Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
RESEARCH ARTICLE
Open Access
Cost effective interventions for the prevention of
cardiovascular disease in low and middle income
countries: a systematic review
Amir Shroufi1*, Rajiv Chowdhury1, Raghupathy Anchala1, Sarah Stevens2, Patricia Blanco1, Tha Han1,
Louis Niessen3,4,5 and Oscar H Franco1,6
Abstract
Background: While there is good evidence to show that behavioural and lifestyle interventions can reduce
cardiovascular disease risk factors in affluent settings, less evidence exists in lower income settings.
This study systematically assesses the evidence on cost-effectiveness for preventive cardiovascular interventions in
low and middle-income settings.
Methods: Design: Systematic review of economic evaluations on interventions for prevention of cardiovascular disease.
Data sources: PubMed, Web of Knowledge, Scopus and Embase, Opensigle, the Cochrane database, Business Source
Complete, the NHS Economic Evaluations Database, reference lists and email contact with experts.
Eligibility criteria for selecting studies: we included economic evaluations conducted in adults, reporting the effect of
interventions to prevent cardiovascular disease in low and middle income countries as defined by the World Bank. The
primary outcome was a change in cardiovascular disease occurrence including coronary heart disease, heart failure and
stroke.
Data extraction: After selection of the studies, data were extracted by two independent investigators using a previously
constructed tool and quality was evaluated using Drummond’s quality assessment score.
Results: From 9731 search results we found 16 studies, which presented economic outcomes for interventions to
prevent cardiovascular disease in low and middle income settings, with most of these reporting positive cost
effectiveness results.
When the same interventions were evaluated across settings, within and between papers, the likelihood of an
intervention being judged cost effective was generally lower in regions with lowest gross national income. While
population based interventions were in most cases more cost effective, cost effectiveness estimates for individual
pharmacological interventions were overall based upon a stronger evidence base.
Conclusions: While more studies of cardiovascular preventive interventions are needed in low and mid income
settings, the available high-level of evidence supports a wide range of interventions for the prevention of
cardiovascular disease as being cost effective across all world regions.
* Correspondence: amir.shroufi@doctors.org.uk
1
Department of Public Health & Primary Care, Cardiovascular Epidemiology
Unit, University of Cambridge, Strangeways Research Laboratory, Wort’s
Causeway, Cambridge CB1 8RN, UK
Full list of author information is available at the end of the article
© 2013 Shroufi et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
Background
Chronic diseases were estimated to account for approximately 50% of the total disease burden in low and middleincome countries in 2005 with further marked increases
expected in the coming years [1].
It has been shown that the concomitant modification of
multiple known risk factors (principally blood pressure
and serum cholesterol concentration) could reduce cardiovascular disease to a large extent [2].
Both pharmacological and non-pharmacological strategies are likely to have a key role in tackling Cardiovascular
Disease (CVD) in low and middle income countries [3];
non pharmacological strategies because of their potential
for wide dissemination as well as their ability to be delivered more cheaply than pharmacological strategies to low
and middle income populations, [4-6] pharmacological
strategies because of the large absolute benefits conferred
to those treated and the greater certainty in attribution of
benefits [7].
While there is evidence to show that population-based
and lifestyle interventions can reduce cardiovascular disease risk factors in affluent settings [8], as well as some
evidence supportive of longer-term benefits in disease
reduction, [6] less evidence exists in lower income settings. To generalise results from high income setting is
not entirely satisfactory because reasonable thresholds
for cost effectiveness will vary markedly – as will affordability [9]. Additionally setting specific information is
important because population-based and preventive interventions are often, to some extent, context specific.
In this paper we evaluate and summarise the existing
evidence on the cost-effectiveness of interventions for the
prevention (primary and secondary) of cardiovascular disease in low and middle income countries. Furthermore,
we describe how the level of cost-effectiveness differs by
setting and intervention type.
Methods
Eligibility criteria
Studies were included if they were [i] randomised controlled trials assessing any cardio-protective intervention
to prevent fatal or non-fatal CVD events (including myocardial infarction, coronary heart disease, stroke and heart
failure); [ii] cohort, case–control, cross sectional studies or
controlled trials reporting economic outcomes, or studies
utilising the results of such studies to model economic
outcomes; [iii] reported economic outcomes in terms of
costs per YLG (years of life gained)/events averted, or
cost-utility ratios, (ie, cost per QALY (quality adjusted life
year) or DALY (disability adjusted life year)) of interventions aimed to prevent CVD; [iv] included adult participants (≥ 18 years old); and [v] published in any language.
We excluded studies if they [vi] were letters, abstracts,
case reports, editorials, descriptive studies, ecological
Page 2 of 13
studies or conference proceedings; [vii] involved nonhuman subjects; [viii] were conducted in affluent settings/
rich countries (see Additional file 1: Appendix 1); [ix] provided only participant reported outcomes and [x] assessed
only the effect of surgical interventions.
Information sources
Between 1st November 2010 and 17 January 2011 (date
last searched) we comprehensively searched the electronic databases Pubmed, Web of Knowledge, Scopus,
Embase, Opensigle, the Cochrane database, Business
Source Complete and the NHS Economic Evaluations
Database. We also carried out domain-limited World
Wide Web searches. (who.org + .htai.org + inahta.org)
No limits were placed on the language or year of publication. Once articles for full text review were identified
their references were checked for additional relevant
publications. We also contacted their authors directly
requesting relevant additional information and details of
any related unpublished studies.
Search strategy
Our full Pub-Med search strategy is shown below. This
was translated for use in other databases with the help of
an experienced librarian.
(((((((((((low and middle income countr*[Title/Abstract])
OR low income countr*[Title/Abstract]) OR Low OR
middle income countr*[Title/Abstract]) OR LMIC[Title/
Abstract]) OR developing countr*[Title/Abstract]) OR high
income countr*[Title/Abstract]) OR undeveloped countr*
[Title/Abstract]) OR south* AND asia[Title/Abstract])
OR middle income countr*[Title/Abstract]) OR resource limited[Title/Abstract])) OR (((((((((("Developing Countries"[Mesh] OR "Africa"[Mesh]) OR "Asia,
Southeastern"[Mesh]) OR "Pacific Islands"[Mesh]) OR
"Micronesia"[Mesh]) OR "Europe, Eastern"[Mesh]) OR
"Middle East"[Mesh]) OR "Asia"[Mesh]) OR "Asia"[Mesh])
OR "Central America"[Mesh]) OR "South America"[Mesh])
AND
((((((((((((("Cardiovascular Diseases"[Mesh] OR "Coronary Artery Disease"[Mesh]) OR "Atherosclerosis"[Mesh])
OR "Coronary Disease"[Mesh]) OR "Myocardial Infarction"
[Mesh]) OR "Myocardial Ischemia"[Mesh]) OR "Stroke"
[Mesh]) OR myocardial[Title/Abstract]) OR ischaemic
heart disease[Title/Abstract]) OR ischemic heart disease
[Title/Abstract]) OR stroke[Title/Abstract]) OR brain vascular accident[Title/Abstract]) OR cerebrovascular[Title/
Abstract]) OR cerebrovascular accident*[Title/Abstract])
OR CVA[Title/Abstract]
AND
((((((((taxation[Title/Abstract]) OR advertising[Title/
Abstract]) OR social marketing[Title/Abstract])) OR
Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
("Taxes"[Mesh] OR "Advertising as Topic"[Mesh])) OR
(((((((((((((((((((diet* AND modification*[Title/Abstract])
OR salt[Title/Abstract]) OR sodium[Title/Abstract]) OR
NaCl[Title/Abstract]) OR salt reduction[Title/Abstract])
OR smoking interventions[Title/Abstract]) OR exercise
interventions[Title/Abstract]) OR physical activity[Title/
Abstract]) OR multiple lifestyle[Title/Abstract]) OR
dietary interventions[Title/Abstract]) OR diet[Title/
Abstract]) OR food[Title/Abstract]) OR brief advice
[Title/Abstract]) OR counselling[Title/Abstract]) OR
incentive based[Title/Abstract]) OR active and passive[Title/Abstract]) OR dietary advice[Title/Abstract])
OR home health education[Title/Abstract]) OR lifestyle
[Title/Abstract])) OR (((((((((((("Primary Prevention"[Mesh]
OR "Secondary Prevention"[Mesh]) OR "prevention and
control "[Subheading]) OR "Self Efficacy"[Mesh]) OR
"Counseling"[Mesh]) OR "Directive Counseling"[Mesh])
OR "Disease Management"[Mesh]) OR "Behavior Control"
[Mesh]) OR "Smoking Cessation"[Mesh]) OR "Behavior
and Behavior Mechanisms"[Mesh]) OR "Sodium Chloride,
Dietary"[Mesh]) OR "Feeding Behavior"[Mesh]) OR "Patient
Education as Topic"[Mesh]))) OR (((((((((((((((((("Cardiovascular Agents"[Mesh] OR "HydroxymethylglutarylCoA Reductase Inhibitors"[Mesh]) OR "Antihypertensive
Agents"[Mesh]) OR "Aspirin"[Mesh]) OR "AngiotensinConverting Enzyme Inhibitors"[Mesh]) OR "Calcium
Channel Blockers"[Mesh]) OR "Adrenergic beta-Antagonists
"[Mesh]) OR smoking cessation[Title/Abstract]) OR nicotine replacement[Title/Abstract]) OR bupropion[Title/
Abstract]) OR bupropion[Title/Abstract]) OR varenicline
[Title/Abstract]) OR chantix[Title/Abstract]) OR champix
[Title/Abstract]) OR cytisine[Title/Abstract]) OR tabex
[Title/Abstract]) OR clonidine[Title/Abstract]) OR nortriptyline[Title/Abstract]) OR nicorette[Title/Abstract])
AND
(((((((("Economics"[Mesh] OR "Socioeconomic Factors"
[Mesh]) OR "Costs and Cost Analysis"[Mesh]) OR "CostBenefit Analysis"[Mesh]) OR cost effectiveness[Title/
Abstract]) OR cost utility[Title/Abstract]) OR financ*
[Title/Abstract]) OR economic[Title/Abstract]) OR monetary[Title/Abstract]) OR cost*[Title/Abstract]
Study selection
Title and abstract for all studies identified by our search
were screened by two independent reviewers (AS, RA,
SS, TH, RC, PB, OhF) against our eligibility criteria to
determine inclusion for full text review. AS reviewed all
abstracts and RA, SS, TH, RC, PB and OhF equally
shared the task of reviewing a duplicate list of all abstracts. Eligibility criteria were systematically applied to
each abstract to derive a list for full text review, where
an abstract was rejected the criteria barring eligibility
Page 3 of 13
were noted. In this way 2 lists of articles for further review were produced. These were then compared and
disagreements were resolved by discussion; where disagreement persisted a third investigator was consulted
(RA, OhF). In this way we arrived at an agreed list of articles for full text review.
All full text manuscripts were then assessed using a
standardised checklist to ascertain definitively whether
they met all eligibility criteria for this review. This was
done independently by two reviewers (AS, OhF). Each
reviewer then compared their selection with that of the
other, reassessing against eligibility criteria in all cases of
disagreement. Disagreements which persisted were resolved through discussion. Where agreement was not
reached the opinion of a third party was sought (RA).
The remaining studies were included within this review.
For definitions used see Additional file 1: Appendix 1.
For income groupings see Additional file 2: Appendix 2.
Data collection process
From each study selected for inclusion we extracted a prespecified set of data items using a data extraction form
which was piloted before use. Data extraction was carried
out by two independent reviewers (AS, OhF). The two
reviewers compared data extraction results, resolving
disagreements by discussion, before producing a final
data extraction form which was entered into Epi Info.
Data items
We extracted data on year of publication, study setting,
geographic origin of publication, publication date, target
population, intervention type, whether embedded within
a trial, the nature analysis undertaken, modelling techniques used, main economic findings and funding source.
We also extracted data on the analytic parameters used.
To aid synthesis of results intervention effect estimates
were categorised by metric used, the setting they related
to and by intervention type.
Risk of bias in individual studies (Quality review)
The quality of included articles was rated independently
by 2 reviewers (AS, SS) according to the checklist for
economic evaluations produced by Drummond [10]. We
chose to present findings of quality review as either ++,
+, or – as has been used by The UK National Institute
for Health and Clinical Excellence (NICE) [11].
Synthesis of results
We used broad categories of cost effectiveness to compare results between studies which we considered useful
to facilitate comparison between studies while allowing
for setting specific variation in costs and effects. Categories used are those suggested by WHO, whereby if
cost/DALY ≤ (Gross national income) GNI per capita
Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
the intervention of interest would be considered: i) very
cost effective, ii) with a cost/DALY of 1–3 times GNI
per capita it would be categorised as cost effective and
iii) with a cost/DALY more than 3 times GNI per capita
classified as “not cost effective” [12]. We added a further
category iv) of “extremely cost effective” in order to
further differentiate cost effectiveness results. We arbitrarily defined this category as ¼ GNI per capita per
DALY gained.
Page 4 of 13
within an intervention study [45]. In 14/16 cases some
form of sensitivity analysis was undertaken. In most cases
(9/16) where this was carried out the impact of changes
in the most consequential variable had a large (>1 order
of magnitude) impact upon results.
2 studies declared pharmaceutical industry funding
[46,47], 3 studies were government funded, [17,24,45] 7 were
funded by another non-industry body [5,12,15,18,20,23,30]
and in 4 cases funding source was not stated
[25,34,36,48].
Risk of bias across studies
We examined whether there was a systematic difference
in the quality of evidence underpinning effectiveness
estimates according to the modality of intervention.
(pharmacological vs lifestyle interventions).
Study conducted and reported in line with the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
PRISMA statement guidelines [13].
Results of individual studies
All of the papers retrieved presented positive results,
supporting some or all of the interventions considered as
cost effective in the setting/s of interest. Where study authors categorised cost effectiveness using GNI the same
thresholds as applied here were used. In all but one case
[46] we arrived at the same categorisation as study authors.
Results
Study selection
Our initial search yielded 9729 results from all databases
with two further studies obtained based upon responses
of experts who were contacted. From these 9731 search
results 93 studies were retrieved in full text after review
of title and abstract against eligibility criteria. Review of
the reference lists of the retrieved studies did not yield
any additional studies.
After review of the full text of these 93 studies a further 77 were excluded leaving 16 articles, which met our
search criteria. In each case the criteria by which a study
was deemed ineligible was recorded. Most studies were
excluded at this stage because they were not of the
study type required [14], or they did not provide results
in terms of QALYs/DALYS/LYG. Eight studies were
excluded due to being conducted in affluent settings
(Figure 1).
Study characteristics
The majority (12/16) of studies retrieved were published
within 5 years of this review. Eight papers evaluated
pharmacological interventions only, while a further 8
papers evaluated a mixture of both pharmacological and
lifestyle interventions. None of the included papers
evaluated only lifestyle interventions (Table 1).
In 6/16 cases the study originated from the setting of
interest, with the other 10 studies originating from the
USA or Europe. Within included papers over 20 different
preventive interventions were evaluated in total. Geographical categories in which interventions were evaluated
included World Bank and World Health Organisation
(WHO) regions as well as individual country level.
Most studies (15/16) were based on stochastic simulation
and we found only one economic evaluation embedded
Tobacco control
We found 6 studies that evaluated tobacco control interventions in one or more low and middle income country
[5,15,17,32,34,36]. Although personal interventions such
as nicotine replacement therapy (NRT) were generally
found to be cost effective, population-based interventions were much more cost effective (by an order of 10–
100 fold) (see Figure 2).
Pharmacological primary prevention using an absolute risk
based approach
7 studies evaluated the cost effectiveness of providing
preventive medication on the basis of absolute risk.
[15,17,18,20,23,24,30] 5 of these found this approach to
be “very cost effective” or “cost effective” in all settings
for which they evaluated this intervention, [17,18,23,24,30]
with cost effectiveness generally increasing at higher risk
thresholds for treatment (see Figure 2).
Less favourably, studies in Tanzania [20] and Kyrgyzstan
[15] reported borderline and negative results respectively for the cost effectiveness of an absolute risk based
approach.
Individual risk factor reduction approach
Of the 16 studies included, 5 evaluated the use of pharmaceuticals for individual risk factor lowering [15,23-25,30].
Drugs to lower “high” blood pressure were found to be
in the “very cost effective” or “cost effective” range in all
studies. In the case of statins, 3 studies reported them
to be cost effective [23-25] while 2 studies found them
to be not cost effective [15,17].
Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
Page 5 of 13
Search results to January 2011
(n=9731)
PubMed (n=2104)
Web of Knowledge (n=864)
Scopus (n=1671)
The Cochrane Library (n=99)
EMBASE (n=3190)
Opensigle (n=9)
Business source complete (n=95)
NHS economic evaluations database (n=17)
Domain limited search (n=7)
Bibliographies and experts (n=2)
Duplicates (n=2974)
Studies excluded after title and abstract
screening by inclusion criteria, described in
methods.
(n=6664)
Studies retrieved for detailed evaluation.
(n=93)
Studies excluded (n=77)
EC 2 (n=46)
EC 3 (n=20)
EC 8 (n=7)
Others (n=4)
(EC = eligibility criteria failed)
Studies to be included in the systematic
review.
(n=16)
Studies of pharmacological interventions only (n=8)
Behavioral interventions only (n=0)
Mixture of pharmacological and non pharmacological interventions (n=8)
Economic evaluations within intervention studies (n=1)
Figure 1 Flow diagram for the selection of studies evaluating the cost effectiveness of interventions for the prevention of
cardiovascular disease in low and middle income countries: systematic review.
Pharmacological secondary prevention
Other legislative interventions
All studies evaluating pharmacological secondary prevention of CVD found this approach to be in the “cost
effective” or “very cost effective” range [15,46,47].
Four of the studies included reported evaluations of legislative interventions such as the compulsory reduction
of salt in food [12,17,23,32] (Figure 2). Interventions of
this type were generally found to be very cost effective,
or extremely cost effective, with the exception of salt
lowering legislation in Sub Saharan Africa which was
found not to be cost effective [32].
Use of mass media
We found 5 studies, which evaluated the use of mass
media to reduce salt consumption, to stop smoking, to
improve dietary characteristics as well as joint campaigns [12,15,17,24,32].
The source of effect estimates underpinning cost effectiveness calculations were derived from a mixture of trial
data, observational data and expert opinion. The use
of mass media was generally found to be “very cost
effective” (Figure 2) [12,15,17,24,32].
Provenance of studies and study estimates of costs and
effects
In all but one case [45] the population-based interventions estimates of effect size were derived from settings
other than the setting of interest. Effect estimates were
obtained utilising the results from a mixture of observational and experimental studies. We found variation in
Intervention
Pharmacological interventions Polypill
Different effects of
intervention used
Effect estimates used within
individual studies
Source of effect estimate-trial type
and principal* source
Reduced absolute
risk CVD
−20% [15]
Meta analysis [16]
Reduced relative
risk of CVD
RR=0.12 [17] for cardiovascular disease
Estimate based on RCT evidence [2]
RR=0.29 for IHD and 0.4 for stroke
(primary prevention) [18]
Overview of RCTs [19]
RR=0.12 for CHD and RR=0.2 for stroke [20]
Multiplicative effects [21,22]
Reduction in BP and
cholesterol + reduced
absolute risk (to account
for effects of aspirin)
20% reduction in cholesterol+33% reduction Product of estimates from RCT
estimates used for Cholesterol
in difference in BP between 115** and
and BP. For Aspirin [16]
current + 20% reduction absolute risk CVD
(to account for benefits aspirin) [23]
20% reduction in cholesterol+28% reduction Product of estimates from RCT
in difference in BP between 115** and
estimates used for Cholesterol
current + 18% reduction absolute risk CVD
and BP. For Aspirin [16]
(to account for benefits aspirin) [24]
Treatment of “high“cholesterol
Reduction in total serum
cholesterol concentration
Tobacco control
Mass media smoking
RCT [21]
−20% [23]
RCT [21]
−22% [25])
RCT [26]
RR=0.84 [20]
Heart Protection Study Group [21].
RR=0.95 [17]
Meta analysis [27]
Reduction in relative risk
of disease
RR=0.82 [17]
Overview of RCTs [28]
RR=0.66 for stroke, RR=0.72 for CHD [20]
Overview of RCTS. [22]
Reduction in the difference
between SBP & 115 mmHg
−33% reduction [15]
Overview of RCTs [19]
−33% reduction [23]
RCT [29]
Blood pressure lowering
10 mmHg lowering of BP, yielding 40% RR
reduction stroke and 14% reduction for
coronary heart disease. [30].
Overview of randomised trials [19]
Reduction in smoking prevalence
−2% [24])
Observational. Friend and Levy. 2002 [31].
−1.5%[15]
Review of observational data [31]
Reduction in relative risk of
cardiovascular disease
Treatment of “high” BP
−20% [15])
Price increase cigarettes
Reduction smoking attributable
death
5-15% [32]
Review of observational data [33]
Nicotine replacement
therapy (gum)
Increased likelihood of cessation
OR=1.66 [34]
Systematic review [35]
Increase in percentage using
NRT who quit
5% [24]
14.3% continuous quit rate compared
to 2.7 if usual care [36].
RCT [37]
Page 6 of 13
Community pharmacist smoking cessation Increase in proportion using
cessation services who
become long term quitters
Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
Table 1 Summary of impacts assumed for interventions evaluated in retrieved studies and associated effect size estimates used to derive economic outcomes
Mass media interventions
Bupropion-smoking cessation
Reduced relative risk of CVD
RR=0.8 [17]
Systematic review [38]
Mass media, diet/cholesterol
Reduced total serum cholesterol
−2% [15]
Cost effectiveness analysis [39]
−2% [23]
Cost effectiveness analysis [39]
−20% (range 10-30%) [24]
Effect of salt on BP from meta
analysis [40] Mass media effects
not supported.
−15% [15]
No reference for impact on salt intake,
impact of salt reduction on BP from
trial data [41]
Mass media salt/reductions
food
Legislative Interventions
Reduced total dietary salt intake
Reduced CVD prevalence
−4% [32]
Review [14] and expert opinion
Combined mass media
Relative risk of CVD
RR=0.98 [17]
Meta analysis [42]
Salt in bread-voluntary/other
Reduced CVD relative risk
RR=0.99 [17]
No reference for impact of legislation,
review of trials supports impact of salt
on CVD [43]
Legislation on salt in food
Reduction in total dietary salt intake
30% reduction [23]
No reference for impact of legislation.
Impact of salt on BP from observational
data [44]
Reduced salt intake via
legislation + education
Reduced systolic BP
−2 mmHg (1-4) mmHg [32]
Review [14] and expert opinion
Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
Table 1 Summary of impacts assumed for interventions evaluated in retrieved studies and associated effect size estimates used to derive economic outcomes
(Continued)
Reduction in the difference between 33% reduction [15]
actual SBP & 115 mmHg
*Where multiple source citations provided the highest in hierarchy of evidence is shown.
**115 mmHg suggested as theoretical minimum risk level for systolic blood pressure by WHO.
Abbreviations: CAD, Coronary Artery Disease; CVD: Cardiovascular Disease; SBP, Systolic Blood pressure, NRT, Nicotine replacement Therapy, WHO, World Health Organisation.
(where available the source of effect estimates cited in each study has been shown).
Page 7 of 13
Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
Page 8 of 13
Figure 2 Levels of cost-effectiveness for different cardiovascular interventions in low and middle income countries arranged by annual
gross domestic products (GDP).
the nature of effects modelled for the same intervention
as well as in the magnitude of change that intervention
was assumed to produce (see Table 2).
In the case of studies evaluating policy interventions,
all effect estimates were based on the observed experience of other locations implementing such policies and/
or expert opinion. Effects on risk factor levels were used
to model expected changes in mortality.
Costs for population-based interventions were generally based upon a theoretical estimation of likely costs
derived from summing individual strategy components,
rather than by measuring the cost of delivering the intervention as a whole in a real life setting.
Parameters used in economic models
Most studies (11/16) used a 3% discount rate for costs
and effects and all but one [46] used the same discount
rate for costs and effects.
In the majority of papers retrieved (10/16) adherence
was not incorporated directly in modelling, although by
using trial data adherence was in effect incorporated at
high levels in others. Where modelled, levels of adherence
ranging from 50% [17] to 95% [15,17,24,25,47] were used.
Six studies used a lifetime time horizon, five used a
10 year horizon, one used 20 years and one 5 years with
the remaining three studies not reporting the time horizon considered. Where altered in sensitivity analysis
the potential impact of the chosen time horizon upon
overall cost effectiveness was of at least one order of
magnitude [45,46].
Discussion
Economic evaluations of cardiovascular prevention in low
and middle income countries have found a wide range
of interventions to be cost effective across all world regions. Given the limited evidence base, findings should be
interpreted with caution; yet can aid rational resource allocation and implementation.
Cost effectiveness estimates for pharmacological interventions were generally supported by stronger evidence
than those for other interventions. Additionally agreement
on effect sizes between studies was generally greater for
pharmacological interventions.
Virtually none of the evaluations are fully based on
data derived from LMICs. We found a consistent difference between the sources of the effect estimates for
population-based interventions compared to personal interventions, with the latter generally based upon studies
lower in the hierarchy of evidence (Table 2). The effectiveness estimates on personal, pharmacologic interventions for the most part are based on studies with reliable
effect sizes in high income countries, supplemented with
LMIC cost estimates. The evaluations of population-based
interventions lack any RCT level of evidence which leads
Setting
Intervention/s
Main economic findings
(outcome metric)
Target
population
Quality score In overall summary
(Drummond) (Figure 2)
Huang Guangyong et al., 2000 [45]
Cost effectiveness of the Beijing Fangshan
cardiovascular prevention programme
China
Health education and
anti-hypertensive drugs
Intervention found to be cost effective
Initially whole
population,
then high risk
+/−
No –limited
comparability
Gaziano et al., 2007 [18] Cardiovascular
disease prevention with a multidrug
regimen in the developing world
6 World Bank Fixed dose combination
Regions
therapy
Found cost effective in all world regions
for primary and secondary prevention
Various
++
Yes
Caro et al. 1999 [25] International economic
analysis of primary prevention of cardiovascular
disease with Pravastatin in WOSCOPS
South Africa
Pravastatin for primary
prevention
Authors describe Pravastatin as efficient for
CVD primary prevention. Note, cost per LYG
close to 3 X GNI per capita for study year.
Thus cost/DALY likely to be > 3 X GNI/Capita
Men with high
cholesterol
+
Yes
Rubinstein et al., 2009 [17] Generalised cost
Argentina
effectiveness analysis of a package of interventions
to reduce cardiovascular disease in Buenos Aires,
Argentina
Personal pharmacological
and non personal
population-based
interventions
All interventions cost effective with exception
of statins to lower “high” cholesterol
Various
++
Yes
Anh Ha and Chisholm, 2010 [24] Cost effectiveness Vietnam
of intervention to prevent cardiovascular disease
in Vietnam
Personal pharmacological
and non personal
population-based
interventions.
Range of interventions judged cost effective and
deliverable at low cost
Various
++
Yes
Gaziano et al., 2005 [30]. Cost effectiveness analysis South Africa
of hypertension guidelines in South Africa
Antihypertensive drugs
Absolute risk based initiation of therapy dominated Hypertensive/
a strategy of initiating medications based on blood high CVD risk.
pressure threshold alone
++
Yes
Schuffham et al., 2006 [47]. The cost effectiveness
of Fluvastatin in Hungary Following Successful PCI
Hungary
statins
Judged to be cost effective
Post PCI
patients
+/−
No-limited
generalisability
Gilbert et al., 2004 [34]. The cost effectiveness of
pharmacological smoking cessation therapies in
developing countries
Seychelles
Smoking cessation
Shown to be cost effective but affordability in
LMIC settings questioned given high cost
Smokers
+
Yes
Robberstad et al., 2007 [20]. Cost effectiveness of
medical interventions to prevent cardiovascular
disease in a Sub-Saharan African country
Tanzania
Pharmaco-prevention
including the polypill
Some interventions judged cost effective but
affordability in this setting questioned
Those over age
45
+
Yes
Redekop et al., 2008 [46]. Costs and effects of
secondary prevention with Perindopril in Stable
Coronary Heart Disease in Poland
Poland
ACE inhibitos for
secondary prevention
Authors report high probability for Perindopril
effectiveness in secondary prevention. Using
reported results against WHO criteria we find
not cost effective – not study conclusions
Those with
existing CHD
+/-
Yes
Thavorn et al., 2007 [36]. A cost effectiveness
analysis of a community pharmacist-based
smoking cessation programme in Thailand
Thailand
Nicotine replacement
therapy
Authors find intervention to be cost saving.
(cost/LYG)
Regular smokers +
Yes
Branded statin
Rosuvasctatin found to be more cost effective
than Atorvastatin
Those at high
risk of CVD
-
No-comparison of 2
drugs of same class
Pharmacological and non
personal population-based
interventions
Wide range of cost effectiveness between
interventions. Blood pressure lowering drugs
and mass media most cost effective
Variable
++
Yes
Araujo et al., 2007 [48]. Cost effectiveness and
Brazil
budget impact analysis of Rosuvastatin and
Atorvastatin for LDL cholesterol and cardiovascular
events lowering within the SUS scenario
Akkazieva et al., 2009 [15]. The health effects
and costs of the interventions to control
cardiovascular disease in Kyrgyzstan
Kyrgyzstan
Page 9 of 13
Authors, year and title
Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
Table 2 Summary of studies included
Murray et al., 2003 [23]. Effectiveness and costs
of interventions to lower systolic blood pressure
and cholesterol
6 world bank Pharmacological and non
regions
personal population-based
interventions
Non personal interventions found to be
most cost effective. Absolute risk based
approach also found to be cost effective
Various
++
Yes
Disease Control Priorities Project * [32,49]
Chapters 44: Prevention of Chronic Disease
by Means of Diet and Lifestyle Changes. 45:
Blood Pressure, Cholesterol and Bodyweight,
46: Tobacco Addiction.
6 world bank Pharmacological and non
regions
personal population-based
interventions.
Tobacco control interventions, salt reduction
and multidrug therapy on the basis of
absolute risk approach likely to be cost
effective in most settings.
Various
++
Yes
WHO + Chisholm *[5,12] Comparative cost
effectiveness of policy instruments for reducing
the global burden of alcohol, tobacco and illicit
drug use.
WHO regions Personal and non personal
interventions for tobacco
control
Most interventions cost effective, non personal
interventions such as taxation and legislation
far more so than personal interventions such
as NRT.
Smokers
++
Yes
Abbreviations: CHD: Coronary Heart Disease. CVD: Cardiovascular Disease. GNI: Gross National Income. GDP: Gross Domestic Product. DALY: Disability Adjusted Life Year. QALY: Quality Adjusted Life Year. YLG: Year of
Life Gained. NRT: Nicotine Replacement Therapy. LMIC: Low and Middle Income. ACE: Angiotensin-Converting Enzyme. LDL: Low Density Lipoprotein. PCI: Percutaneous Coronary intervention. * Material concerning
analysis presented in more than one journal article.
Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
Table 2 Summary of studies included (Continued)
Page 10 of 13
Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
to greater uncertainties. Whereas individual interventions
may be attractive, although based on HIC evidence, this is
not the case in the area of tobacco control. Personal interventions such as Nicotine Replacement Therapy (NRT)
appear to be far less cost effective than population-based
interventions in low-resource settings. There are few trials
of population-based interventions in low and middle income countries, leading to a lack of effectiveness information (Table 2).
Our findings are relevant for policy makers at the international level e.g. UN agencies with responsibilities in
health across societal sectors, national government agencies and ministries, local private, non-profit and for-profit
organizations in health care as well as professional medical
societies and other health professional bodies. Given the
uncertainties in the study findings, local relevance should
be assessed, given disease epidemiology and available resources, and, next, taken into account, while making decisions and formulating country policies and guidelines.
Several methodological observations can be made.
Most importantly, study methodologies across the identified articles are highly heterogeneous, in terms of analytic methods, input parameters and data used and the
baseline against which the intervention of interest was
evaluated. We utilise a null baseline to aid comparison,
real world costs of implementing a given intervention
may be higher if on going activities need to be wound
down. Choice of time horizon was of particular consequence and some interventions were found on sensitivity
analysis to move from cost ineffective as this parameter
was altered [46,47]. The adoption of standard parameters for discounting rates, time horizons and study perspectives would help address this as would widespread
adoption of a standard (counterfactual or null) baseline
as proposed by WHO [12]. The published articles and
background documentations do not allow for a detailed
analysis of how this diversity would affect our comparison of the study findings nor do they allow adaptations
of the calculations to facilitate a better comparison.
Next, most studies use known or predicted changes in
risk factors, associated with each intervention of interest,
within a stochastic or deterministic model, to estimate
the anticipated changes in disease occurrence that would
result. The Framingham equations, employed in most
studies, also limit the reliability of results as they under
predict risk in high risk populations while over
predicting risk in low risk populations [50-53] Resulting
cost effectiveness estimates may therefore be unduly
favourable in low risk populations and vice versa. Lastly,
most studies do not distinguish trial efficacy results
from real-life effectiveness of implemented interventions. Especially, in many rural and urban areas, provider
compliance, system compliance, and patient compliance,
may lower the impact of the intervention and may raise
Page 11 of 13
the health care costs and broader societal costs for patients or the existing systems (see Additional file 3: Appendix 3).
Finally, the limitations of the cost effectiveness categorisation we have used should be acknowledged. Specifically,
presently labelling an intervention as “cost effective” at
less than 3 x GNI/capita does not necessarily imply that
it should be adopted. Shifting resources from this to
another intervention, even a very cost effective one,
could lead to unacceptable transaction costs and be
unwise if there are other compelling societal reasons
to allocate resources in a different way.
Conclusions
In sum, there is evidence supportive of a wide range of
interventions to prevent cardiovascular disease in most
parts of the world; nevertheless further setting specific
research of preventive interventions in this field is needed
and should include economic evaluation. Lifestyle interventions appear to be of generally greater cost effectiveness,
while pharmacological interventions offer an impact of
greater certainty and magnitude. These modalities of
interventions can thus be seen as complementary, offsetting
potential gain against certainty of outcome. Policymakers
should aim to balance distribution of relevant resources
between these areas, favouring the most cost effective in
each class, while accounting for other criteria such as,
affordability, access, and equity. Healthcare infrastructures
concerned differ markedly [54], both among countries
and within countries.
The economic evidence on both pharmacological and
lifestyle interventions supports large-scale implementation strategies and efforts in all settings confronted with
the growing NCD epidemic.
Additional files
Additional file 1: Appendix 1. Definitions used in this review.
Additional file 2: Appendix 2. Income groupings – WHO World Health
Report 2008 (http://www.who.int/whosis/whostat/EN_WHS08_Full.pdf).
Additional file 3: Appendix 3. Findings from studies reporting costs
per treated individual. Per capita costs for selected interventions to
prevent cardiovascular disease in LMIC settings compared to per capita
expenditure on health for the year considered in that study.
Competing interests
The authors declare that they have no competing interest.
Authors’ contribution
OhF and AS developed the idea for the study; OhF, LN, AS participated in
the concept and design . RC, RA, SS, PB, TH; OhF and AS contributed to the
systematic review process; RC produced the summary analysis presented as
Figure 2. All authors contributed to the writing of this manuscript. All
authors read and approved the final manuscript.
Authors’ information
Rajiv Chowdhury and Raghupathy Anchala joint second author.
Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
Acknowledgements
We would like to thank Isla Kuhn, librarian at Cambridge Medical School
library for assistance in searching for and retrieving studies.
We would also like to thank Xiaohui Zhao, Statistician, Department of Public
Health & Primary Care, Cambridge University for assistance with Chinese
translation.
Author details
1
Department of Public Health & Primary Care, Cardiovascular Epidemiology
Unit, University of Cambridge, Strangeways Research Laboratory, Wort’s
Causeway, Cambridge CB1 8RN, UK. 2East of England Public Health and
Social Care Directorate, Eastbrook, Shaftsbury Road, Cambridge CB2 8DF, UK.
3
Centre for Control of Chronic Diseases Bangladesh, icddrb, Dhaka,
Bangladesh. 4Johns Hopkins School of Public Health, Baltimore, USA.
5
University of East-Anglia, Norwich, UK. 6Cardiovascular Epidemiology Group,
Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.
Received: 9 October 2012 Accepted: 8 February 2013
Published: 28 March 2013
References
1. Ezzati M, Lopez AD, Rodgers A, Hoorn SV, Murray CJL, Comparative Risk
Assessment Collaborating Group: Selected major risk factors and global
and regional burden of disease. Lancet 2002, 360(9343):1347–1360.
2. Wald NJ, Law MR: A strategy to reduce cardiovascular disease by more
than 80%. BMJ 2003, 326(7404):1419.
3. Ezzati M, Hoorn SV, Rodgers A, Lopez AD, Mathers CD, Comparative Risk
Assessment Collaborating Group: Estimates of global and regional
potential health gains from reducing multiple major risk factors. Lancet
2003, 362(9380):271–280.
4. Cappuccio FP, Kerry SM, Micah FB, Rhule JP, Eastwood JB: A community
programme to reduce salt intake and blood pressure in Ghana
[ISRCTN88789643]. BMC Public Health 2006, 6:13.
5. Chisholm D, Doran C, Shibuya K, Rehm J: Comparative cost-effectiveness
of policy instruments for reducing the global burden of alcohol, tobacco
and illicit drug use. Drug Alcohol Rev 2006, 25(6):553–565.
6. Cook NR, Cutler JA, Obarzanek E, Buring JE, Rexrode KM, Kumanyika SK,
Appel LJ, Whelton PK: Long term effects of dietary sodium reduction on
cardiovascular disease outcomes: observational follow-up of the trials of
hypertension prevention (TOHP). BMJ 2007, 334(7599):885–888.
7. Mendis S, Fukino K, Cameron A, Laing R, Filipe A, Khatib O, Leowski J, Ewen
M: The availability and affordability of selected essential medicines for
chronic diseases in six low- and middle-income countries. Bull World
Health Organ 2007, 85(4):279–288.
8. Harsha DW, Lin PH, Obarzanek E, Karanja NM, Caballero B: Dietary
approaches to stop hypertension: a summary of study results. DASH
Collaborative Research Group. J Am Diet Assoc 1999, 99(8 Suppl):S35–S39.
9. Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K: The burden and
costs of chronic diseases in low-income and middle-income countries.
Lancet 2007, 370(9603):1929–1938.
10. Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ: Methods for the
Economic Evaluation of Health Care Programmes. 3rd edition. Oxford: Oxford
University Press; 2005.
11. National Institute for Health and Clinical Excellence: Methods for
development of NICE public health guidance.; March 2006.
12. World Health Organisation: Choosing Interventions that are Cost Effective
(WHO-CHOICE). [Internet] Available from: http://www.who.int/choice/
interventions/rf_tobacco/en/index.html. [Last accessed January 2011]
13. Moher D, Altman DG, Liberati A, Tetzlaff J: PRISMA statement. Epidemiology
2011, 22(1):128. author reply 128.
14. Nissinen A, Berrios X, Puska P: Community-based non-communicable
disease interventions: lessons from developed countries for developing
ones. Bull World Health Organ 2001, 79(10):963–970.
15. Akkazieva B, Chisholm D, Akunov N, Jacab M: The health effects and costs of
the interventions to control cardiovascular disease in Kyrgyzstan 2009;
[Internet] Available from: http://hpac.kg/images/pdf/prp60cvd_eng.pdf. [Last
accessed Dec 2010]
16. Antithrombotic Trialists’ Collaboration: Collaborative meta-analysis of
randomised trials of antiplatelet therapy for prevention of death,
myocardial infarction, and stroke in high risk patients. BMJ 2002,
324(7329):71–86.
Page 12 of 13
17. Rubinstein A, García Martí S, Souto A, Daniel F, Augustovski F: Generalized
cost-effectiveness analysis of a package of interventions to reduce
cardiovascular disease in Buenos Aires, Argentina. Cost effectiveness and
resource allocation: C/E. 2009, 7:10.
18. Gaziano TA, Opie LH, Weinstein MC: Cardiovascular disease prevention
with a multidrug regimen in the developing world: a cost-effectiveness
analysis. Lancet 2006, 368(9536):679–686.
19. Collins R, Peto R, MacMahon S, Hebert P, Fiebach NH, Eberlein KA, Qizilbash N,
Taylor JO, Hennekens CH: Blood pressure, stroke, and coronary heart disease.
Part 2, Short-term reductions in blood pressure: overview of randomised
drug trials in their epidemiological context. Lancet 1990, 335(8693):827–838.
20. Robberstad B, Hemed Y, Norheim OF: Cost-effectiveness of medical
interventions to prevent cardiovascular disease in a sub-Saharan African
country-the case of Tanzania. Cost effectiveness and resource allocation:
C/E. 2007, 5:3.
21. Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study
of cholesterol-lowering with simvastatin in 5963 people with diabetes: a
randomised placebo-controlled trial. Lancet 2003, 361(9374):2005–2016.
22. Blood Pressure Lowering Treatment Trialists’ Collaboration: Effects of ACE
inhibitors, calcium antagonists, and other blood-pressure-lowering
drugs: results of prospectively designed overviews of randomised trials.
Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet 2000,
356(9246):1955–1964.
23. Murray CJL, Lauer JA, Hutubessy, Niessen L, Tomijima N, Lawes CM, Evans
DB: Effectiveness and costs of interventions to lower systolic blood
pressure and cholesterol: a global and regional analysis on reduction of
cardiovascular-disease risk. Lancet 2003, 361(9359):717–725.
24. Ha DA, Chisholm D: Cost-effectiveness analysis of interventions to prevent
cardiovascular disease in Vietnam. Health Policy Plan 2010, 26:210–222.
25. Caro J, Klittich W, McGuire A, Ford I, Pettit J, Norrie J, Shepherd J:
International economic analysis of primary prevention of cardiovascular
disease with Pravastatin in WOSCOPS. West of Scotland Coronary
Prevention Study. Eur Heart J 1999, 20(4):263–268.
26. Shepherd J, Cobbe SM, Ford I, Isles CG, Lorimer AR, MacFarlane PW, Packard
CJ: Prevention of coronary heart disease with Pravastatin in men with
hypercholesterolemia. West of Scotland Coronary Prevention Study
Group. N Engl J Med 1995, 333(20):1301–1307.
27. Law MR, Wald NJ, Rudnicka AR: Quantifying effect of statins on low
density lipoprotein cholesterol, ischaemic heart disease, and stroke:
systematic review and meta-analysis. BMJ 2003, 326(7404):1423.
28. Law MR, Wald NJ, Morris JK, Jordan RE: Value of low dose combination
treatment with blood pressure lowering drugs: analysis of 354
randomised trials. BMJ 2003, 326(7404):1427.
29. MRC trial of treatment of mild hypertension: principal results. Medical
Research Council Working Party. Br Med J (Clin Res Ed) 1985, 291(6488):97–104.
30. Gaziano TA, Steyn K, Cohen DJ, Weinstein M, Opie L: Cost-effectiveness
analysis of hypertension guidelines in South Africa: absolute risk versus
blood pressure level. Circulation 2005, 112(23):3569–3576.
31. Friend K, Levy DT: Reductions in smoking prevalence and cigarette
consumption associated with mass-media campaigns. Health Educ Res
2002, 17(1):85–98.
32. Jamison DT: Disease control priorities in developing countries [electronic resource].
Washington: IBRD/The World Bank and Oxford University Press; 2006.
33. Jha P, Chaloupka FJ (Eds): Tobacco control in developing countries. Oxford,
UK: Oxford Univ Pr; 2000:237–272.
34. Gilbert AR, Pinget C, Bovet P, Cornuz J, Shamlaye C, Paccaud F: The cost
effectiveness of pharmacological smoking cessation therapies in developing
countries: a case study in the Seychelles. Tob Control 2004, 13(2):190–195.
35. Stead LF, Perera R, Bullen C, Mant D, Lancaster T: Nicotine replacement therapy
for smoking cessation. Cochrane Database Syst Rev 2004, (3):CD000146.
36. Thavorn K, Chaiyakunapruk N: A cost-effectiveness analysis of a
community pharmacist-based smoking cessation programme in
Thailand. Tob Control 2008, 17(3):177–182.
37. Maguire TA, McElnay JC, Drummond A: A randomized controlled trial of a
smoking cessation intervention based in community pharmacies.
Addiction 2001, 96(2):325–331.
38. Hughes JR, Stead LF, Lancaster T: Antidepressants for smoking cessation.
Cochrane Database Syst Rev 2007, (1):CD000031.
39. Tosteson AN, Weinstein MC, Hunink MG, Mittleman MA, Goldman PA,
Goldman L: Cost-effectiveness of population wide educational approaches
to reduce serum cholesterol levels. Circulation 1997, 95(1):24–30.
Shroufi et al. BMC Public Health 2013, 13:285
http://www.biomedcentral.com/1471-2458/13/285
Page 13 of 13
40. He FJ, MacGregor GA: Effect of longer-term modest salt reduction on
blood pressure. Cochrane Database Syst Rev 2004, (3):CD004937.
41. Law MR, Frost CD, Wald NJ: By how much does dietary salt reduction
lower blood pressure? III–Analysis of data from trials of salt reduction.
BMJ 1991, 302(6780):819–824.
42. Sellers DE, Crawford SL, Bullock K, McKinlay JB: Understanding the
variability in the effectiveness of community heart health programs: a
meta-analysis. Soc Sci Med 1997, 44(9):1325–1339.
43. He FJ, MacGregor GA: How far should salt intake be reduced?
Hypertension 2003, 42(6):1093–1099.
44. Frost CD, Law MR, Wald NJ: By how much does dietary salt reduction
lower blood pressure? II–Analysis of observational data within
populations. BMJ 1991, 302(6780):815–818.
45. Huang G, Gu D, Wu X, Duan X, Xu X, Wu J, Xie B: Cost-effectiveness
analysis of Beijing Fangshan cardiovascular prevention program in
1992–1997. Zhonghua Yu Fang Yi Xue Za Zhi 2000, 34(2):78–80.
46. Redekop WK, Orlewska E, Maciejewski P, Rutten FFH, Niessen L: Costs and
effects of secondary prevention with perindopril in stable coronary heart
disease in Poland: an analysis of the EUROPA study including 1251
Polish patients. Pharmacoeconomics 2008, 26(10):861–877.
47. Scuffham PA, Kósa J: The cost-effectiveness of fluvastatin in Hungary
following successful percutaneous coronary intervention. Cardiovasc
Drugs Ther 2006, 20(4):309–317.
48. Araujo D, Bahia L, Souza C: Cost-effectiveness and budget impact analysis of
rosuvastatin and atorvastatin for LDL-cholesterol and cardiovascular events
lowering within the SUS scenario. Int J Atheroscler 2007, 2(3):189–194.
49. Gaziano TA, Galea G, Reddy KS: Scaling up interventions for chronic
disease prevention: the evidence. Lancet 2007, 370(9603):1939–1946.
50. Michos ED, Nasir K, Braunstein JB, Rumberger JA, Budoff MJ, Post WS, Blumenthal
RS: Framingham risk equation underestimates subclinical atherosclerosis risk
in asymptomatic women. Atherosclerosis 2006, 184(1):201–206.
51. Karim R, Hodis HN, Detrano R, Liu CR, Mack WJ: Relation of Framingham
risk score to subclinical atherosclerosis evaluated across three arterial
sites. Am J Cardiol 2008, 102(7):825–830.
52. Shah PK: Screening asymptomatic subjects for subclinical atherosclerosis:
can we, does it matter, and should we? J Am Coll Cardiol 2010, 56(2):98–105.
53. Schlendorf KH, Nasir K, Blumenthal RS: Limitations of the Framingham risk
score are now much clearer. Prev Med 2009, 48(2):115–116.
54. Bovet P, Gervasoni JP, Mkamba M, Balampama M, Lengeler C, Paccaud F: Low
utilization of health care services following screening for hypertension in
Dar es Salaam (Tanzania): a prospective population-based study. BMC Public
Health 2008, 8:407.
doi:10.1186/1471-2458-13-285
Cite this article as: Shroufi et al.: Cost effective interventions for the
prevention of cardiovascular disease in low and middle income
countries: a systematic review. BMC Public Health 2013 13:285.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit