D, Albrecht J. The Financial Burden of Non-Communicable Diseases in the European Union: A Systematic Review. Eur J Public Health 2019. [Epub ahead of print].

4. Tarride JE, Lim M, DesMeules M, et al. A review of the cost of cardiovascular disease. Can J Cardiol 2009;25:e195-202.

5. Muka T, Imo D, Jaspers L, et al. The Global Impact of Non-Communicable Diseases on Healthcare Spending and National Income: A Systematic Review. Eur J Epidemiol 2015;30:251-77.

6. Luengo-Fernández R, Leal J, Gray A, et al. Cost of Cardiovascular Diseases in the United Kingdom. Heart 2006;92:1384-9.

7. Wilkins E, Wilson L, Wickramasinghe, et al. European Cardiovascular Disease Statistics. European Heart Network, Brussels (2017).

8. Shaw LJ, Goyal A, Mehta C, et al. 10-Year Resource


Annals of Translational Medicine, Vol 8, No 7 April 2020 Page 3 of 3

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(7):512 | http://dx.doi.org/10.21037/atm.2020.01.20 Utilization and Costs for Cardiovascular Care. J Am Coll

Cardiol 2018;71:1078-89.

9. Goetzel RZ, Pei X, Tabrizi MJ, et al. Ten modifiable health risk factors are linked to more than one-fifth of employer- employee health care spending. Health Aff (Millwood) 2012;31:2474-84.

10. King DE, Xiang J, Pilkerton CS. Multimorbidity trends in United States adults, 1988–2014. J Am Board Fam Med 2018;31:503-13.

11. Lindbohm JV, Sipilä PN, Mars NJ, et al. 5-year versus risk-category-specific screening intervals for cardiovascular disease prevention: a cohort study. Lancet Public Health 2019;4:e189-99.

12. Pandya A, Weinstein MC, Salomon JA, et al. Who Needs Laboratories and Who Needs Statins? Comparative and Cost-Effectiveness Analyses of Non–Laboratory-Based, Laboratory-Based, and Staged Primary Cardiovascular Disease Screening Guidelines. Circ Cardiovasc Qual

Outcomes 2014;7:25-32.

13. Lindholm L, Stenling A, Norberg M, et al. A Cost- Effectiveness Analysis of a Community Based CVD Program in Sweden Based on a Retrospective Register Cohort. BMC Public Health 2018;18:452.

14. Schwappach DL, Boluarte TA, Suhrcke M. The Economics of Primary Prevention of Cardiovascular Disease - A Systematic Review of Economic Evaluations.

Cost Eff Resour Alloc 2007;5:5.

15. Suhrcke M, Boluarte TA, Niessen L. A Systematic Review of Economic Evaluations of Interventions to Tackle Cardiovascular Disease in Low- And Middle-Income Countries. BMC Public Health 2012;12:2.

16. Aminde LN, Takah NF, Zapata-Diomedi B, et al. Primary and secondary prevention interventions for cardiovascular disease in low-income and middle-income countries:

a systematic review of economic evaluations. Cost Eff Resour Alloc 2018;16:22.

Cite this article as: Santos JV, Vandenberghe D, Lobo M, Freitas A. Cost of cardiovascular disease prevention: towards economic evaluations in prevention programs. Ann Transl Med 2020;8(7):512. doi: 10.21037/atm.2020.01.20


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