Milk Powder Fortified with Potassium and Phytosterols to Decrease the Risk of Cardiovascular Events among the Adult Population in Malaysia: A Cost-Effectiveness Analysis

Abstract

This study evaluated the cost-effectiveness of the consumption of a milk powder product fortified with potassium (+1050.28 mg/day) and phytosterols (+1200 mg/day) to lower systolic blood pressure and low-density lipoprotein cholesterol, respectively, and, therefore, the risk of myocardial infarction (MI) and stroke among the 35-75-year-old population in Malaysia. A Markov model was created against a do-nothing option, from a governmental perspective, and with a time horizon of 40 years. Different data sources, encompassing clinical studies, practice guidelines, grey literature, and statistical yearbooks, were used. Sensitivity analyses were performed to evaluate the impact of uncertainty on the base case estimates. With an incremental cost-effectiveness ratio equal to international dollars (int$) 22,518.03 per quality-adjusted life-years gained, the intervention can be classified as very cost-effective. If adopted nationwide, it would help prevent at least 13,400 MIs, 30,500 strokes, and more than 10,600 and 17,100 MI- and stroke-related deaths. The discounted cost savings generated for the health care system by those who consume the fortified milk powder would amount to int$8.1 per person, corresponding to 0.7% of the total yearly health expenditure per capita. Sensitivity analyses confirmed the robustness of the results. Together with other preventive interventions, the consumption of milk powder fortified with potassium and phytosterols represents a cost-effective strategy to attenuate the rapid increase in cardiovascular burden in Malaysia.

Keywords: Malaysia; blood pressure; cardiovascular; cholesterol; cost-effectiveness analysis; fortified food; phytosterols; potassium.

Figure 1

Decision tree representation of one branch of the Markov model structure for each arm. The model was based on the structure of Li [27]. The “well” and “chronic cardiovascular disease (CVD)” states are populated by individuals without and with prior myocardial infarction (MI) or stroke, respectively. The initial distribution of the population was set as follows: 3.83% of the individuals started in the “chronic CVD” state, and the remaining 96.17% started from the “well” state [28]. Individuals in the “well” state can remain in their state or progress to “chronic CVD” in the case of a first-ever MI or stroke. In each cycle, individuals in the “well” and the “chronic CVD” states may experience an MI or stroke and are characterized by the same survival probabilities as other individuals in their state, regardless of their medical history. “Other death” accounts for all individuals who die of causes that differ from CVDs.

Figure 2

Tornado diagram. Bars represent the relative importance of the input parameters on the expected value (EV): the larger the bar, the higher the impact of that item. In the legend, the inputs to whom the bars correspond are in order of importance. The initial letter indicates the type of input: “u” stands for utility, “c” for cost, and “n” for number.

Figure 3

Monte Carlo simulation. Dots represent the values of the incremental cost-effectiveness ratio in 5000 simulations carried out to consider the uncertainty input parameters. The ellipse represents 95% of all data points. The line passing through the intersection of the axes represents the willingness to pay (WTP), corresponding to the gross domestic product per capita; 58.3% of the dots are located in the northeast quadrant on the right of the WTP line, that is, due to stochastic and parametric uncertainty, we expect the fortified milk powder to be a cost-effective intervention in 58.3% of the cases.