Provider costs for prevention and treatment of cardiovascular and related conditions in low- and middle-income countries: a systematic review

We conducted our review according to the PRISMA guidelines [14]. We searched the following databases: Medline, EMBASE, NHS-EED, HEED and EconLit. We adapted the search terms specifically to each database, using 1) terms related to cardiovascular diseases and risk conditions plus 2) terms for LMICs and regions plus 3) terms denoting economic evaluation. Additional file 1 details the full strategy. We limited our results to articles published on or after January 1^st, 2000 until approximately July 1^st, 2014. We screened eligible titles and abstracts to determine which articles would be included for final review. Two independent reviewers reviewed the full text articles. In addition, we examined the references of the included articles and prior reviews for potentially relevant studies. Broadly, the following criteria were used to determine inclusion:

We used both the Drummond Checklist and Mogyorosy and Smith’s 2012 literature review for guidance in creating the following guidelines regarding quality and inclusion [15, 16]:

To inform the organization and synthesis of the literature across conditions and interventions, we created a conceptual framework of the clinical and public health considerations in CVD treatment (Fig. 1). There are several points at which one can intervene on cardiovascular risk factors, risk conditions, and CVDs themselves, both within and outside of the health system. This review examines only the costs that exist within the health sector, and health facilities specifically, but across the spectrum of cardiovascular risk conditions and diseases themselves.

For each eligible study we entered the following information into an electronic database: condition(s), country or region, target population, type of treatment or intervention, and level of care. We also noted study methods, such as sample size and strategy, exchange rate, discount rate, sensitivity analysis, and cost categories. The total treatment or intervention costs, defined as the total cost per patient, were extracted in their original currency and year. For acute events, we used the total cost per patient as presented. For recurring costs, such as hemodialysis treatments or ongoing hypertension management, we calculated the cost per treatment or per year. Differences in inpatient and outpatient costs were noted where reported and applicable. Of note, most of the included studies reported multiple costs, particularly if they discussed more than one CVRD intervention or more than one geographic setting.

We converted all costs to US Dollars (2012), the currency and year in which we present all costs in this paper. When possible, we extracted the data in local currency units (LCUs), inflated it to 2012 rates using the World Bank consumer price indices, and converted it to 2012 US Dollars via World Bank rates. When costs were presented for regions, we used the largest LMIC country in the region as a proxy. For data presented in international dollars, we converted it back into LCUs using World Bank Purchasing Power Parity, then we followed our standard processes. Once the data were in a common currency, we grouped similar interventions and qualitatively compared the magnitudes and variability of total and input costs. We combined data into the two overarching groups to reflect our aforementioned framework: management of CVD risk conditions and treatment of acute and chronic CVDs. The former group included hypertension, hyperlipidemia, CKD, T2DM, and generic CVD prevention. The latter group focused specifically on ischemic heart disease, non-ischemic heart diseases, stroke, heart failure, T2DM sequelae (specifically, microvascular complications such as foot ulcers and retinopathy), and end-stage renal disease (ESRD), which is due predominately to poorly controlled hypertension and T2DM.

Our review identified 60 cost estimates from 31 articles for clinical management of CVD risk conditions such as hypertension, hyperlipidemia, chronic kidney disease and T2DM). There were also brief mentions of pharmacological tobacco cessation measures, rheumatic fever and generic CVD prevention strategies such as polypill use. More than three-quarters of this data came from Asian countries, and more than half from China, India or Thailand.

We found 14 unit costs for hypertension management in LMICs, with drug therapy ranging from $2.21–$76.29. Using general practitioners in community programs cost only $0.81–$8.67 per patient per year, compared to annual outpatient costs to manage hypertension, which ranged from $38.00 to $565.54 per patient. Only three studies mentioned the costs of managing dyslipidemia, which were similar to managing hypertension. One study looked at the costs of managing chronic kidney disease across China, Malaysia and Thailand, with China being more expensive than Malaysia by a scale of six to eight. We identified 30 unit costs for managing diabetes. Two studies produced four costs on diagnosing diabetes, the most expensive of which were based in tertiary hospitals. Seven studies presented ten annual per patient costs of managing diabetes in a clinical setting, which ranged from $56.25 in India to $2,479.82 in China; the costs were higher in cases with complications and sequelae. Nine studies also presented 16 costs on inpatient and outpatient treatment for diabetes. Inpatient stays per bed-day ranged from $59.92–$143.14 with an average length of stay of around 7 days. An outpatient visit ranged from $4.63–$34.28, and we also found a ten-fold variation in yearly outpatient costs.

Our review also identified 83 cost estimates from 34 studies regarding the treatment of ischemic heart disease (IHD), stroke, heart failure, non-ischemic heart diseases, T2DM sequelae, and end-stage renal disease (ESRD).

Treatment of IHD typically consists of diagnostic procedures, surgical or other advanced medical procedures, and post-operative and long-term outpatient care. We found 8 articles analyzing IHD treatment with a total of 18 unit costs. An inpatient visit averaged $8,800, with a range from $455 to $22,500. The highest inpatient costs were associated with longer hospitalization periods, more severe conditions, and surgical interventions. The costs of surgical procedures, including catheter-based procedures (stenting and angioplasty) or coronary artery bypass surgery (CABG), ranged from $4,000–$22,000 per patient per procedure depending on the diagnostics, the complexity of the procedure, and whether medical therapy and recovery costs were included in the total cost estimates.

Our search returned 15 articles and 24 unit costs for both ischemic stroke (IS) and hemorrhagic stroke (HS), though many studies did not specify the type of stroke. In most settings, IS is the more common of the two, is generally easier to treat, and has a lower case-fatality rate. Four articles compared the costs HS and IS treatment [17‐20]. Hemorrhagic strokes were generally more severe, required longer hospital stays, and involved surgical or intensive care unit costs; HS treatment costs were between 0 % and 50 % higher than IS treatment. The majority of articles provided the inpatient cost per stroke event, but did not distinguish the type of strokes. The average inpatient cost of a stroke was $3,240, but this varied widely by geographic setting, technical resources used, and average length of stay.

Five studies reported costs of T2DM sequelae, namely, diabetic foot ulcers and retinopathy. Severity of these impairments and costs saved by screening drove the total costs of both, though in opposite directions [21‐25]. For instance, screening for retinopathy was generally below $30, while diabetic foot ulcers ranged from less than $1 to over $7,000 in the cases of infection and amputation.

Five studies reported costs of end-stage renal disease (ESRD), primarily long-term dialysis or renal transplantation. The cost of one session of hemodialysis for ESRD ranged $79 to $97 [26‐28], while one study estimated average annual dialysis costs at $61,000 in Southeast Asia [29]. Kidney transplantation and post-operative care ran from $5,000 to $21,000 in the Sudan and Iran, respectively [28, 30].

Other types of CVD, such as heart failure, Chagas cardiomyopathy (CC), congenital heart disease, and rheumatic heart disease, are important contributors to the burden of NCDs in LMICs. However, we identified only a handful of studies on the cost of treating these conditions (Table 2).