Health Benefits and Cost-Effectiveness of Asymptomatic Screening for Hypertension and High Cholesterol and Aspirin Counseling for Primary Prevention

Predictors of Blood Pressure, Cholesterol, and Cardiovascular Screening Among Saudis at Primary Healthcare Settings in Riyadh, Saudi Arabia

Purpose

This study was conducted to estimate proportion of individuals undergoing screening for cardiovascular disease (CVD) and its risk factors and to identify predictors of CVD, blood pressure, and blood cholesterol screening.

Patients and Methods

This cross-sectional study was conducted in 48 primary healthcare centers in Saudi Arabia and 14,239 participants were enrolled. The analysis was performed in SPSS version 26 and adjusted odds ratios (AOR) and 95% Cis were reported.

Results

Blood pressure screening was reported by 35.3%, cholesterol screening by 9.3%, and cardiovascular screening by 3.7%. Significant positive predictors for blood pressure screening included older age (50-75 years: AOR 1.34, 95% CI: 1.20-1.50; ≥75 years: AOR 2.12, 95% CI: 1.84-2.43), being married (AOR: 1.15; 95% CI: 1.04-1.27), non-smoking (AOR: 1.97; 95% CI: 1.79-2.17), physical activity (AOR: 1.16; 95% CI: 1.05-1.28), and diabetes (AOR: 2.14; 95% CI: 1.88-2.44). For cholesterol screening, significant positive predictors were older age (≥75 years: AOR 1.89, 95% CI: 1.56-2.29), unemployment (AOR: 1.26; 95% CI: 1.10-1.45), insurance coverage (AOR: 1.52; 95% CI: 1.33-1.74), smoking (AOR: 1.32; 95% CI: 1.14-1.53), diabetes history (AOR: 1.33; 95% CI: 1.09-1.61), and hypertension (AOR: 1.66; 95% CI: 1.36-2.02). For cardiovascular screening, significant positive predictors included older age (≥75 years: AOR 1.81, 95% CI: 1.35-2.43), unemployment (AOR: 1.53; 95% CI: 1.24-1.88), insurance coverage (AOR: 1.56; 95% CI: 1.27-1.92), smoking (AOR: 1.89; 95% CI: 1.52-2.34), diabetes (AOR: 1.85; 95% CI: 1.41-2.43), and high cholesterol (AOR: 1.76; 95% CI: 1.31-2.36).

Conclusion

A very low proportion of Saudi residents have undergone blood pressure, cholesterol, and CVD screening. Common predictors of screening included older age, insurance coverage, diabetes, hypertension, physical activity, and high cholesterol levels. Low prevalence of screening is alarming, and Saudi Government needs to implement strategies that can help increase proportion of Saudi residents who receive blood pressure, cholesterol, and CVD screening.

Cost-Effectiveness of Ferritin Screening Thresholds for Iron Deficiency in Reproductive-Age Women

Iron deficiency (ID) is a top five leading cause of disability-adjusted life-years in women of reproductive age around the world. Despite its enormous health burden, no screening guidelines exist for the detection and treatment of ID in women of reproductive age. We sought to determine the cost-effectiveness of screening versus no screening for ID in women of reproductive age in the United States. A lifetime simulation of women of reproductive age was conducted using a Markov cohort model under three strategies: (1) no screening, (2) screening at a ferritin threshold of 15 μg/L, and (3) screening at a ferritin threshold of 25 μg/L, from the US health system perspective, and at a willingness-to-pay threshold of $100 000/quality-adjusted life year (QALY). Epidemiologically informed ID prevalence estimates sourced from the National Health and Nutrition Examination Survey were employed for model parameterization. The primary outcome was the incremental cost-effectiveness ratio (ICER, in $/QALY). Base-case results for the three strategies accrued $209 700, $210 200, and $210 200 discounted lifetime costs and 23.6, 24.0, and 24.4 discounted lifetime QALYs, respectively. Screening at a ferritin threshold of 25 μg/L was the cost-effective intervention with an ICER of $680/QALY (95% credible interval $350-$750/QALY). In dual base-case analyses examining intravenous rather than oral iron repletion for treatment, screening at a ferritin threshold of 25 μg/L remained the cost-effective intervention with an ICER of $2300/QALY (95% CI $1800-$3800/QALY). In probabilistic sensitivity analyses, screening at a ferritin threshold of 25 μg/L was the cost-effective intervention in 100% of 10 000 second order Monte Carlo iterations.

Who bears the distance cost of public primary healthcare? Hypertension among the elderly in rural India

Hypertension is one of the most prevalent NCDs in the world. Its prevalence is especially high among the elderly, a demographic group on the rise in low and middle income countries. Extant medical literature calls for early detection to prevent aggravation of problems when old. In this paper, we investigate whether diagnosis of hypertension among adults aged 45 and above, is correlated with geographic access to primary public healthcare services, after accounting for a rich set of potentially confounding covariates. Our study focuses on rural India where access to public primary health services is especially poor but hypertension rates are high. Using the first wave of the Longitudinal Ageing Survey of India (LASI) 2017-19, we find that hypertensive adults belonging to poor households, face a distance cost of public primary health facilities and are 8 percent less likely to be aware of their hypertension when Primary Health Centres are 10 km away. Since almost 10 percent of villages in India are at least 10 km away from PHCs, this exclusionary effect is significant. Our analysis suggests that even though public primary facilities are poorly staffed and managed in India, and private care is popular, geographical expansion of public primary facilities can still play an active role in NCDs and public primary health financing should take heed of the need for such expansion.

Metabolic syndrome burden, determinants and treatment status in an urban slum resettlement colony in Delhi, India

BACKGROUND

Metabolic syndrome (MetS) in low-resource settings contributes to accentuated risk of cardiovascular disease, including stroke. The study objective was to estimate the prevalence, determinants and treatment status of MetS in an urban slum resettlement population in Delhi, India.

METHODS

This study was conducted from February to May 2023. Multiphase sampling was conducted with 1910 individuals screened for abdominal obesity (AO), with 996 detected as having AO, of which, 400 were selected by simple random sampling and further evaluated for triglycerides (TGs), high-density lipoprotein (HDL) and fasting glucose levels.

RESULTS

Among the 400 participants detected as having AO, 211 had evidence of MetS (52.75% [95% confidence interval 47.83 to 57.62]). The most prevalent combination of MetS clustering was for all five components (AO, diabetes mellitus [DM], hypertension [HTN], low HDL and high TGs; 14.69%), followed by AO, DM and HTN (12.32%). On adjusted analysis, the odds of having MetS was found to be independently associated with increasing age (≥40 y) but not sex.

CONCLUSIONS

A high burden of MetS and suboptimal treatment status is prevalent in urban slum populations. Screening of individuals with AO, especially in those >40 y of age, can be an effective programmatic strategy for early diagnosis and management of MetS and its underlying components.

Pediatric Blood Pressure and Cardiovascular Health in Adulthood

PURPOSE OF REVIEW

This review summarizes current knowledge on blood pressure in children and adolescents (youth), with a focus on primary hypertension-the most common form of elevated blood pressure in this demographic. We examine its etiology, progression, and long-term cardiovascular implications. The review covers definitions and recommendations of blood pressure classifications, recent developments in measurement, epidemiological trends, findings from observational and clinical studies, and prevention and treatment, while identifying gaps in understanding and suggesting future research directions.

RECENT FINDINGS

Youth hypertension is an escalating global issue, with regional and national variations in prevalence. While the principles of blood pressure measurement have remained largely consistent, challenges in this age group include a scarcity of automated devices that have passed independent validation for accuracy and a generally limited tolerance for ambulatory blood pressure monitoring. A multifaceted interplay of factors contributes to youth hypertension, impacting long-term cardiovascular health. Recent studies, including meta-analysis and sophisticated life-course modelling, reveal an adverse link between youth and life-course blood pressure and subclinical cardiovascular outcomes later in life. New evidence now provides the strongest evidence yet linking youth blood pressure with clinical cardiovascular events in adulthood. Some clinical trials have expanded our understanding of the safety and efficacy of antihypertensive medications in youth, but this remains an area that requires additional attention, particularly regarding varied screening approaches. This review outlines the potential role of preventing and managing blood pressure in youth to reduce future cardiovascular risk. A global perspective is necessary in formulating blood pressure definitions and strategies, considering the specific needs and circumstances in low- and middle-income countries compared to high-income countries.

Should Commercial Diagnostic Testing Be Stimulated or Discouraged? Analyzing Willingness-to-Pay and Market Externalities of Three Commercial Diagnostic Tests in The Netherlands

INTRODUCTION

Consumers may purchase commercial diagnostic tests (CDT) without prior doctor consultation. This paper analyzes three CDT markets-commercial cholesterol tests (CCT), direct-to-consumer genetic health tests (DGT) and total body scans (TBS)-in the context of the universal, collectively financed health care system of the Netherlands.

METHODS

An online willingness-to-pay (WTP) questionnaire was sent to a representative sample of 1500 Dutch consumers. Using contingent valuation (CV) methodology, an array of bids for three self-tests were presented to the respondents. The results were extrapolated to the Dutch population and compared to current prices and follow-up medical utilization, allowing analysis from a societal perspective.

RESULTS

Overall, 880 of 1500 respondents completed the questionnaire (response rate 59%). Of the respondents, 26-44% were willing to pay a positive amount for the CDT. Willingness-to-pay was correlated to age and household income, but not to health status or prior experience with these tests. At mean current prices of €29 for CCT, €229 for DGT and €1,650 for TBS, 3.3%, 2.5%, and 1.1%, were willing to purchase a CCT, DGT, and TBS, respectively. All three CDT resulted in net costs to the health system, estimated at €5, €16, and €44 per test, respectively. Reducing volumes by 90,000 CCTs (19%), 19,000 DGTs (5%) and 4,000 TBSs (2.5%) in 2019 would optimize welfare.

CONCLUSION

Most respondents were unwilling to consume CDT at any price or only if the CDT were provided for free. However, for a small group of consumers, societal costs exceed private benefits. Therefore, CDT regulation could provide small welfare gains.

The apparent need for better communication between clinicians and patients regarding elevated blood pressure among United States emerging adults

Objectives: To examine the discrepancy between 'told' and screened blood pressure (BP) category, and the association between body composition and told BP category. Methods: Between 08/2019-03/2020 college students (n = 1057) were asked what category they had previously been told their BP falls into prior to having their BP and body composition (waist circumference, body mass index (BMI), and body fat percentage) objectively assessed. Results: A disproportionate number (>80%) who were told that they had normal BP were categorized as having elevated BP. Men told they had borderline/high BP had less favorable body compositions than those told they had low/normal BP. Less favorable body composition was associated with increased likelihood of men being told that they had borderline/high BP. Conclusions: Better BP screening policies and procedures would ensure healthcare providers discuss elevated BP with emerging adults regardless of body composition and avoid missing opportunities to delivery of early and cost-effective interventions.

Examining disparities in cardiovascular disease prevention strategies and incidence rates between urban and rural populations: insights from Kazakhstan

Kazakhstan is experiencing a high burden of cardiovascular disease (CVD), and the country has implemented a range of strategies aimed at controlling CVD. The study aims to conduct a content analysis of the policies implemented in the country and augment it with an analysis of official statistics over a 15-year period, from 2006 to 2020. The study also includes comparisons of incidence rates between urban and rural areas. A comprehensive search was conducted to identify policy documents that regulate the provision of primary, secondary, and tertiary prevention of cardiovascular diseases. Additionally, official data on the incidence of arterial hypertension, ischemic heart disease, acute myocardial infarction, and cerebrovascular disease were extracted from official statistics, disaggregated by urban and rural areas. Forecast modeling was utilized to project disease incidences up to 2030. The study reveals that Kazakhstan primarily focuses on tertiary prevention of cardiovascular diseases, with less attention given to secondary prevention, and primary prevention is virtually non-existent. In general, screening for arterial hypertension appears to be more successful than for ischemic heart disease. The incidence of arterial hypertension has increased threefold for urban residents and 1.7-fold for rural residents. In urban areas, residents saw a twofold increase in ischemic heart disease incidence, while it remained the same in rural areas. The findings of this study have practical implications for decision-makers, who can use the results to enhance the effectiveness of existing CVD prevention strategies.

Health Economic Research Assessing the Value of Early Detection of Cardiovascular Disease: A Systematic Review

INTRODUCTION

Cardiovascular disease (CVD) is the most prominent cause of death worldwide and has a major impact on healthcare budgets. While early detection strategies may reduce the overall CVD burden through earlier treatment, it is unclear which strategies are (most) efficient.

AIM

This systematic review reports on the cost effectiveness of recent early detection strategies for CVD in adult populations at risk.

METHODS

PubMed and Scopus were searched to identify scientific articles published between January 2016 and May 2022. The first reviewer screened all articles, a second reviewer independently assessed a random 10% sample of the articles for validation. Discrepancies were solved through discussion, involving a third reviewer if necessary. All costs were converted to 2021 euros. Reporting quality of all studies was assessed using the CHEERS 2022 checklist.

RESULTS

In total, 49 out of 5552 articles were included for data extraction and assessment of reporting quality, reporting on 48 unique early detection strategies. Early detection of atrial fibrillation in asymptomatic patients was most frequently studied (n = 15) followed by abdominal aortic aneurysm (n = 8), hypertension (n = 7) and predicted 10-year CVD risk (n = 5). Overall, 43 strategies (87.8%) were reported as cost effective and 11 (22.5%) CVD-related strategies reported cost reductions. Reporting quality ranged between 25 and 86%.

CONCLUSIONS

Current evidence suggests that early CVD detection strategies are predominantly cost effective and may reduce CVD-related costs compared with no early detection. However, the lack of standardisation complicates the comparison of cost-effectiveness outcomes between studies. Real-world cost effectiveness of early CVD detection strategies will depend on the target country and local context.

REGISTRATION OF SYSTEMATIC REVIEW

CRD42022321585 in International Prospective Registry of Ongoing Systematic Reviews (PROSPERO) submitted at 10 May 2022.

Personalized Disease Prevention (PDP): study protocol for a cluster-randomized clinical trial

BACKGROUND

The US Preventive Services Task Force recommends 25 primary preventive services for middle-aged adults, but it can be difficult to do them all.

METHODS

The Personalized Disease Prevention (PDP) cluster-randomized clinical trial will evaluate whether patients and their providers benefit from an evidence-based decision tool to prioritize preventive services based on their potential to improve quality-adjusted life expectancy. The decision tool will be individualized for patient risk factors and available in the electronic health record. This Phase III trial seeks to enroll 60 primary care providers (clusters) and 600 patients aged 40-75 years. Half of providers will be assigned to an intervention to utilize the decision tool with approximately 10 patients each, and half will be assigned to usual care. Mixed-methods follow-up will include collection of preventive care utilization from electronic health records, patient and physician surveys, and qualitative interviews. We hypothesize that quality-adjusted life expectancy will increase by more in patients who receive the intervention, as compared with controls.

DISCUSSION

PDP will test a novel, holistic approach to help patients and providers prioritize the delivery of preventive services, based on patient risk factors in the electronic health record.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05463887. Registered on July 19, 2022.

The Cost-Effectiveness of a Telemedicine Screening Program for Diabetic Retinopathy in New York City

Background

A telemedicine screening initiative was implemented by the Montefiore Health System to improve access to eyecare for a multi-ethnic, at-risk population of diabetic patients in a largely underserved urban community in the Bronx, New York. This retrospective, cross-sectional analysis evaluates the societal benefit and financial sustainability of this program by analyzing both cost and revenue generation based on current standard Medicare reimbursement rates.

Methods

Non-mydriatic fundus cameras were placed in collaboration with a vendor in eight outpatient primary care sites throughout the Montefiore Health Care System, and data was collected between June 2014 and July 2016. Fundus photos were electronically transmitted to a central reading center to be systematically reviewed and coded by faculty ophthalmologists, and patients were subsequently scheduled for ophthalmic evaluation based upon a predetermined treatment algorithm. A retrospective chart review of 2251 patients was performed utilizing our electronic medical record system (Epic Systems, Verona WI). Revenue was projected utilizing standard Medicare rates for our region while societal benefit was calculated using quality adjusted life years (QALY).

Results

Of the 2251 patient charts reviewed, 791 patients (35.1%) were seen by Montefiore ophthalmologists within a year of the original screening date. Estimated revenue generated by these visits was $276,800, with the majority from the treatment of retinal disease ($208,535), and the remainder from other ophthalmic conditions detected in the fundus photos ($68,265). There was a societal benefit of 14.66 quality adjusted life years (QALYs) with an estimated value of $35,471/QALY.

Conclusion

This telemedicine initiative was successful in identifying many patients with diabetic retinopathy and other ophthalmic conditions who may otherwise not have been formally evaluated. Our analysis demonstrates the program to generate a downstream revenue of nearly $280K with a cost benefit below <50% of the threshold of $100,000/QALY, and therefore cost-effective in marginalized communities.

Characteristics of participants who take up screening tests for diabetes and lipid disorders: a systematic review

OBJECTIVES

To perform a systematic review on the characteristics of participants who attended screening programmes with blood glucose tests, lipid profiles or a combination of them, respectively.

DESIGN

Systematic review following the Meta-analysis Of Observational Studies in Epidemiology checklist.

DATA SOURCES

PubMed and Medline databases for English literature from 1 January 2000 to 1 April 2020.

ELIGIBILITY CRITERIA

Original observational studies that reported baseline characteristics of apparently healthy adult participants screening for diabetes and lipid disorders were included in this review.

DATA EXTRACTION

We examined their sociodemographic characteristics, including age, gender, body mass index (BMI) and lifestyle habits. The quality of the included articles was evaluated by the Appraisal of Cross-sectional Studies.

RESULTS

A total of 33 articles involving 38 studies in 22 countries were included and analysed in this systematic review. Overall, there was a higher participation rate among subjects who were female in all screening modalities (female vs male: 46.6%-63.9% vs 36.1%-53.4% for diabetes screening; 48.8%-58.4% vs 41.6%-51.2% for lipid screening; and 36.4%-76.8% vs 23.2%-63.6% for screening offering both). Compared with the BMI standard from the WHO, participants in lipid screening had lower BMI (male: 23.8 kg/m2 vs 24.2 kg/m2, p<0.01; female: 22.3 kg/m2 vs 23.6 kg/m2, p<0.01). Furthermore, it is less likely for individuals of lower socioeconomic status to participate in diabetes or lipid screening in developed areas.

CONCLUSIONS

We identified that individuals from lower socioeconomic groups were less likely to take up programmes for diabetes and/or lipid screening in developed areas. These populations are also likely to be at higher risk of non-communicable diseases. Future studies should investigate the barriers and facilitators of screening among non-participants, where targeted interventions to enhance their screening uptake are warranted.

Priorities among effective clinical preventive services in British Columbia, Canada

BACKGROUND

Despite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing.

METHODS

We calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a 'strong or conditional (weak) recommendation for' by the Canadian Task Force on Preventive Health Care or an 'A' or 'B' rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year gained.

RESULTS

Clinical preventive services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. In addition, alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in British Columbia adults born between 1945 and 1965, and screening for type 2 diabetes approach these high-value clinical preventive services.

CONCLUSIONS

These results enable policy makers to say with some confidence what preventive manoeuvres are worth doing but further work is required to determine the best way to deliver these services to all those eligible and to establish what supportive services are required. After all, if a clinical preventive service is worth doing, it is worth doing well.

Higher inflammation is associated with cardiometabolic phenotype and biochemical health in women with obesity

Introduction Metabolic or inflammatory markers may predict adverse outcomes in women with obesity. We sought to describe metabolic-obesity phenotypes of women using novel staging tools and investigate relationships with inflammation. Methods In a cross-sectional study, we collected fasting blood samples from sixty-four females with body mass index (BMI) ≥28kg/m2. Participants were classified as metabolically healthy (MHO) or unhealthy (MUO) using the Cardiometabolic Disease Staging System (CMDS) and Edmonton Obesity Staging System (EOSS). Data was analyzed using independent sample t-tests, Pearson’s correlations, and multiple logistic regression. Results Mean (SD) age was 40.2 (9.3) years with median (IQR) BMI 31.8 (30.3-35.7) kg/m2. The prevalence of MUO was 46.9% and 81.3% using CMDS and EOSS criteria respectively. Women with raised CMDS scores had higher C3 (1.34 (0.20) vs 1.18 (0.15), p =.001) and CRP (2.89 (1.31-7.61) vs. 1.39 (0.74-3.60), p=.034). C3 correlated with insulin (r =0.52), hemoglobin A1c (r=0.37), and C-peptide (r=0.58), all p<.05. C3 above the median (>1.23 g/L) increased odds of raised CMDS score, when controlled for age, BMI, ethnicity, and smoking (β=7.1, 95%CI 1.78, 28.4, p=.005). Conclusion The prevalence of MUO was lower using CMDS than EOSS. C3 and CRP may be useful clinical biomarkers of risk or treatment targets in women with obesity.

Screening for primary aldosteronism in the hypertensive obstructive sleep apnea population is cost-saving

BACKGROUND

Guidelines recommend screening for primary aldosteronism in patients diagnosed with hypertension and obstructive sleep apnea. Recent studies have shown that adherence to these recommendations is extremely low. It has been suggested that cost is a barrier to implementation. No analysis has been done to rigorously evaluate the cost-effectiveness of widespread implementation of these guidelines.

METHODS

We constructed a decision-analytic model to evaluate screening of the hypertensive obstructive sleep apnea population for primary aldosteronism as per guideline recommendations in comparison with current rates of screening. Probabilities, utility values, and costs were identified in the literature. Threshold and sensitivity analyses assessed robustness of the model. Costs were represented in 2020 US dollars and health outcomes in quality-adjusted life-years. The model assumed a societal perspective with a lifetime time horizon.

RESULTS

Screening per guideline recommendations had an expected cost of $47,016 and 35.27 quality-adjusted life-years. Continuing at current rates of screening had an expected cost of $48,350 and 34.86 quality-adjusted life-years. Screening was dominant, as it was both less costly and more effective. These results were robust to sensitivity analysis of disease prevalence, test sensitivity, patient age, and expected outcome of medical or surgical treatment of primary aldosteronism. The screening strategy remained cost-effective even if screening were conservatively presumed to identify only 3% of new primary aldosteronism cases.

CONCLUSIONS

For patients with hypertension and obstructive sleep apnea, rigorous screening for primary aldosteronism is cost-saving due to cardiovascular risk averted. Cost should not be a barrier to improving primary aldosteronism screening adherence.

Healthcare service use patterns among autistic adults: A systematic review with narrative synthesis

LAY ABSTRACT

Autistic adults often have complex healthcare needs due to factors like having other health conditions, sensory sensitivities, and limited access to healthcare providers who are trained to provide care for them. All these factors may influence the healthcare services that autistic adults use. In this review, we searched six electronic research databases to gather the most recent evidence about how often autistic adults use five important healthcare services (the emergency department, hospitalization, outpatient mental health, preventive services, and primary care) compared to populations of non-autistic adults. A total of 16 articles were ultimately included in this review. Most articles found that autistic adults had equal or higher use of healthcare services than non-autistic adults. Autistic adults frequently used the emergency department and hospital. This may indicate that routine outpatient care in the community is not meeting their needs. Our findings show the importance of improving care at this level for autistic adults to reduce overuse of the emergency department (in this article referred to as ED) and hospital.

Prevalence of Diabetes and Hypertension Among King Abdulaziz University Employees: Data From First Aid and Cardiopulmonary Resuscitation Training Program

Objectives Saudi Arabia has a very high rate of chronic illnesses, especially hypertension (HTN) and diabetes. This study aimed to investigate the prevalence and control of diabetes and hypertension among employees at a university in Saudi Arabia, including the associated risk factors, and to evaluate the need for early screening among these individuals. Methods This retrospective study used data from the first aid training program. In total, there were 3964 employees who completed the program, and only 1000 employees were enrolled. The program was conducted at King Abdulaziz University (KAU), Jeddah, Saudi Arabia. Blood pressure (BP), random blood sugar, and body mass index (BMI) were measured in all employees. Descriptive data, including mean, standard deviation (SD), crosstab, chi-square, and linear regression, were analyzed. Categorical variables were described using frequencies and percentages. Results The prevalence of hypertension and diabetes was 31% and 5%. There were 365 males and 635 females. Employees with risk factors such as gender, age, and body mass index had significant effects on having high blood pressure and random blood glucose measurements. Of the employees who reported being free from chronic diseases, 2.9% had abnormal random blood glucose readings (prediabetic and diabetic ranges), while 37.4% had abnormal blood pressure readings (prehypertensive and hypertensive ranges). Conclusion The high prevalence of hypertension and diabetes reflects the crucial role of early screening in diabetes and hypertension protocols and raising awareness regarding protocol implementation in Saudi Arabia to improve quality of life (QoL) at the individual and community levels.

Validation of the Prevention Impacts Simulation Model (PRISM)

Introduction

Demonstrating the validity of a public health simulation model helps to establish confidence in the accuracy and usefulness of a model’s results. In this study we evaluated the validity of the Prevention Impacts Simulation Model (PRISM), a system dynamics model that simulates health, mortality, and economic outcomes for the US population. PRISM primarily simulates outcomes related to cardiovascular disease but also includes outcomes related to other chronic diseases that share risk factors. PRISM is openly available through a web application.

Methods

We applied the model validation framework developed independently by the International Society of Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making modeling task force to validate PRISM. This framework included model review by external experts and quantitative data comparison by the study team.

Results

External expert review determined that PRISM is based on up-to-date science. One-way sensitivity analysis showed that no parameter affected results by more than 5%. Comparison with other published models, such as ModelHealth, showed that PRISM produces lower estimates of effects and cost savings. Comparison with surveillance data showed that projected model trends in risk factors and outcomes align closely with secular trends. Four measures did not align with surveillance data, and those were recalibrated.

Conclusion

PRISM is a useful tool to simulate the potential effects and costs of public health interventions. Results of this validation should help assure health policy leaders that PRISM can help support community health program planning and evaluation efforts.

Health screening for emerging non-communicable disease burdens among the global poor: Evidence from sub-Saharan Africa

Evidence for the effectiveness of population health screenings to reduce the burden of non-communicable diseases in low-income countries remains very limited. We investigate the sustained effects of a health screening in Malawi where individuals received a referral letter if they had elevated blood pressure. Using a regression discontinuity design and a matching estimator, we find that receiving a referral letter reduced blood pressure and the probability of being hypertensive by about 22 percentage points four years later. These lasting effects are explained by a 20 percentage points increase in the probability of being diagnosed with hypertension. There is also evidence of an increase in the uptake of medication, while we do not identify improvements in hypertension-related knowledge or risk behaviors. On the contrary, we find an increase in sugar intake and a decrease in physical activity both of which are considered risky behaviors in Western contexts. The health screening had some positive effects on mental health. Overall, this study suggests that population-based hypertension screening interventions are an effective tool to improve health in low-income contexts.

All-cause mortality, cardiovascular mortality, and incidence of cardiovascular disease according to a screening program of cardiovascular risk in South Korea among young adults: a nationwide cohort study

OBJECTIVES

We aimed to determine whether there are any differences in all-cause and cause-specific mortality with cardiovascular disease (CVD) risk between health screening attenders and non-attenders among young adults.

STUDY DESIGN

We performed a retrospective cohort study using claim data from the Korean National Health Insurance Service database.

METHODS

Individuals aged 20-39 years who had received health screening at least once between 2002 and 2005 were classified as attenders, and the others were classified as non-attenders. After propensity score matching according to attendance of health screening, 2,060,409 attenders and 2,060,409 non-attenders were included. We estimated adjusted hazard ratios (HRs) and 95% confidence interval (CI) for all-cause mortality, cause-specific mortality, and hospitalization of CVD from 2006 to 2015.

RESULTS

Survival from all-cause mortality was greater among attenders than among non-attenders (log rank P < 0.001). Similarly, death from CVD (log rank P = 0.007) and CVD events (log rank P < 0.001) were less likely among attenders. The risk for all-cause mortality in attenders was significantly lower than that in non-attenders (HR = 0.83, 95% CI = 0.81 to 0.84). The risk for CVD mortality (HR = 0.80, 95% CI = 0.73 to 0.87) and hospitalization of CVD (HR = 0.92, 95% CI = 0.91 to 0.94) were lower in attenders. In stratified analyses, the risk for all-cause and cause-specific mortalities was lower among attenders regardless of insurance type.

CONCLUSIONS

Among young adults, the risk for all-cause mortality, CVD mortality, and hospitalization of CVD were lower for those who underwent health screenings. Future studies that evaluate the cost-effectiveness of health screening with additional consideration of psychosocial aspects are needed.

The effect of feedback on cardiovascular risk factors on optimization of primary prevention: The PharmLines initiative

BACKGROUND

It is unknown whether population based single assessment of cardiovascular disease (CVD) risk and feedback to individuals and general practitioners results in initiation of preventive cardiovascular pharmacotherapy in those at risk.

METHODS

The population based cohort study Lifelines was linked to the IADB.nl pharmacy database to assess information on the initiation of preventive medication (N = 48,770). At the baseline visit, information on cardiovascular risk factors was collected and reported to the participants and their general practitioners. An interrupted-time-series-analysis was plotted, in which the start year of blood pressure and lipid lowering medication was displayed in years before or after the baseline visit. Subsequently, predictors of the initiation of pharmacotherapy were determined and possible reduction in cardiovascular events that could be achieved by optimal treatment of individuals at risk.

RESULTS

Before the Lifelines baseline visit, 34% (out of 1,527, 95% Confidence interval (CI) 32%-36%) and 30% (out of 1,991, 95%CI 28%-32%) of the individuals at risk had a blood pressure or lipid lowering drug prescription, respectively. In those at risk, the use of blood pressure lowering medication, increased substantially during the year of the baseline visit. Treating individuals at increased risk (≥5% 10-year risk) with lipid or blood pressure lowering medication (N = 8515 and N = 6899) would have prevented 162 and 183 CVD events, respectively, in the upcoming five years.

CONCLUSION

Primary prevention of CVD in the general population appears suboptimal. Feedback of cardiovascular risk factors resulted in a substantial increase of blood pressure lowering medication and extrapolated health benefits.

Cardiovascular Events and Costs With Home Blood Pressure Telemonitoring and Pharmacist Management for Uncontrolled Hypertension

Uncontrolled hypertension is a leading contributor to cardiovascular disease. A cluster-randomized trial in 16 primary care clinics showed that 12 months of home blood pressure telemonitoring and pharmacist management lowered blood pressure more than usual care (UC) for 24 months. We report cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, hospitalized heart failure, coronary revascularization, and cardiovascular death) and costs over 5 years of follow-up. In the telemonitoring intervention (TI group, n=228), there were 15 cardiovascular events (5 myocardial infarction, 4 stroke, 5 heart failure, 1 cardiovascular death) among 10 patients. In UC group (n=222), there were 26 events (11 myocardial infarction, 12 stroke, 3 heart failure) among 19 patients. The cardiovascular composite end point incidence was 4.4% in the TI group versus 8.6% in the UC group (odds ratio, 0.49 [95% CI, 0.21-1.13], P=0.09). Including 2 coronary revascularizations in the TI group and 10 in the UC group, the secondary cardiovascular composite end point incidence was 5.3% in the TI group versus 10.4% in the UC group (odds ratio, 0.48 [95% CI, 0.22-1.08], P=0.08). Microsimulation modeling showed the difference in events far exceeded predictions based on observed blood pressure. Intervention costs (in 2017 US dollars) were $1511 per patient. Over 5 years, estimated event costs were $758 000 in the TI group and $1 538 000 in the UC group for a return on investment of 126% and a net cost savings of about $1900 per patient. Telemonitoring with pharmacist management lowered blood pressure and may have reduced costs by avoiding cardiovascular events over 5 years. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT00781365.

Health and Budgetary Impact of Achieving 10-Year U.S. Sodium Reduction Targets

INTRODUCTION

This study estimates the health, economic, and budgetary impact resulting from graduated sodium reductions in the commercially produced food supply of the U.S., which are consistent with draft U.S. Food and Drug Administration voluntary guidance and correspond to Healthy People 2020 objectives and the 2015-2020 Dietary Guidelines for Americans.

METHODS

Reduction in mean U.S. dietary sodium consumption to 2,300 mg/day was implemented in a microsimulation model designed to evaluate prospective cardiovascular disease-related policies in the U.S.

POPULATION

The analysis was conducted in 2018-2020, and the microsimulation model was constructed using various data sources from 1948 to 2018. Modeled outcomes over 10 years included prevalence of systolic blood pressure ≥140 mmHg; incident myocardial infarction, stroke, cardiovascular disease events, and cardiovascular disease-related mortality; averted medical costs by payer in 2017 U.S. dollars; and productivity.

RESULTS

Reducing sodium consumption is expected to reduce the number of people with systolic blood pressure ≥140 mmHg by about 22% and prevent approximately 895.2 thousand cardiovascular disease events (including 218.9 thousand myocardial infarctions and 284.5 thousand strokes) and 252.5 thousand cardiovascular disease-related deaths over 10 years in the U.S. Savings from averted disease costs are expected to total almost $37 billion-most of which would be attributed to Medicare ($18.4 billion) and private insurers ($13.4 billion)-and increased productivity from reduced disease burden and premature mortality would account for another $18.2 billion in gains.

CONCLUSIONS

Systemic sodium reductions in the U.S. food supply can be expected to produce substantial health and economic benefits over a 10-year period, particularly for Medicare and private insurers.

Cost-effectiveness analysis of aspirin for primary prevention of cardiovascular events among patients with type 2 diabetes in China

The use of aspirin for primary prevention of cardiovascular disease (CVD) in patients with diabetes mellitus (DM) is associated with lower rates of cardiovascular events but increased risks of bleeding complications. We aimed to examine the cost-effectiveness of aspirin therapy for primary prevention of CVD in Chinese DM patients. A life-long Markov model was developed to compare aspirin therapy (100mg daily) versus no use of aspirin in DM patients with no history of CVD. Model validation was conducted by comparing the simulated event rates with data reported in a clinical trial. Direct medical costs and quality-adjusted life-years gained (QALYs) were the primary outcomes from the perspective of healthcare system in China. Sensitivity analyses were performed to examine the uncertainty of model inputs. Base-case analysis showed aspirin therapy was more costly (USD1,086 versus USD819) with higher QALYs gained (11.94 versus 11.86 QALYs) compared to no use of aspirin. The base-case results were sensitive to the odds ratio of all-cause death in aspirin therapy versus no use of aspirin. Probabilistic sensitivity analysis found that aspirin therapy gained an additional 0.066 QALYs (95% CI: -0.167 QALYs-0.286 QALYs) at higher cost by USD352 (95% CI: USD130-644)). Using 30,000 USD/QALY as willingness-to-pay threshold, aspirin therapy and no use of aspirin were the preferred option in 68.71% and 31.29% of 10,000 Monte Carlo simulations, respectively. In conclusion, aspirin therapy appears to be cost-effective compared with no use of aspirin in primary prevention of CVD in Chinese DM patients.

Estimating the Impact of Novel Digital Therapeutics in Type 2 Diabetes and Hypertension: Health Economic Analysis

BACKGROUND

Behavioral interventions can meaningfully improve cardiometabolic conditions. Digital therapeutics (DTxs) delivering these interventions may provide benefits comparable to pharmacologic therapies, displacing medications for some patients.

OBJECTIVE

Our objective was to estimate the economic impact of a digital behavioral intervention in type 2 diabetes mellitus (T2DM) and hypertension (HTN) and estimate the impact of clinical inertia on deprescribing medications.

METHODS

Decision analytic models estimated health resource savings and cost effectiveness from a US commercial payer perspective. A 3-year time horizon was most relevant to the intervention and payer. Effectiveness of the DTx in improving clinical outcomes was based on cohort studies and published literature. Health resource utilization (HRU), health state utilities, and costs were drawn from the literature with costs adjusted to 2018 dollars. Future costs and quality-adjusted life years (QALYs) were discounted at 3%. Sensitivity analyses assessed uncertainty.

RESULTS

Average HRU savings ranged from $97 to $145 per patient per month, with higher potential benefits in T2DM. Cost-effectiveness acceptability analyses using a willingness-to-pay of $50,000/QALY indicated that the intervention would be cost effective at total 3-year program costs of $6468 and $6620 for T2DM and HTN, respectively. Sensitivity analyses showed that reduced medication costs are a primary driver of potential HRU savings, and the results were robust within values tested. A resistance to deprescribe medications when a patient's clinical outcomes improve can substantially reduce the estimated economic benefits. Our models rely on estimates of clinical effectiveness drawn from limited cohort studies with DTxs and cannot account for other disease management programs that may be implemented. Performance of DTxs in real-world settings is required to further validate their economic benefits.

CONCLUSIONS

The DTxs studied may provide substantial cost savings, in part by reducing the use of conventional medications. Clinical inertia may limit the full cost savings of DTxs.

A review of the cost-effectiveness of adult influenza vaccination and other preventive services

The Centers for Disease Control and Prevention recommend annual influenza vaccination of persons ≥6 months old. However, in 2016-17, only 43.3% of U.S. adults reported receiving an influenza vaccination. Limited awareness about the cost-effectiveness (CE) or the economic value of influenza vaccination may contribute to low vaccination coverage. In 2017, we conducted a literature review to survey estimates of the CE of influenza vaccination of adults compared to no vaccination. We also summarized CE estimates of other common preventive interventions that are recommended for adults by the U.S. Preventive Services Task Force. Results are presented as costs in US$2015 per quality-adjusted life-year (QALY) saved. Among adults aged 18-64, the CE of influenza vaccination ranged from $8000 to $39,000 per QALY. Assessments for adults aged ≥65 yielded lower CE ratios, ranging from being cost-saving to $15,300 per QALY. Influenza vaccination was cost-saving to $85,000 per QALY for pregnant women in moderate or severe influenza seasons and $260,000 per QALY in low-incidence seasons. For other preventive interventions, CE estimates ranged from cost-saving to $170,000 per QALY saved for breast cancer screening among women aged 50-74, from cost-saving to $16,000 per QALY for colorectal cancer screening, and from $27,000 to $600,000 per QALY for hypertension screening and treatment. Influenza vaccination in adults appears to have a similar CE profile as other commonly utilized preventive services for adults. Efforts to improve adult vaccination should be considered by adult-patient providers, healthcare systems and payers given the health and economic benefits of influenza vaccination.

Effectiveness of health literacy intervention on cardiovascular diseases among university students of Pakistan

Background

Global burden of cardiovascular diseases is alarming which is intricately linked with health literacy. To what extent improvement in health literacy can lower down cardiovascular diseases occurrence has not yet properly documented. This study focused on assessing the knowledge and existing lifestyle behavior about cardiac diseases among university students. We further aimed to improve this awareness after imparting an educational intervention among undergraduate non-medical students to sensitize them about risk factors.

Method

A pre and post approaches with cross sectional study design was conducted in University of Gujrat during April–September 2017. Using structured questionnaire comprising of response items about hypertension, heart attack, stroke and preventive practices, data was randomly collected from students (n = 100). Survey respondents were also given a lecture regarding cardiovascular diseases awareness and a post test evaluation was also conducted on same group of students.

Results

With response rate of 86.95%, mean age of participating students was 21.2 (SD ± 1.34) years. Female students comprised of 53% out of which 57% were from rural background. Assessment of cardiovascular disease knowledge revealed maximum mean pre test score 30.53 (SD ± 7.61) and for post test 40.65 (SD ± 4.34) (p < 0.00). Mean score for using preventive practices was 13.02 (SD ± 2.97) for pre test whereas for post test it was 14.09 (SD ± 2.90) (p < 0.00). Intervention impact was significant on hypertension related complications (p < 0.000), symptoms of heart attack (p < 0.000), symptoms of stroke (p < 0.000) and preventive practices (p < 0.00).

Conclusion

Findings presented here show a fair degree of awareness among university students about study title prior to any educational intervention. However, by attending educational session, a significant increase in the positive lifestyle behavior and knowledge was noticed. We conclude that health promotion activities in educational institutes to sensitize students can bring rational changes in Pakistani society to promote healthy behavior and minimize cardiovascular disease risks.

Secular Trends in Lipid Profiles in Korean Adults Based on the 2005-2015 KNHANES

Dyslipidemia is a primary, critical risk factor for cardiovascular disease. Therefore, evaluating the trends in lipid profiles is crucial for the development of health policies and programs. We studied trends in lipid profiles in Korean adults over an 11-year period according to the use of lipid-lowering medications through age-specific analysis. A total of 73,890 participants were included in the Korean National Health and Nutrition Examination Survey III (2005)-VI (2013–2015). The proportion of participants on lipid-lowering medications has increased. This trend was apparent in age groups of over 40 years in both men and women. Lipid-lowering medications successfully reduced mean total cholesterol (TC), but there was no favorable trend in TC in participants not taking lipid-lowering medication in both men and women. Unlike men, triglyceride and non-high-density lipoprotein cholesterol (HDL) decreased in women without lipid-lowering medications. In age-specific hypercholesterolemia, the prevalence of hypercholesterolemia significantly increased in the age groups of 30–59 and 30–49 years in men and women without lipid-lowering medications, respectively. Meanwhile, mean HDL-C levels increased over the 11-year period regardless of lipid-lowering drug use in both men and women. These analyses identified an upward trend in TC and HDL-C over the 11-year period.

Delivering clinical preventive services in the Islamic Republic of Iran: A model for screening and behavior consultation practices

Background: Screening and behavior consultation are considered to be limited, dispersed and expensive services across the country. To deliver efficient and equitable services current disordered practices need to be consolidated.

Methods: An analysis of current situation, learned lessons and future scopes of country’s preventive care delivery, along with a review of international experience and generous participation of various stakeholders, led to proposing a model for screening and behavior consultation practices in IR. Iran.

Results: Upon the results of the previous steps, the desired model was based on the network system and family physician. Comprehensive health centers and other centers affiliated to the network are the most appropriate service positions. However, private and academic preventive centers are playing their rules.

Conclusion: The proposed model matches the overall pattern of service delivery in the health system (network system with the private sector and the educational sector).

Cost-effectiveness of adult vaccinations: A systematic review

BACKGROUND

Coverage levels for many recommended adult vaccinations are low. The cost-effectiveness research literature on adult vaccinations has not been synthesized in recent years, which may contribute to low awareness of the value of adult vaccinations and to their under-utilization. We assessed research literature since 1980 to summarize economic evidence for adult vaccinations included on the adult immunization schedule.

METHODS

We searched PubMed, EMBASE, EconLit, and Cochrane Library from 1980 to 2016 and identified economic evaluation or cost-effectiveness analysis for vaccinations targeting persons aged ≥18 years in the U.S. or Canada. After excluding records based on title and abstract reviews, the remaining publications had a full-text review from two independent reviewers, who extracted economic values that compared vaccination to "no vaccination" scenarios.

RESULTS

The systematic searches yielded 1688 publications. After removing duplicates, off-topic publications, and publications without a "no vaccination" comparison, 78 publications were included in the final analysis (influenza = 25, pneumococcal = 18, human papillomavirus = 9, herpes zoster = 7, tetanus-diphtheria-pertussis = 9, hepatitis B = 9, and multiple vaccines = 1). Among outcomes assessing age-based vaccinations, the percent indicating cost-savings was 56% for influenza, 31% for pneumococcal, and 23% for tetanus-diphtheria-pertussis vaccinations. Among age-based vaccination outcomes reporting $/QALY, the percent of outcomes indicating a cost per QALY of ≤$100,000 was 100% for influenza, 100% for pneumococcal, 69% for human papillomavirus, 71% for herpes zoster, and 50% for tetanus-diphtheria-pertussis vaccinations.

CONCLUSIONS

The majority of published studies report favorable cost-effectiveness profiles for adult vaccinations, which supports efforts to improve the implementation of adult vaccination recommendations.

Long-term follow-up on biological risk factors, adiposity, and cardiorespiratory fitness development in a physical education intervention: a natural experiment (CHAMPS-study DK)

Background

Schools are a key setting for large-scale primordial non-communicable disease prevention in young people, but little data on sustainability of impacts on cardiometabolic risk markers is available.

Methods

Six and a half year follow-up of a natural experiment. In 2008, six public schools in the municipality of Svendborg (Denmark) augmented their curricular physical education (intervention) and four matched schools served as controls. At long term follow up in 2015 n = 312 participants aged 5–11 years had complete data (33% of children providing necessary baseline data). The intervention, that consisted of a trebling of weekly physical education lessons and courses provided to physical education teachers, was provided at intervention schools up until 6th grade. Participants attended 6th to 10th grade at follow-up. Differences in the homeostasis model assessment of insulin resistance, blood pressure, triglycerides, cholesterol ratios, cardiorespiratory fitness, waist-circumference, and a composite score of these, between participants attending intervention and control schools were analysed by mixed linear regression models. Differences in physical activity at follow-up was analysed cross-sectionally (no baseline available) in n = 495.

Results

Compared to controls, children at intervention schools had a non-significant − 0.07 (− 0.32 to 0.18) standard deviations lower composite risk score 6.5 years after project initiation. Likewise, no statistically significant differences between intervention and control schools were found for any of the other outcomes (p-values ≥ 0.41). However, six of seven outcomes were in a direction favouring intervention schools. No statistically significant differences between intervention and control schools were observed for physical activity outcomes (p-values ≥ 0.13).

Conclusions

An augmented physical activity program including 270 min of weekly physical education provided for three to seven years did not materialize in statistically significant differences in established risk markers in children from intervention compared to control schools. As the intervention was discontinued after 6th grade, the post-intervention effect of augmented physical education throughout adolescence is unknown. School-based physical activity programs may benefit from incorporating instruments for behaviour translation to leisure time in their intervention models to increase the probability of achieving public health relevance.

Trial registration

ClinicalTrials.gov Identifier: NCT03510494.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5524-4) contains supplementary material, which is available to authorized users.

The health of working nurses: Hypertension prevalence, awareness, treatment and control by medication

AIMS

To investigate hypertension awareness, prevalence and treatment in nurses.

BACKGROUND

Nurses are the largest health workforce group, currently facing an ageing demographic and the risk of chronic disease such as hypertension. Little is known about hypertension in nurses despite the potential impact on work productivity.

METHODS

A cross-sectional online survey was distributed to nurses and midwives via the professional association and nursing directors. Questions were taken from published longitudinal health studies for blood pressure, hypertension and key sociodemographic and health factors.

RESULTS

The participants' (n = 5,041) mean age was 47.99 (SD 11.46) years. The majority knew their blood pressure, more so if they were female, of higher body mass index and aged 45-64 years, but less so if they were smokers. Hypertension prevalence increased with age, peaking at the oldest ages and the majority were treated (anti-hypertensive medication), less so if aged <55 years. Many nurses treated for hypertension had poor blood pressure control, were most often aged 45-54 years and were smokers.

CONCLUSIONS

Hypertension prevalence is less in nurses than in the general population, however, once diagnosed treatment is not optimized.

IMPLICATIONS FOR NURSING MANAGEMENT

The potential impact of hypertension on older nurses' work productivity justifies work-based support for risk reduction behaviours.