Health and Economic Implications of National Treatment Coverage for Cardiovascular Disease in India: Cost-Effectiveness Analysis

Abstract

Background: Whether to cover cardiovascular disease costs is an increasingly pressing question for low- and middle-income countries. We sought to identify the impact of expanding national insurance to cover primary prevention, secondary prevention, and tertiary treatment for cardiovascular disease in India.

Methods and results: We incorporated data from coverage experiments into a validated microsimulation model of myocardial infarction and stroke in India to evaluate the cost-effectiveness of alternate coverage strategies. Coverage of primary prevention alone saved 3.6 million disability-adjusted life-years (DALY) per annum at an incremental cost-effectiveness ratio of $469 per DALY averted when compared with the status quo of no coverage. Coverage of primary and secondary preventions was dominated by a strategy of covering primary prevention and tertiary treatment, which prevented 6.6 million DALYs at an incremental cost-effectiveness ratio of $2241 per DALY averted, when compared with that of primary prevention alone. The combination of all 3 categories yielded the greatest impact at an incremental cost per DALY averted of $5588 when compared with coverage of primary prevention plus tertiary treatment. When compared with the status quo of no coverage, coverage of all 3 categories of prevention/treatment yielded an incremental cost-effectiveness ratio of $1331 per DALY averted. In sensitivity analyses, coverage of primary preventive treatments remained cost-effective even if adherence and access to therapy were low, but tertiary coverage would require avoiding unnecessary procedures to remain cost-effective.

Conclusions: Coverage of all 3 major types of cardiovascular treatment would be expected to have high impact and reasonable cost-effectiveness in India across a broad spectrum of access and adherence levels.

Keywords: cost-effectiveness; developing countries; health policy; healthcare economics and organizations; insurance; myocardial infarction; stroke.

Figure 1

Ischemic heart disease treatment strategies in India.^, Absolute risk is calculated over a 10-y horizon using the Framingham risk score, per current World Health Organization guidelines.^, Note that the inclusion of statin criteria of treating people with total cholesterol >8 mmol/L is meant to capture high-risk subgroups (ie, familial hypercholesterolemia). ACEI indicates angiotensin-converting enzyme inhibitor; ASA, aspirin; BP, blood pressure; and CABG, coronary artery bypass grafting.

Figure 2

Efficiency frontier of alternative coverage strategies for cardiovascular disease in India. The points reveal that all 3 major types of treatment—primary, secondary, and tertiary—for cardiovascular disease would be expected to be cost-effective in India, but strategies excluding primary preventive interventions would be less efficient (lower and to the right, meaning less effective but more costly) than strategies including primary prevention. 1′ indicates primary prevention coverage; 2′, secondary treatment coverage; and 3′, tertiary treatment coverage; all, coverage of primary, secondary, and tertiary care.