ABC | Volume 111, Nº1, July 2018

Original Article Stevens et al The Economic Burden of Heart Conditions in Brazil Arq Bras Cardiol. 2018; 111(1):29-36 b Percentage reflects the evidence from studies among populations aged 20 years and over. c As promoted by the WHO Choosing Interventions that are Cost-Effective project, an intervention that costs less than three times the national annual GDP/ capita is considered cost-effective, whereas one that costs less than once the national annual GDP/capita is considered highly cost-effective. Table 3 – Financial cost of heart conditions in Brazil per case, 2015 (reais) HF MI AF HTN Health system cost per case 5 085 (65%) 48 118 (72%) 3 075 (94%) 25 (14%) Productivity cost per case 2 693 (35%) 18 678 (28%) 187 (6%) 156 (86%) Total financial cost per case 7 777 66 797 3 262 180 HF: heart failure; MI: myocardial infarction; AF: atrial fibrillation; HTN: hypertension. Table 4 – Loss of wellbeing of heart conditions in Brazil, 2015 Condition YLDs YLLs DALYs HF 270 806 (14%) 251 136 (18%) 521 941 (16%) MI 2 128 (0.1%) 1 112 469 (80%) 1 114 597 (34%) AF 269 014 (14%) 28 237 (2%) 297 251 (9%) HTN 1 380 312 (72%) 1 380 312 (42%) Total (unadjusted) 1 922 260 1 391 842 3 314 102 Total (adjusted for comorbidities)^ 1 901 386 1 340 453 3 241 838 HF: heart failure, MI: myocardial infarction, AF: atrial fibrillation, HTN: hypertension. ^ : Comorbidity totals do not sum to the total of the individual conditions as one person can have more than one condition and the interaction between conditions causes the total estimate of the four conditions together to vary. YLDs: years lost due to disability; YLLs: years of life lost due to premature mortality; DALYs: disability-adjusted life-years. Results Cost of illness for heart failure, myocardial infarction, atrial fibrillation and hypertension The four heart conditions were estimated to affect approximately 45.7 million people in Brazil, 32.0% of the adult b population. After adjusting for comorbidities, heart conditions were conservatively estimated to result in a financial cost of 56.2 billion reais (17.3 billion USD) in 2015 in Brazil. Of this, approximately 62.9% was health system cost. In 2015, the burden of these four conditions comprised approximately 5.5% of total national healthcare expenditure. Prevalence/incidence HTN has the highest prevalence of the four conditions, followed by HF. As outlined in Table 1 there were 48.9 million conditions affecting 45.7 million people (some people have more than one condition). Economic impact MI imposes the greatest financial cost, followed by HF, HTN and, finally, AF. Table 2 outlines the cost per condition by bearer of cost, demonstrating that each condition impacts individuals, government and society differently. Health costs make up the majority of expenditure for HF, MI and AF, reflecting the nature of Brazil’s health system. Table 3 shows that HTN has the lowest cost per case and MI the highest. While the costs per case seem quite small for HTN, they reflect the total cost of the condition divided by the total number of people with the condition; whether they are receiving treatment or not. This per person cost should be considered in this ‘average’ context, rather than reflecting the actual health costs incurred for someone receiving treatment. Loss of wellbeing In addition, the heart conditions included impose a substantial wellbeing loss as outlined in Table 4. Of the 3.2 million disability adjusted life years (DALYs), adjusted for comorbidities, there are 1.9 million healthy years lost due to disability (YLD) and over 1.3 million years of life lost due to premature mortality (YLL). Cost-effectiveness analysis for heart failure Base case result Over the 30-year time horizon, the estimated discounted cumulative costs for the TM and STS interventions were 50,098 and 44,038 reais higher than SC, respectively, but generated an additional 1.91 and 1.63 QALY, respectively. This resulted in an estimated incremental cost-effectiveness ratio (ICER) of 26,437–81,984 reais/QALY and 27,281 reais/QALY for TM and STS, respectively, compared to SC, noting a willingness to pay (WTP) threshold of 27,328 reais/QALY. The threshold was based on one to three times the GDP per capita of Brazil. 6c The incremental net monetary benefit was 1,688 reais for TM vs SC and 77 reais for STS vs SC (Table 5). 33