Dominance-based distributional cost-effectiveness analysis of cardiovascular disease risk screening in Sri Lanka.

Abstract

Objectives: Screening for cardiovascular disease (CVD) risk is potentially cost-effective but its net health impact by socioeconomic status (SES) likely depends on a) who is screened, b) the socioeconomic profile of risk factors, and c) the criteria for prescribing preventive medication. We conducted a dominance-based distributional cost-effectiveness analysis (DCEA) of CVD risk screening strategies in Sri Lanka to compare their equity-efficiency trade-offs.

Methods: Using nationally representative data, we modelled four strategies of opportunistic CVD risk screening at public outpatient clinics and the current screening program (comparator). We measured SES with an assets index. For each strategy, we simulated costs, quality-adjusted life years (QALYs) and the distribution of QALYs net of health opportunity costs by SES. Assuming aversion to pro-rich inequality, we used generalized concentration curve dominance to rank these distributions and calculated equally distributed equivalent (EDE) net QALYs for each.

Results: The most cost-effective (lowest ICER) strategy was opportunistic (vs invited) screening at age ≥ 40 (vs ≥ 35) with statins prescribed at CVD risk ≥ 10% (vs ≥ 20%) and antihypertensives at blood pressure ≥ 130/80 mm Hg (vs ≥ 140/90) for those risks and diabetics. Given net QALYs generated by SES and aversion to pro-rich inequality, this strategy dominated all others (except one), and it generated more EDE net QALYs. This strategy dominated another with a similar ICER that added statins for people with diabetes.

Conclusions: Dominance-based DCEA identified modifications to CVD risk screening in Sri Lanka that would likely improve equity while remaining efficient.