Cost-Effectiveness of Improved Hypertension Management in India through Increased Treatment Coverage and Adherence: A Mathematical Modeling Study

Figures

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  Figure 1. Structure of the microsimulation model. The above microsimulation model was used with a cycle time of one month to estimate costs and DALYs in two hypothetical cohort of 10,000 individuals (males and females respectively) with ages 40-69yr at the start of the simulation. Multiple scenarios with combinations of coverage and adherence were simulated, and the incremental cost per DALY averted was calculated in reference to the status quo of 17% coverage and 30% adherence. The blue square indicates the choice between various intervention scenarios, and the orange circle indicates the chosen intervention. The health states (indicated by green pentagon) comprises of (1) well (no past CVD event), (2) occurrence of a CVD event, (3) surviving post a myocardial infarction (postMI), (4) surviving post a stroke (postStroke), and (5) deceased state. The blue-colored branches from each heath state lead to another heath state based on the probability of the intermediate event (indicated by the green circle). The (2) CVD event is a transitionary markov state and comprises of either an occurrence of MI or stroke. CVD = Cardiovascular disease, MI = Myocardial infarction, DALYs = Disability…

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  Figure 2. Increasing coverage vis-à-vis adherence. We assessed multiple scenarios of coverage and adherence to antihypertensive treatment compared to the status quo (coverage = 17%, adherence = 30%), and present the cost-effectiveness (panel A), incremental cost (panel B) and DALYs averted (panel C). Each column provides information for a coverage scenario with varying adherence, and each row provides information for a adherence scenario with varying treatment coverage. In panel A, the cells in blue indicate a cost-saving scenario, and cells in purple and yellow indicate a highly cost-effective scenario. The gradient of cell color is indicative of the changing cost-effectiveness. In panel B and C, the incremental cost and DALYs averted is presented with different scenarios of coverage and adherence compared to status quo. In general, moving from yellow to blue is advantageous. The results are based on 1000 simulation runs with a time horizon of 20 years in two hypothetical cohort of 10,000 individuals (males and females respectively) with ages of 40–69 yrs at the start of the simulation. ICER = Incremental Cost Effectiveness Ratio, DALY = Disability Adjusted Life Year, CS = Cost Saving.

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  Figure 3. Incremental costs and DALYs averted under changes in sensitivity parameters. We assessed the robustness of our model through changes in select input parameters in a one-way sensitivity analysis. The x-axis and y-axis represent the DALYs averted and incremental cost compared to the status quo, and the error bars are based on the 95% confidence intervals. The text in the parenthesis along with the scenario name is the ICER ($/DALYs averted), with CS representing cost-saving scenario. The base case analysis) was cost-saving. If the medication cost was increased, the scenarios were no longer cost-saving, but the ICERs were below $110 and thus highly cost-effective. When the programmatic cost was quadrupled, the scenario did not save overall costs, but remained highly cost-effective. Under the assumption that the Globorisk calculator overestimates CVD risk, we ran the simulation with a 20% reduction in baseline risk and found the scenario no longer saved costs. If the treatment protocol was changed to the current NPCDCS guideline the cost savings increased. If the simulations were run with a reduced time horizon of 10 years, the scenario was highly cost-effective. When the simulations…