Using Community Health Workers to Manage Hypertension in Urban India: A Cost-Effectiveness Analysis Adrianna Murphy, M.Sc. London School of Hygiene and Tropical Medicine; Harvard School of Public Health Joshua Schulman-Marcus, M.D. Columbia University Medical School Dorairaj Prabhakaran, M.D., M.P.H. Centre for Chronic Disease Control Tom Gaziano, M.D., PhD. Harvard Medical School; Harvard School of Public Health Burden of CVD in India Source: KS Reddy. 2007. ”India wakes up to the threat of cardiovascular diseases" Journal of the American College of Cardiology. Oct 2;50(14):1370-2 A potential role for Community Health Workers ? The Evidence: • • • • • Lin, T. et al; 2004 Yuchi, Taiwan 6 visits by CHWs 3.8 mm/Hg reduction for men 7.1 mm/Hg reduction for women The Evidence: • • • • Levin, et al.; 2003 Inner City Baltimore 1 visit from CHW 6.5 mm/Hg reduction To analyse cost-effectiveness: • Estimate risk of CVD events (fatal and non) • Estimate cost of CVD events • Design hypothetical CHW intervention • Estimate costs of CHW intervention Risk: Global Markov CVD Model Population estimates Adults ages 35-74 By age and sex UN Population Division Distribution of risk factors Region specific Global Burden of Disease Project Ten-year risk of CVD events Framingham Risk Score Annual probability of nonCVD death Based on life tables WHO Fatal or nonfatal CVD events Costs: Global Markov CVD Model Likelihood of hospitalization or secondary treatment WHO PREMISE Cost of medications Management Sciences for Health Cost of clinic visits and hospitalizations WHO CHOICE Cost of CVD CHW intervention: design + = 3 mm/Hg reduction in systolic blood pressure CHW intervention: costs • Cost estimates from WHO-CHOICE; expert opinion • CHW salary = 3,908 USD/year • Total cost of intervention for one year = $ 141, 904; $6.44/patient, $3.22/visit Results • $141,000 cost offset by $110,000 saved • 65 DALYs averted annually • $475/DALY averted Results: sensitivity analysis • +/-25% of overall program costs • $140-1600 per DALY averted • CHW salary below $1,400 or number of visits reduced = intervention cost-saving Results: sensitivity analysis • 3 to 7 mm/Hg decrease • At 5mm/Hg ICER = $180/DALY averted • Anything above 5.3 mm/Hg reduction = intervention cost-saving Conclusions A hypothetical intervention for which CHWs are paid $3900 annually, and achieve a 3 mm/Hg reduction in blood pressure is very cost-effective. At higher estimates of blood pressure reduction the intervention becomes cost-saving. CHW intervention may also lead to improvements in other CVD risk factors and reductions in CVD-related morbidity would likely lead to increases in work productivity.