Is diabetes and hypertension screening worthwhile in resource-limited settings? An economic evaluation based on a pilot of a Package of Essential Non-communicable disease interventions in Bhutan.

In response to a lack of cost-effective data on screening and early treatment of diabetes and hypertension in resource-limited settings, a model-based economic evaluation was performed on the World Health Organization (WHO)'s Package of Essential Non-communicable (PEN) disease interventions for primary health care in Bhutan. Both local and international data were applied in the model in order to derive lifetime costs and outcomes resulting from the early treatment of diabetes and hypertension. The results indicate that the current screening option (where people who are overweight, obese or aged 40 years or older who visit primary care facilities are screened for diabetes and hypertension) represents good value for money compared to 'no screening'. The study findings also indicate that expanding opportunistic screening (70% coverage of the target population) to universal screening (where 100% of the target population are screened), is likely to be even more cost-effective. From the sensitivity analysis, the value of the screening options remains the same when disease prevalence varies. Therefore, applying this model to other healthcare settings is warranted, since disease prevalence is one of the major factors in affecting the cost-effectiveness results of screening programs.

Package of essential noncommunicable disease (PEN) interventions in primary health-care settings of Bhutan: a performance assessment study

Background: A World Health Organization (WHO) package of essentialnoncommunicable (PEN) disease interventions was piloted in two districts ofBhutan by non-physician health workers. They conducted risk assessment amongpatients aged over 40 years who visited the outpatient department of healthinstitutions. Blood glucose was also measured among those who were overweight/obese (body mass index ≥23 kg/m2) or had a high waist circumference (>80 cmin women and >90 cm in men). Appropriate counselling, treatment and referralwere provided to the patients. The performance of the PEN project in detectingand managing noncommunicable diseases (NCDs) and their risk factors wasassessed.Methods: All health institutions of Paro (one district hospital and three basic healthunits [BHUs]) and Bumthang districts (one district hospital and four BHUs), wereincluded in the PEN pilot assessment study. All patients who had presented to theclinics in the pilot districts from 1 June to 31 August 2012 constituted the studypopulation. The data were collected from the clinical form, supervisor’s report andmonthly report of the PEN project. The characteristics of patients with an NCDat registration and at the third follow-up visit were compared in a before–afteranalysis. Absolute changes in the characteristics of patients were computed forthose who had completed the required followups during a 3-month assessmentperiod.Results: In a 3-month period, 39 079 patients had attended clinics in the pilotdistricts. About 10% of the clinic attendees (3818/39 079) were aged over 40 years;of these, 22.6% (864/3818) had a high blood pressure, and 49.7% (1896/3818)were overweight/obese or had a high waist circumference. Screening of overweight/obese/high waist circumference cases revealed that 26.1% (494/1896) had highblood sugar levels. Out of the 896 patients who were registered on PEN protocols,13% had >20% risk of developing cardiovascular diseases (CVDs) in next 10years as per the WHO/International Society of Hypertension risk-assessmentcharts. Among 444 who had three follow-up visits, high 10-year-CVD risk (>20%)had declined from 13% to 7.3%. Among 400 persons with hypertension, use ofmedication increased and high blood pressure declined from 42.3% to 21.5%.Among 115 persons with diabetes, use of anti-diabetes medication increased andhigh blood sugar declined from 68/100 to 51/100.Conclusion: Implementation of the PEN intervention in the primary health-caresetting of Bhutan led to improvement in blood pressure and diabetes control, andreduction in CVD risk