The cost of coronary heart disease and the promise of prevention

This editorial refers to ‘The impact of coronary heart disease prevention on work productivity: a ten year analysis’, by Ella Zomer et al., doi: 10.1093/eurjpc/zwaa037. Coronary heart disease (CHD) is the leading cause of death and disability worldwide.1 It has a significant impact on the global economy and productivity, and it continues to worsen.2 The American Heart Association recently published its 2030 Impact Goal that focuses on different measures of health such as health-adjusted life expectancy and aims to raise the bar for healthy life expectancy from 66 years of age to at least 67 years globally by 2030.3 In addition, a recently published position paper from the European Association of Preventive Cardiology stresses the importance of reducing cardiovascular disease costs and discusses some of the evidence behind the cost-effectiveness of primary prevention strategies.4 With increasingly aging populations and rising healthcare costs, it is critical to focus on cost-effective strategies that impact not only direct healthcare costs but also incorporate indirect costs such as productivity while improving the overall well-being of populations. Current guidelines have emphasized the importance of prevention strategies while considering their cost-effectiveness.5 However, the evidence provided in guidelines focuses on direct costs without incorporating indirect costs and, therefore, likely underestimates the impact of CHD. In this issue of the European Journal of Preventive Cardiology, Savira et al. evaluate the impact of cardiovascular prevention on productivity in the Australian working-age population over 10 years using the measure ‘productivity-adjusted life years’ (PALYs). The study sought to evaluate the effect of preventing new cases of CHD on the Australian population’s longevity and productivity. Their study demonstrates several important findings. First, among the total Australian working population, the study projects a life expectancy of ∼133 million and PALYs of ∼83 million. Second, they predicted that the number of working Australians with CHD would increase by 11% over the next ten years, which equates to 39,990 new CHD cases (1.73% of the Australian working-age population). Third, these new cases of CHD will account for 14,202 deaths; 8,228 life years lost; 104,206 PALYs; and total cost of US$14.8 billion that could be avoided if the CHD cases were prevented. Fourth, among the contributors to loss of productivity, labour force dropout (i.e. early retirement) accounted for most of the estimated loss in productivity (69.4%) followed by presenteeism (i.e. at work but not fully functioning, 21%), absenteeism (8.7%), and premature mortality (0.9%). Finally, they identified significant sex differences, with males contributing 61% to the total CHD-related loss in productivity. The authors conclude that these values present important health and economic opportunities for employers and policymakers. Regarding the methods used in this study, the authors had previously used a similar approach, but in closed cohorts, to evaluate the impact of type 2 diabetes and smoking.6,7 The current study constructed a dynamic life table model using the total Australian working population (aged 15–69 years) over 10 years from 2020 to 2029, stratified by CHD status. They included three health states: ‘alive without CHD’, ‘alive with CHD’, and ‘dead’. Absenteeism and presenteeism estimates were derived from prior studies.8,9 A financial value was ascribed to the PALY using the gross domestic product (GDP) per full-time worker. Estimation of life expectancy, PALYs, and cost (GDP per PALYs) were calculated by CHD status. Productivity loss related to CHD was based on prior studies that estimated a loss of 6.7 days of work (range: 1.2–17.8 days) and 16.3 days of unproductive time at work per person per year (range: 0–32.4).8 The authors repeated the model simulation, assuming that all new CHD cases could be prevented, and the differences between the models represented the impact of CHD prevention. Appropriate discounting (∼5% per year) was performed for all outcomes starting after the first year. A sensitivity analysis was performed to account for the risk of mortality associated with CHD, early retirement due to CHD, different base case estimates, different discounting rates including the World Health Organization rate of 3%, and extending the time horizon to 20 years. They used several data sources for this study, including data from the Australian Bureau of Statistics for population-related data including mortality, migration, birth rates, and labour participation and the Australian Institute of Health and Welfare for CHD prevalence rates. This study highlights the important impact of CHD on productivity and the potential economic benefits of prevention. These findings are consistent with prior studies, including a recent study by Schofield et al. that used the measure ‘productivity life years’ to evaluate the impact of chronic health conditions including CHD on older workers in Australia aged 45–64 years using a microsimulation model.2 The authors projected a 62% increase in costs incurred from loss of income, a 35% increase in welfare payments, and a 58% increase in lost income tax revenue due to CHD between the years of 2015–2030 that totals to a loss of US$755 million in GDP for 2015, which increased to US$1082 million in 2030. These studies, however, did not incorporate some of the factors used in the current study, including CHD-related labour force dropout, absenteeism, and presenteeism. This accounts for the different total costs estimated. Another strength of the current study is the use of a dynamic life table method that allowed for movement in and out of the model due to birth, death, migration, and aging beyond the working-age used. Importantly, the measures of labour force participation are not only relevant from an economic standpoint but are also an important indicator of physical functioning and psychological well-being in those with chronic conditions such as CHD. Finally, the mechanisms of lost productivity from CHD are likely multiple and include CHD-related acute hospitalizations, ongoing exertional or resting symptoms of ischaemia, symptoms related to underlying ischaemic cardiomyopathy, and depression related to underlying CHD. The important findings of this study clearly illustrate the economic potential of CHD prevention that could inform the public and policymakers alike. Multiple population-level prevention strategies have proven to be successful and cost-effective (Figure 1).10 Despite the success of individual-level prevention strategies, such as smoking cessation programmes, blood pressure control, and cholesterol reduction therapies, the current study emphasizes the additional need for population-level strategies given the scale of CHD in populations. The European Guidelines on Prevention has recommended a population-level approach that follows the Geoffrey Rose Paradigm, emphasizing that small changes in the risk of disease across a community consistently lead to more significant reductions in disease burden than a large change in high-risk individuals only.5 Multiple initiatives have been successful that governmental and non-governmental agencies could employ. These include policies that promote a healthy diet (e.g., banning of industrial trans fats, taxes on sugar-rich foods and beverages, marketing restrictions), environmental changes to facilitate healthier dietary selection and physical activity, and community-level initiatives (e.g., availability of healthy foods at schools and workplaces, increasing green space and recreational space). The current study’s estimates of indirect costs from CHD suggest that such population-level interventions are likely to be cost-effective when incorporating productivity gains.11 This becomes even more important as government budgets face competing needs from unexpected hazards such as the COVID-19 pandemic and other chronic conditions. Impact of coronary heart disease and potential prevention strategies. QALYs, quality-adjusted life years; PALY, productivity-adjusted life years; HALYs, health-adjusted life years; DALYs, disability-adjusted life years. Impact of coronary heart disease and potential prevention strategies. QALYs, quality-adjusted life years; PALY, productivity-adjusted life years; HALYs, health-adjusted life years; DALYs, disability-adjusted life years. The results of this study should be interpreted with consideration of a few caveats. First, the estimates presented likely underestimate the incidence of CHD, given that they did not include less severe cases of CHD that do not result in hospitalization. Also, the productivity loss estimates reflected chronic CHD and did not consider acute episodes of CHD that may have a greater loss in productivity, especially in the first year following the event. The authors justify this by findings of prior studies showing that the impact of acute CHD declines with time and plateaus at 1 year.8 Second, estimates of absenteeism and presenteeism related to CHD were derived from a US population, given the absence of these data in the Australian population. To minimize the impact this has on the difference between the two strata of populations (CHD and no CHD), estimates of absenteeism and presenteeism for the population without CHD were also derived from a US population.9 Finally, the generalizability of this study may be limited, given the population selected, and the actual estimates are population specific. Therefore, populations from other countries will need to conduct similar studies to estimate their specific burden of CHD and associated economic impact. Future studies will need to incorporate sociodemographic factors into the model, including race/ethnicity, given the significant disparities that exist in society today. Overall, the study by Savira et al. highlights the substantial opportunities that could be provided by CHD prevention strategies for both public health officials and policymakers. Evaluating these strategies will require the incorporation of indirect costs such as productivity to truly understand the broad scope of their benefits. Conflict of interest: none declared. The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.