Abstract
Background: The evidence on the economic burden of cardiovascular disease (CVD) in low- and middle- income countries (LMICs) remains scarce. We conducted a comprehensive systematic review to establish the magnitude and knowledge gaps in relation to the economic burden of CVD and hypertension on households, health systems and the society. Methods: We included studies using primary or secondary data to produce original economic estimates of the impact of CVD. We searched sixteen electronic databases from 1990 onwards without language restrictions. We appraised the quality of included studies using a seven-question assessment tool. Results: Eighty-three studies met the inclusion criteria, most of which were single centre retrospective cost studies conducted in secondary care settings. Studies in China, Brazil, India and Mexico contributed together 50% of the total number of economic estimates identified. The quality of the included studies was generally low. Reporting transparency, particularly for cost data sources and results, was poor. The costs per episode for hypertension and generic CVD were fairly homogeneous across studies; ranging between $500 and $1500. In contrast, for coronary heart disease (CHD) and stroke cost estimates were generally higher and more heterogeneous, with several estimates in excess of $5000 per episode. The economic perspective and scope of the study appeared to impact cost estimates for hypertension and generic CVD considerably less than estimates for stroke and CHD. Most studies reported monthly costs for hypertension treatment around $22. Average monthly treatment costs for stroke and CHD ranged between $300 and $1000, however variability across estimates was high. In most LMICs both the annual cost of care and the cost of an acute episode exceed many times the total health expenditure per capita. Conclusions: The existing evidence on the economic burden of CVD in LMICs does not appear aligned with policy priorities in terms of research volume, pathologies studied and methodological quality. Not only is more economic research needed to fill the existing gaps, but research quality needs to be drastically improved. More broadly, national-level studies with appropriate sample sizes and adequate incorporation of indirect costs need to replace small-scale, institutional, retrospective cost studies. Keywords: Non-communicable disease, Cardiovascular disease, Hypertension, Economic burden, Systematic review, Low-income, Middle-income
Generated Summary
This systematic review examined the economic burden of cardiovascular disease (CVD) and hypertension in low- and middle-income countries (LMICs). The review included studies using primary or secondary data to produce original economic estimates of the impact of CVD and hypertension. Sixteen electronic databases were searched from 1990 onwards, without language restrictions, to identify relevant studies. The quality of the included studies was assessed using a seven-question assessment tool. A total of 83 studies met the inclusion criteria. The majority of these studies were single-center, retrospective cost studies conducted in secondary care settings. Studies conducted in China, Brazil, India, and Mexico collectively contributed to 50% of the total number of economic estimates identified. The quality of the included studies was generally low, especially concerning reporting transparency. The review aimed to establish the magnitude and knowledge gaps in relation to the economic burden of CVD and hypertension on households, health systems, and the society. The findings from the review aim to inform policy and research objectives as well as synthesize data for future economic modeling exercises.
Key Findings & Statistics
- Eighty-three studies met the inclusion criteria, with the majority being single center retrospective cost studies.
- Studies in China, Brazil, India, and Mexico contributed 50% of the total economic estimates.
- The costs per episode for hypertension and generic CVD were fairly homogeneous, ranging from $500 to $1500.
- Coronary heart disease (CHD) and stroke cost estimates were higher and more heterogeneous, with several estimates in excess of $5000 per episode.
- Most studies reported monthly costs for hypertension treatment around $22.
- Average monthly treatment costs for stroke and CHD ranged between $300 and $1000.
- In most LMICs, both the annual cost of care and the cost of an acute episode exceed many times the total health expenditure per capita.
- The initial search across all seven NCDs returned 64,952 records, and 19,646 further records were identified at the June 2015 update, leading to a total of 84,598 titles. After excluding the duplicates, 54,137 titles and abstracts were screened for eligibility and 478 studies potentially relevant for CVD and hypertension were screened for full-text. 81 studies met the inclusion criteria and two further studies were identified through manual searches, leading to a total of 83 included papers, reporting economic estimates for/from 28 countries.
- Key study characteristics are summarized in Table 2. Most studies examined the economic impact of stroke (29%, n = 24) and 20% of studies looked at generic CVD, i.e. either unspecified cardiovascular condition(s) or a multitude of cardiovascular disorders for which economic estimates were reported without disaggregation by pathology. Secondary care was the most common study setting: 46% of studies (n = 38) were conducted in secondary and outpatient care jointly, while 26% (n = 22) looked at secondary care only and 7% (n = 6) focused on primary care alone. Five studies included an explicit non-CVD control group, while the others did not have a control group.
- Most studies were institutional (48%, n = 40), i.e. they were conducted in either one health facility (40%, n = 33) or a limited number of facilities (8%, n = 7). The remaining were nationwide studies (36%, n = 30), within-country regional (11%, n = 9) or others e.g. city or international. Retrospective cost studies dominated the sample (43%, n = 34) to the detriment of cost-of-illness studies (18%, n = 14), database analyses (14%, n = 11) or prospective cost studies (13%, n = 10). The majority of included papers were published after 2005 (76%, n = 63). Of the 28 countries for which at least one economic estimate was available, the most estimates were reported for China (20%, n = 17), India (12%, n = 10), Brazil (10%, n = 8) and Mexico (10%, n = 8).
- Most studies did not use a sampling method conducive to generalizable results. In most cases, the quality of the CVD incidence/ prevalence data source (i.e. how CVD was/had been diagnosed in study patients) could not be assessed. Two thirds of the studies included an exploration of uncertainty and/or heterogeneity in the economic estimates. This often took the form of regression analysis. Data sources for expenditure, resource use and unit costs were clearly presented in 57% (n = 47) of studies. Productivity costs were included in estimation and cost data were transparently presented in less than a third of the included papers. Most studies (n = 29, 35%) reported costs from the health care provider’s perspective. A patient and a societal perspective were adopted in 21% (n = 17) and 22% (n = 18) of studies, respectively. The majority of studies reported direct costs only. However, 23 studies also reported estimates of indirect costs. One study reported the effects of CVD on absenteeism, e.g. number of productive days lost due to illness, but did not attempt to calculate indirect costs associated with lost days.
- For studies which reported costs for time horizons longer than one month (e.g. six months or one year), we estimated the monthly cost by dividing the total cost by the respective number of months, e.g. annual costs were divided by 12. Most studies reported costs for hypertension, for a median of $22 per month across estimates. The medians for average monthly treatment costs for stroke and CHD were higher, but varied with study scope and economic perspective from as little as $50 per month (e.g. CHD, patient perspective) to over $1000 (e.g. CHD, provider perspective). However the number of data points for CHD, stroke and heart failure was much more limited than for hypertension and variability across estimates was higher.
- For example, the annual direct cost per patient of hypertension could be as high as 5.9 times the total health expenditure per capita, with a median ratio of 0.7.
Other Important Findings
- The economic perspective and scope of the study appeared to impact cost estimates for hypertension and generic CVD considerably less than estimates for stroke and CHD.
- For example, most institutional-level stroke studies tended to underestimate direct costs per episode relative to national-level studies.
- Studies on stroke and CHD conducted from the perspective of the patient tended to estimate higher direct costs than studies taking the perspective of the provider.
- The study emphasizes the need for more economic research to fill existing gaps and to improve research quality in this area.
- The studies reported the cost of CVD as a proportion of national or regional GDP: Brazil (26%) and Serbia (1.8%).
Limitations Noted in the Document
- The studies were conducted in secondary care settings.
- The research did not reflect current and upcoming disease burden trends, with a dearth of economic estimates from sub-Saharan Africa, Central America, and Eastern Europe.
- Many studies were informed by data collected in one service provider, which seriously limits their generalisability and usefulness for national decision-makers.
- Most studies concentrated on hospital care, with very few studies including economic aspects of CVD care in primary and community care.
- The majority of the included studies were retrospective cohorts without a control group.
- The quality of the included studies was generally low, particularly in relation to reporting transparency.
- The review acknowledges the possibility of missing some grey literature sources.
- The study did not exclude studies on quality considerations.
- Economic evaluations were excluded.
- Studies reporting the economic burden of CVD risk factors other than hypertension were excluded.
Conclusion
The review highlights the substantial economic impact of CVD and hypertension in LMICs, emphasizing the need for improved research to inform effective NCD policies. The annual costs of CVD care in LMICs often exceed health expenditure per capita, raising concerns about financial protection and health financing sustainability. The authors confirm previous findings suggesting that current evidence on the economic burden of CVD in LMICs does not align with policy priorities in terms of volume, focus, and methodological quality. This highlights the need for more economic research of better methodological quality in areas with current gaps, specifically: i) in community and primary care settings; ii) incorporating an appropriate control group; iii) collecting data from multiple sites with a view to representativeness; and iv) incorporating the full economic consequences of CVD prevention and care, not merely direct medical costs. Furthermore, the rationale for conducting cost studies requires a stronger justification in many cases. The study concludes that country-specific results of higher methodological quality are needed to inform national planning and decision-making. Key recommendations include:
- Prioritizing economic research in community and primary care settings.
- Adopting appropriate control groups in study designs.
- Collecting data from multiple sites to ensure representativeness.
- Incorporating the full economic consequences of CVD prevention and care.