AddREssing Social Determinants TO pRevent hypErtension (The RESTORE Network): Overview of the Health Equity Research Network to Prevent Hypertension.

BACKGROUND: The American Heart Association funded a Health Equity Research Network on the prevention of hypertension, the RESTORE Network, as part of its commitment to achieving health equity in all communities. This article provides an overview of the RESTORE Network. METHODS: The RESTORE Network includes five independent, randomized trials testing approaches to implement non-pharmacological interventions that have been proven to lower blood pressure (BP). The trials are community-based, taking place in churches in rural Alabama, mobile health units in Michigan, barbershops in New York, community health centers in Maryland, and food deserts in Massachusetts. Each trial employs a hybrid effectiveness-implementation research design to test scalable and sustainable strategies that mitigate social determinants of health (SDOH) that contribute to hypertension in Black communities. The primary outcome in each trial is change in systolic BP. The RESTORE Network Coordinating Center has five cores: BP measurement, statistics, intervention, community engagement, and training that support the trials. Standardized protocols, data elements and analysis plans were adopted in each trial to facilitate cross-trial comparisons of the implementation strategies, and application of a standard costing instrument for health economic evaluations, scale up, and policy analysis. Herein, we discuss future RESTORE Network research plans and policy outreach activities designed to advance health equity by preventing hypertension. CONCLUSIONS: The RESTORE Network was designed to promote health equity in the US by testing effective and sustainable implementation strategies focused on addressing SDOH to prevent hypertension among Black adults.

Modelling the impact of plain packaging of tobacco products on cardiovascular disease in Argentina.

INTRODUCTION: Tobacco packaging design is conceived to be attractive. Plain packaging of tobacco products reduces this attractiveness by standardising their shape, size, font and colours. METHODS: To evaluate the effect of applying plain packaging to tobacco products on cardiovascular events and mortality in Argentina, we used the Cardiovascular Disease Policy Model-Argentina, a local adaptation of a well-established computer simulation model that projects cardiovascular and mortality events for the population 35-94 years old using local demographic and consumption data, during the period 2015-2024. After a literature review, we estimated that the implementation of plain packaging of tobacco products would result in an absolute decrease in tobacco prevalence of 0.55% (base-case scenario) and performed a sensitivity analysis assuming a higher and lower decrease of 1.01% and 0.095%, respectively. RESULTS: Over the 2015-2024 period, the decrease in smoking prevalence associated with plain packaging (0.55%) is projected to avert 1880 myocardial infarctions (MI), 820 strokes and 4320 total deaths in Argentina. The higher estimate of smoking prevalence reduction (1.01%) would translate into 3450 fewer MIs, 1490 fewer strokes and 7920 fewer deaths, while the lower estimate of smoking prevalence reduction (0.095%) would result in 330 fewer MIs, 140 fewer strokes and 750 fewer deaths. CONCLUSIONS: The implementation of plain packaging of tobacco products could reduce cardiovascular events in Argentina, even in the absence of other tobacco control measures. Actual health benefits are likely higher than those presented here, since plain packaging may be most impactful by preventing young people from initiating smoking.

Projected Impact of Nonpharmacologic Management of Stage 1 Hypertension Among Lower-Risk US Adults.

Background: The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines newly classified 31 million US adults as having stage 1 hypertension. The ACC/AHA guidelines recommend behavioral change without pharmacology for the low-risk portion of this group. However, the nationwide reduction in cardiovascular disease (CVD) and associated healthcare expenditures achievable by evidence-based dietary improvements, sustained weight loss, adequate physical activity, and alcohol moderation remain unquantified. We estimated the effect of systolic BP (SBP) control and behavioral changes on 10-year CVD outcomes and costs. Methods: We used the CVD Policy Model to simulate CVD events, mortality, and healthcare costs among US adults aged 35-64. We simulated interventions on a target population, identified from the 2015-2018 National Health and Nutrition Examination Survey, with low-risk stage 1 systolic hypertension: defined as untreated SBP 130-139 mmHg and diastolic BP <90 mmHg; no history of CVD, diabetes, or chronic kidney disease; and low 10-year risk of CVD. We used published meta-analyses and trials to estimate the effects of behavior modification on SBP. We assessed the extent to which intermittent healthcare utilization or partial uptake of nonpharmacologic therapy would decrease CVD events prevented. Results: Controlling SBP to <130 mmHg among the estimated 8.8 million U.S. adults (51% women) in the target population could prevent 26,100 CVD events, avoid 2,900 deaths, and save $1.6 billion in healthcare costs over 10 years. The Dietary Approaches to Stop Hypertension (DASH) diet could prevent 16,000 CVD events among men and 12,000 among women over a decade. Other nonpharmacologic interventions could avert between 3,700 and 19,500 CVD events. However, only 5.5 million (61%) of the target population regularly utilized healthcare where recommended clinician counseling could occur. Conclusions: As only two-thirds of U.S. adults with Stage 1 hypertension regularly receive medical care, substantial benefits to cardiovascular health and associated costs may only stem from policies that promote widespread adoption and sustained adherence of nonpharmacologic therapy. Future work should quantify the population-level costs, benefits, and efficacy of improving the food system and local infrastructure on health behavior change.

Cardiac Rehabilitation and the COVID-19 Pandemic: Persistent Declines in Cardiac Rehabilitation Participation and Access Among US Medicare Beneficiaries.

BACKGROUND: The impact of the COVID-19 pandemic on participation in and availability of cardiac rehabilitation (CR) is unknown. METHODS: Among eligible Medicare fee-for-service beneficiaries, we evaluated, by month, the number of CR sessions attended per 100 000 beneficiaries, individuals eligible to initiate CR, and centers offering in-person CR between January 2019 and December 2021. We compared these outcomes between 2 periods: December 1, 2019 through February 28, 2020 (period 1, before declaration of the pandemic-related national emergency) and October 1, 2021 through December 31, 2021 (period 2, the latest period for which data are currently available). RESULTS: In period 1, Medicare beneficiaries participated in (mean±SD) 895±84 CR sessions per 100 000 beneficiaries each month. After the national emergency was declared, CR participation sharply declined to 56 CR sessions per 100 000 beneficiaries in April 2020. CR participation recovered gradually through December 2021 but remained lower than prepandemic levels (period 2: 698±29 CR sessions per month per 100 000 beneficiaries, P=0.02). Declines in CR participation were most marked among dual Medicare and Medicaid enrollees and patients residing in rural areas or socially vulnerable communities. There was no statistically significant change in CR eligibility between the 2 periods. Compared with 2618±5 CR centers in period 1, there were 2464±7 in period 2 (P<0.01). Compared with CR centers that survived the pandemic, 220 CR centers that closed were more likely to be affiliated with public hospitals, located in rural areas, and serve the most socially vulnerable communities. CONCLUSIONS: The COVID-19 pandemic was associated with a persistent decline in CR participation and the closure of CR centers, which disproportionately affected rural and low-income patients and the most socially vulnerable communities. Innovation in CR financing and delivery is urgently needed to equitably enhance CR participation among Medicare beneficiaries.

Impacto sanitario de la prohibición total de publicidades de tabaco en argentina.

Health impact of the total ban on advertising of tobacco productsThe objective was to estimate the health impact of the total ban on advertising of tobacco products in terms of avoided cardiovascular events in those over 35 years of age in Argentina.The Cardiovascular Disease Policy Model (CVDPM) was used, which is a Markov simulation model used to represent and project mortality and morbidity due to cardiovascular disease (CVD) in the population aged 35 or over. It constitutes a demographic-epidemiological model, which represents the population between 35 and 95 years of age and uses a logistic regression model based on the Framingham equation to estimate the annual incidence of cardiovascular disease. We assumed that implementing a complete ban on the advertising of tobacco products would lead to a 9% reduction in tobacco consumption.The complete ban on advertising could prevent 15,164 deaths over a period of 10 years, of which 2610 would be the result of coronary heart disease and 747 due to stroke. These reductions would mean an annual decrease of 0.46% of total deaths, 0.60% of deaths from coronary heart disease and 0.33% in deaths from stroke. In addition, during the same period, it would avoid 6630 acute myocardial infarctions and 2851 strokes (reductions of 1.35% and 0.40%, respectively).We hope that these findings might contribute to the strengthening of sanitary tobacco control policies in Argentina based on the remarkable benefits of banning the advertising of tobacco products in full and in line with current global recommendations.

Cost-Effectiveness of Hypertension Treatment by Pharmacists in Black Barbershops.

BACKGROUND: In LABBPS (Los Angeles Barbershop Blood Pressure Study), pharmacist-led hypertension care in Los Angeles County Black-owned barbershops significantly improved blood pressure control in non-Hispanic Black men with uncontrolled hypertension at baseline. In this analysis, 10-year health outcomes and health care costs of 1 year of the LABBPS intervention versus control are projected. METHODS: A discrete event simulation of hypertension care processes projected blood pressure, medication-related adverse events, fatal and nonfatal cardiovascular disease events, and noncardiovascular disease death in LABBPS participants. Program costs, total direct health care costs (2019 US dollars), and quality-adjusted life-years (QALYs) were estimated for the LABBPS intervention and control arms from a health care sector perspective over a 10-year horizon. Future costs and QALYs were discounted 3% annually. High and intermediate cost-effectiveness thresholds were defined as <$50 000 and <$150 000 per QALY gained, respectively. RESULTS: At 10 years, the intervention was projected to cost an average of $2356 (95% uncertainty interval, -$264 to $4611) more per participant than the control arm and gain 0.06 (95% uncertainty interval, 0.01-0.10) QALYs. The LABBPS intervention was highly cost-effective, with a mean cost of $42 717 per QALY gained (58% probability of being highly and 96% of being at least intermediately cost-effective). Exclusive use of generic drugs improved the cost-effectiveness to $17 162 per QALY gained. The LABBPS intervention would be only intermediately cost-effective if pharmacists were less likely to intensify antihypertensive medications when systolic blood pressure was ≥150 mm Hg or if pharmacist weekly time driving to barbershops increased. CONCLUSIONS: Hypertension care delivered by clinical pharmacists in Black barbershops is a highly cost-effective way to improve blood pressure control in Black men.

Characteristics of Populations Excluded From Clinical Trials Supporting Intensive Blood Pressure Control Guidelines.

Background Only one third of patients recommended intensified treatment by the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline for high blood pressure would have been eligible for the clinical trials on which recommendations were largely based. We sought to identify characteristics of adults who would have been trial-ineligible in order to inform clinical practice and research priorities. Methods and Results We examined the proportion of adults diagnosed with hypertension who met trial inclusion and exclusion criteria, stratified by age, diabetes mellitus status, and guideline recommendations in a cross-sectional study of the National Health and Nutrition Examination Survey, 2013-2016. Of the 107.7 million adults (95% CI, 99.3-116.0 million) classified as having hypertension by the ACC/AHA guideline, 23.1% (95% CI, 20.8%-25.5%) were below the target blood pressure of 130/80 mm Hg, 22.2% (95% CI, 20.1%-24.4%) would be recommended nonpharmacologic treatment, and 54.6% (95% CI, 52.5%-56.7%) would be recommended additional pharmacotherapy. Only 20.6% (95% CI, 18.8%-22.4%) of adults with hypertension would be trial-eligible. The majority of adults <50 years were excluded because of low cardiovascular risk and lack of access to primary care. The majority of adults aged ≥70 years were excluded because of multimorbidity and limited life expectancy. Reasons for trial exclusion were similar for patients with and without diabetes mellitus. Conclusions Intensive blood pressure treatment trials were not representative of many younger adults with low cardiovascular risk and older adults with multimorbidity who are now recommended more intensive blood pressure goals.

Cardiovascular and diabetes burden attributable to physical inactivity in Mexico.

BACKGROUND: Physical inactivity (PI) is associated with the development of non-communicable chronic diseases. The purposes of this study were to estimate the extent to which the 31% relative increase in PI among 35-64 years old Mexicans between 2006 and 2012 influenced diabetes (T2D) and cardiovascular disease (CVD) incidence and mortality, and to estimate the impact of the World Health Organization recommended 10% and 15% relative decrease in PI on CVD and T2D incidence and mortality by 2025 and 2030, respectively. METHODS: Estimates were derived using the Cardiovascular Disease Policy Model-Mexico, a computer simulation, Markov model. Model inputs included cross-national data on PI levels from 2006 and 2012 measured using the International Physical Activity Questionnaire and the published literature review on the independent relationship between PI and cardiometabolic risk. RESULTS: The models estimated that the 31% increase in PI resulted in an increase in the number of cases of T2D (27,100), coronary heart disease (10,300), stroke (2200), myocardial infarction (1500), stroke deaths (400) and coronary heart disease deaths (350). A hypothetical 10% lowering of PI by 2025 compared to status quo is projected to prevent 8400 cases of T2D, 4200 cases of CHD, 1000 cases of stroke, 700 cases of MI, and 200 deaths of CHD and stroke, respectively. A 15% reduction resulted in larger decreases. CONCLUSIONS: While the burden of T2D and CVD raised from 2006 to 2012 in association with increased PI, achieving the WHO targets by 2030 could help reverse these trends.

Projected impact of a reduction in sugar-sweetened beverage consumption on diabetes and cardiovascular disease in Argentina: A modeling study.

BACKGROUND: Sugar-sweetened beverage (SSB) consumption is associated with obesity, diabetes, and hypertension. Argentina is one of the major consumers of SSBs per capita worldwide. Determining the impact of SSB reduction on health will inform policy debates. METHODS AND FINDINGS: We used the Cardiovascular Disease Policy Model-Argentina (CVD Policy Model-Argentina), a local adaptation of a well-established computer simulation model that projects cardiovascular and mortality events for the population 35-94 years old, to estimate the impact of reducing SSB consumption on diabetes incidence, cardiovascular events, and mortality in Argentina during the period 2015-2024, using local demographic and consumption data. Given uncertainty regarding the exact amount of SSBs consumed by different age groups, we modeled 2 estimates of baseline consumption (low and high) under 2 different scenarios: a 10% and a 20% decrease in SSB consumption. We also included a range of caloric compensation in the model (0%, 39%, and 100%). We used Monte Carlo simulations to generate 95% uncertainty intervals (UIs) around our primary outcome measures for each intervention scenario. Over the 2015-2024 period, a 10% reduction in SSBs with a caloric compensation of 39% is projected to reduce incident diabetes cases by 13,300 (95% UI 10,800-15,600 [low SSB consumption estimate]) to 27,700 cases (95% UI 22,400-32,400 [high SSB consumption estimate]), i.e., 1.7% and 3.6% fewer cases, respectively, compared to a scenario of no change in SSB consumption. It would also reduce myocardial infarctions by 2,500 (95% UI 2,200-2,800) to 5,100 (95% UI 4,500-5,700) events and all-cause deaths by 2,700 (95% UI 2,200-3,200) to 5,600 (95% UI 4,600-6,600) for "low" and "high" estimates of SSB intake, respectively. A 20% reduction in SSB consumption with 39% caloric compensation is projected to result in 26,200 (95% UI 21,200-30,600) to 53,800 (95% UI 43,900-62,700) fewer cases of diabetes, 4,800 (95% UI 4,200-5,300) to 10,000 (95% UI 8,800-11,200) fewer myocardial infarctions, and 5,200 (95% UI 4,300-6,200) to 11,000 (95% UI 9,100-13,100) fewer deaths. The largest reductions in diabetes and cardiovascular events were observed in the youngest age group modeled (35-44 years) for both men and women; additionally, more events could be avoided in men compared to women in all age groups. The main limitations of our study are the limited availability of SSB consumption data in Argentina and the fact that we were only able to model the possible benefits of the interventions for the population older than 34 years. CONCLUSIONS: Our study finds that, even under conservative assumptions, a relatively small reduction in SSB consumption could lead to a substantial decrease in diabetes incidence, cardiovascular events, and mortality in Argentina.

Association of Low Socioeconomic Status With Premature Coronary Heart Disease in US Adults.

Importance: Individuals with low socioeconomic status (SES) bear a disproportionate share of the coronary heart disease (CHD) burden, and CHD remains the leading cause of mortality in low-income US counties. Objective: To estimate the excess CHD burden among individuals in the United States with low SES and the proportions attributable to traditional risk factors and to other factors associated with low SES. Design, Setting, and Participants: This computer simulation study used the Cardiovascular Disease Policy Model, a model of CHD and stroke incidence, prevalence, and mortality among adults in the United States, to project the excess burden of early CHD. The proportion of this excess burden attributable to traditional CHD risk factors (smoking, high blood pressure, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, type 2 diabetes, and high body mass index) compared with the proportion attributable to other risk factors associated with low SES was estimated. Model inputs were derived from nationally representative US data and cohort studies of incident CHD. All US adults aged 35 to 64 years, stratified by SES, were included in the simulations. Exposures: Low SES was defined as income below 150% of the federal poverty level or educational level less than a high school diploma. Main Outcomes and Measures: Premature (before age 65 years) myocardial infarction (MI) rates and CHD deaths. Results: Approximately 31.2 million US adults aged 35 to 64 years had low SES, of whom approximately 16 million (51.3%) were women. Compared with individuals with higher SES, both men and women in the low-SES group had double the rate of MIs (men: 34.8 [95% uncertainty interval (UI), 31.0-38.8] vs 17.6 [95% UI, 16.0-18.6]; women: 15.1 [95% UI, 13.4-16.9] vs 6.8 [95% UI, 6.3-7.4]) and CHD deaths (men: 14.3 [95% UI, 13.0-15.7] vs 7.6 [95% UI, 7.3-7.9]; women: 5.6 [95% UI, 5.0-6.2] vs 2.5 [95% UI, 2.3-2.6]) per 10 000 person-years. A higher burden of traditional CHD risk factors in adults with low SES explained 40% of these excess events; the remaining 60% of these events were attributable to other factors associated with low SES. Among a simulated cohort of 1.3 million adults with low SES who were 35 years old in 2015, the model projected that 250 000 individuals (19%) will develop CHD by age 65 years, with 119 000 (48%) of these CHD cases occurring in excess of those expected for individuals with higher SES. Conclusions and Relevance: This study suggested that, for approximately one-quarter of US adults aged 35 to 64 years, low SES was substantially associated with early CHD burden. Although biomedical interventions to modify traditional risk factors may decrease the disease burden, disparities by SES may remain without addressing SES itself.

Update of the cardiovascular disease policy model to predict cardiovascular events in Argentina.

Cardiovascular disease (CVD) is the leading cause of death in Argentina. Computer simulation models allow to extrapolate evidence to broader populations than the originally studied, over longer timeframes, and to compare different subpopulations. The Cardiovascular Disease Policy Model (CVDPM) is a computer simulation state transition model used to represent and project future CVD mortality and morbidity in the population 35 years-old and older. The objective of this study was to update Argentina's version of the CVDPM. For this purpose, information from the 2010 National Census, the 2013 National Risk Factor Survey, CESCAS I study, and PrEViSTA study were used to update the dynamics of population size, demographics, and CVD risk factor distributions over time. Model projections were later calibrated by comparing them to actual data on CVD events and mortality in the year 2010 (baseline year) in Argentina. Country statistics for people 35 years-old and older reported for 2010 a total of 41 219 myocardial infarctions (MIs), 58 658 strokes, and 281 710 total deaths. The CVDPM, in turn, predicted 41 265 MIs (difference: 0.11%), 58 584 strokes (difference: 0.13%), and 280 707 total deaths (difference: 0.36%) in the same population. In all cases, the final version of the model predicted the actual number of events with an accuracy superior to 99.5%, and could be used to forecast the changes in CVD incidence and mortality after the implementation of public policies.

La enfermedad cardiovascular (ECV) es la principal causa de muerte en Argentina. Los modelos de simulación por computadora permiten extrapolar evidencia a poblaciones más amplias que las originalmente estudiadas, a lo largo de períodos prolongados, y comparar diferentes subpoblaciones. El Cardiovascular Disease Policy Model (CVDPM, por sus siglas en inglés) es un modelo de simulación utilizado para representar y proyectar la mortalidad y morbilidad por ECV en la población de 35 o más años. El objetivo de este trabajo fue actualizar la versión argentina del CVDPM. Para esto, se utilizó información del Censo Nacional 2010, la Encuesta Nacional de Factores de Riesgo 2013, el estudio CESCAS I, y el estudio PrEViSTA, para actualizar la dinámica del tamaño de la población, sus características demográficas, y la distribución de factores de riesgo cardiovasculares a lo largo del tiempo. Las proyecciones del modelo se calibraron comparándolas con información sobre eventos de ECV y mortalidad en el año 2010 (año de referencia) en Argentina. Las estadísticas argentinas informaron que en 2010 la población de 35 o más años sufrió un total de 41 219 infartos de miocardio (IM), 58 658 accidentes cerebrovasculares y 281 710 muertes totales. El CVDPM predijo 41 265 IM (diferencia: 0.11%), 58 584 accidentes cerebrovasculares (diferencia: 0.13%) y 280 707 muertes totales (diferencia: 0.36%). En todos los casos, la versión final del modelo predijo el número real de eventos cardiovasculares con una precisión superior al 99.5%, pudiendo ser utilizado para pronosticar cambios en la incidencia y mortalidad de ECV debidos de la implementación de políticas públicas.

Actualización del modelo de políticas en enfermedad cardiovascular en Argentina / Update of the cardiovascular disease policy model to predict cardiovascular events in Argentina

La enfermedad cardiovascular (ECV) es la principal causa de muerte en Argentina. Los modelos de simulació;n por computadora permiten extrapolar evidencia a poblaciones más amplias que las originalmente estudiadas, a lo largo de períodos prolongados, y comparar diferentes subpoblaciones. El Cardiovascular Disease Policy Model (CVDPM, por sus siglas en ingló;©s) es un modelo de simulació;n utilizado para representar y proyectar la mortalidad y morbilidad por ECV en la població;n de 35 o más aó;±os. El objetivo de este trabajo fue actualizar la versió;n argentina del CVDPM. Para esto, se utilizó; informació;n del Censo Nacional 2010, la Encuesta Nacional de Factores de Riesgo 2013, el estudio CESCAS I, y el estudio PrEViSTA, para actualizar la dinámica del tamaó;±o de la població;n, sus características demográficas, y la distribució;n de factores de riesgo cardiovasculares a lo largo del tiempo. Las proyecciones del modelo se calibraron comparándolas con informació;n sobre eventos de ECV y mortalidad en el aó;±o 2010 (aó;±o de referencia) en Argentina. Las estadísticas argentinas informaron que en 2010 la població;n de 35 o más aó;±os sufrió; un total de 41 219 infartos de miocardio (IM), 58 658 accidentes cerebrovasculares y 281 710 muertes totales. El CVDPM predijo 41 265 IM (diferencia: 0.11%), 58 584 accidentes cerebrovasculares (diferencia: 0.13%) y 280 707 muertes totales (diferencia: 0.36%). En todos los casos, la versió;n final del modelo predijo el nó;ºmero real de eventos cardiovasculares con una precisió;n superior al 99.5%, pudiendo ser utilizado para pronosticar cambios en la incidencia y mortalidad de ECV debidos de la implementació;n de políticas pó;ºblicas.

Cardiovascular disease (CVD) is the leading cause of death in Argentina. Computer simulation models allow to extrapolate evidence to broader populations than the originally studied, over longer timeframes, and to compare different subpopulations. The Cardiovascular Disease Policy Model (CVDPM) is a computer simulation state transition model used to represent and project future CVD mortality and morbidity in the population 35 years-old and older. The objective of this study was to update Argentina’s version of the CVDPM. For this purpose, information from the 2010 National Census, the 2013 National Risk Factor Survey, CESCAS I study, and PrEViSTA study were used to update the dynamics of population size, demographics, and CVD risk factor distributions over time. Model projections were later calibrated by comparing them to actual data on CVD events and mortality in the year 2010 (baseline year) in Argentina. Country statistics for people 35 years-old and older reported for 2010 a total of 41 219 myocardial infarctions (MIs), 58 658 strokes, and 281 710 total deaths. The CVDPM, in turn, predicted 41 265 MIs (difference: 0.11%), 58 584 strokes (difference: 0.13%), and 280 707 total deaths (difference: 0.36%) in the same population. In all cases, the final version of the model predicted the actual number of events with an accuracy superior to 99.5%, and could be used to forecast the changes in CVD incidence and mortality after the implementation of public policies.

Update of the cardiovascular disease policy model to predict cardiovascular events in Argentina

Cardiovascular disease (CVD) is the leading cause of death in Argentina. Computer simulation models allow to extrapolate evidence to broader populations than the originally studied, over longer timeframes, and to compare different subpopulations. The Cardiovascular Disease Policy Model (CVDPM) is a computer simulation state transition model used to represent and project future CVD mortality and morbidity in the population 35 years-old and older. The objective of this study was to update Argentina’s version of the CVDPM. For this purpose, information from the 2010 National Census, the 2013 National Risk Factor Survey, CESCAS I study, and PrEViSTA study were used to update the dynamics of population size, demographics, and CVD risk factor distributions over time. Model projections were later calibrated by comparing them to actual data on CVD events and mortality in the year 2010 (baseline year) in Argentina. Country statistics for people 35 years-old and older reported for 2010 a total of 41 219 myocardial infarctions (MIs), 58 658 strokes, and 281 710 total deaths. The CVDPM, in turn, predicted 41 265 MIs (difference: 0.11%), 58 584 strokes (difference: 0.13%), and 280 707 total deaths (difference: 0.36%) in the same population. In all cases, the final version of the model predicted the actual number of events with an accuracy superior to 99.5%, and could be used to forecast the changes in CVD incidence and mortality after the implementation of public policies.

La enfermedad cardiovascular (ECV) es la principal causa de muerte en Argentina. Los modelos de simulació;n por computadora permiten extrapolar evidencia a poblaciones más amplias que las originalmente estudiadas, a lo largo de períodos prolongados, y comparar diferentes subpoblaciones. El Cardiovascular Disease Policy Model (CVDPM, por sus siglas en ingló;©s) es un modelo de simulació;n utilizado para representar y proyectar la mortalidad y morbilidad por ECV en la població;n de 35 o más aó;±os. El objetivo de este trabajo fue actualizar la versió;n argentina del CVDPM. Para esto, se utilizó; informació;n del Censo Nacional 2010, la Encuesta Nacional de Factores de Riesgo 2013, el estudio CESCAS I, y el estudio PrEViSTA, para actualizar la dinámica del tamaó;±o de la població;n, sus características demográficas, y la distribució;n de factores de riesgo cardiovasculares a lo largo del tiempo. Las proyecciones del modelo se calibraron comparándolas con informació;n sobre eventos de ECV y mortalidad en el aó;±o 2010 (aó;±o de referencia) en Argentina. Las estadísticas argentinas informaron que en 2010 la població;n de 35 o más aó;±os sufrió; un total de 41 219 infartos de miocardio (IM), 58 658 accidentes cerebrovasculares y 281 710 muertes totales. El CVDPM predijo 41 265 IM (diferencia: 0.11%), 58 584 accidentes cerebrovasculares (diferencia: 0.13%) y 280 707 muertes totales (diferencia: 0.36%). En todos los casos, la versió;n final del modelo predijo el nó;ºmero real de eventos cardiovasculares con una precisió;n superior al 99.5%, pudiendo ser utilizado para pronosticar cambios en la incidencia y mortalidad de ECV debidos de la implementació;n de políticas pó;ºblicas.

A Cost Analysis and Cost-Utility Analysis of a Community Pharmacist-Led Intervention on Reducing Cardiovascular Risk: The Alberta Vascular Risk Reduction Community Pharmacy Project (RxEACH).

BACKGROUND: A randomized trial (the Alberta Vascular Risk Reduction Community Pharmacy Project) showed that a community pharmacist-led intervention was efficacious for reducing cardiovascular (CV) risk. However, the cost of this strategy is unknown. OBJECTIVES: We examined the short- and long-term cost of a pharmacist-led intervention to reduce CV risk compared to usual care. METHODS: We conducted a trial-based cost analysis from the perspective of a publicly funded healthcare system. Over 3 and 12 months of follow-up, we examined specific intervention costs (pharmacy claims), related intervention costs (laboratory tests and medications), and ongoing healthcare costs (physician claims, emergency department visits, and hospital admissions). We also used the validated CV Disease Policy Model-Canada to estimate the long-term effects. RESULTS: A total of 684 participants (mean age 62, 57% male) were included. Overall, there were no significant differences in healthcare costs at 3 or 12 months between the usual care and intervention groups (P = .127). The CV disease-related healthcare cost of managing a patient over a lifetime was estimated to be Can$45 530 (95% uncertainty interval [UI], 45 460-45 580) and Can$40 750 (95% UI, 37 780-43 620) in usual care and intervention groups, respectively, an incremental cost savings of Can$4770 per patient (95% UI, 1900-7760). The intervention dominated usual care (better outcomes and lower costs) across 3-year, 5-year, 10-year, and lifetime horizons. CONCLUSION: This economic analysis suggests that a clinical pathway-driven pharmacist-led intervention (previously shown to reduce CV risk) was associated with similar measured healthcare costs over 1 year, and lower extrapolated healthcare costs over a patient lifetime. This strategy could be broadly implemented to realize its benefits.

Cost-Effectiveness of Alirocumab: A Just-in-Time Analysis Based on the ODYSSEY Outcomes Trial.

Background: The ODYSSEY Outcomes (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) trial included participants with a recent acute coronary syndrome. Compared with participants receiving statins alone, those receiving a statin plus alirocumab had lower rates of a composite outcome including myocardial infarction (MI), stroke, and death. Objective: To determine the cost-effectiveness of alirocumab in these circumstances. Design: Decision analysis using the Cardiovascular Disease Policy Model. Data Sources: Data sources representative of the United States combined with data from the ODYSSEY Outcomes trial. Target Population: U.S. adults with a recent first MI and a baseline low-density lipoprotein cholesterol level of 1.81 mmol/L (70 mg/dL) or greater. Time Horizon: Lifetime. Perspective: U.S. health system. Intervention: Alirocumab or ezetimibe added to statin therapy. Outcome Measures: Incremental cost-effectiveness ratio in 2018 U.S. dollars per quality-adjusted life-year (QALY) gained. Results of Base-Case Analysis: Compared with a statin alone, the addition of ezetimibe cost $81 000 (95% uncertainty interval [UI], $51 000 to $215 000) per QALY. Compared with a statin alone, the addition of alirocumab cost $308 000 (UI, $197 000 to $678 000) per QALY. Compared with the combination of statin and ezetimibe, replacing ezetimibe with alirocumab cost $997 000 (UI, $254 000 to dominated) per QALY. Results of Sensitivity Analysis: The price of alirocumab would have to decrease from its original cost of $14 560 to $1974 annually to be cost-effective relative to ezetimibe. Limitation: Effectiveness estimates were based on a single randomized trial with a median follow-up of 2.8 years and should not be extrapolated to patients with stable coronary heart disease. Conclusion: The price of alirocumab would have to be reduced considerably to be cost-effective. Because substantial reductions already have occurred, we believe that timely, independent cost-effectiveness analyses can inform clinical and policy discussions of new drugs as they enter the market. Primary Funding Source: University of California, San Francisco, and Institute for Clinical and Economic Review.

Economic Impact of Financial Incentives and Mailing Nicotine Patches to Help Medicaid Smokers Quit Smoking: A Cost-Benefit Analysis.

An RCT designed to increase Medicaid smokers' quitting success was conducted in California during 2012-2013. In the trial, alternative cessation treatment strategies were embedded in the state's ongoing quitline services. It found that modest financial incentives of up to $60 per participant and sending nicotine patches induced significantly higher cessation rates compared with usual care alone and usual care plus nicotine patches. Building upon that study, this study assessed potential population-level costs and benefits of integrating financial incentives and nicotine patches in a quitline setting for Medicaid smokers. A cost-benefit analysis was undertaken from the Medicaid program's perspective. The Cardiovascular Disease Policy Model was used to simulate future healthcare expenditures over a 10-year horizon for each treatment strategy for a study cohort of California Medicaid enrollees who were aged 35-64 years in 2014 (n=2,452,000). To simulate potential population-level benefits under each treatment strategy, each treatment was applied to all active smokers in the study cohort (n=478,300). Sensitivity analyses were conducted by varying key parameters, such as cessation costs, discount rate, relapse rates, and time horizon. Adding both financial incentives and nicotine patches to usual quitline care would result in $15 million net savings over 10 years, with a benefit-cost ratio of 1.30 compared with the usual care plus nicotine patches strategy. It would yield $44 million net savings, with a benefit-cost ratio of 1.90 compared with usual care alone. The strategy of providing financial incentives and mailing nicotine patches directly to Medicaid smokers who call the quitline is cost saving. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.