Heart conditions impose physical, social, financial and health related quality of life limitations on individuals. These conditions result in an economic burden and impact on society due to expenditures on health care treatment, productivity losses from employment impacts, costs of providing formal and informal care, and lost wellbeing. Circulatory diseases presently represent the biggest health burden world-wide, accounting for over 17 million deaths every year; this represents half of all non-communicable disease deaths.1
We conducted a cost-of-illness analysis to assess the economic impact of four heart conditions in Mexico in 2015: hypertension (HTN), myocardial infarction (MI), atrial fibrillation (AF) and heart failure (HF). These conditions were considered noting the increasing prevalence and impacts of these conditions,1 and the study’s ability to provide a common framework to assess their impact, allowing both the health costs and broader economic impacts to be asses- sed. Noting that new methods will need to be devised to address these conditions in the future, both from an access and equality perspective, the study also analyzed the cost effectiveness of two interventions for HF: telemedicine (TM) and structured telephone support (STS) to assess whether alternative models of care can lead to improved outcomes.
A standard cost of illness framework was used to assess the costs associated with the four conditions in 2015. The analysis assessed the prevalence and (in the case of myocardial infarction) incidence of the conditions, the associated expenditures on health care treatment, productivity losses from reduced employment, costs of providing formal and informal care, and lost wellbeing. The analysis was informed by a targeted literature review, data scan and modelling. All inputs and methods were validated by consulting nine clinicians and other stakeholders in Mexico. The cost-effectiveness analysis was based on a meta-analysis and economic evaluation of post-discharge programs in patients with heart failure, assessed from the perspective of the Instituto Mexicano del Seguro Social.
Health system expenditures were estimated based on the proportion of total health expenditure spent treating individual health conditions in Mexico,2 adjusted for the number of admissions and the average length of stay for the four conditions in Mexico3 and a cost loading per person per day in hospital, based on the cost of treating each of these conditions4 (see Appendix for further information).
Consistent with the ‘full or near-full employment’ criterion,b a human capital approach to the estimation of productivity losses was adopted. Calculations involving productivity losses were based on employment rates by age-gender groups. It was assumed that those with heart conditions were, in the absence of the condition, as likely to be employed as others in their corresponding age-gender group. Forgone wage income was based on wage data for Mexico.5 Absenteeism was associated with all of the conditions. For HF it was estimated as 12.66 days for those with New York Heart Association (NYHA) class III/IV and 3.04 days per year for those with NYHA I/II.6 Absenteeism was estimated as 3.03 days per year6 for HTN, 75 days per year for those admitted to hospital7 with MI, and 2.1 days per year8 for AF. Reduced employment participation, where individuals are no longer able to be employed due to their condition, was identified for both HF and MI, but not AF or HTN. For HF, there was a 13% lower employment participation rate (based on those with coronary heart disease).9 The study also showed increased withdrawal of unemployed people from the labour force, especially those aged below 60 years and those engaged in manual work. For MI, there was a 21% lower employment participation (based on those with acute coronary syndrome (ACS) five years after an event).10 As the lower employment participation rates in both the coronary heart disease and ACS studies were based on populations in developed countries these rates were adjusted by the observed rates of reduced employment participation for those with disability in Europe and Latin America, as reported by the Organisation for Economic Co-operation and Development (OECD). Forgone income due to premature death was based on mortality statistics for each condition and the otherwise expected life expectancy according to WHO life tables (see Appendix for further information).
The four heart conditions were estimated to affect approximately 20.5 million people in Mexico, 25.6% of the adultc population. HTN had the highest prevalence of the four conditions, followed by HF. After adjusting for comorbidities, heart conditions were conservatively estimated to result in a financial cost of 96.4 billion pesos (6.1 billion USD) in 2015 in Mexico. Of this, approximately 46% was the health system cost (Table1). In 2015, the burden of these four conditions comprised approximately 4% of total national healthcare expenditure.
Myocardial infarction imposes the greatest financial cost (39.0 billion pesos/2.5 billion USD), followed by heart failure (27.0 billion pesos/1.7 billion USD), hypertension (22.7 billion pesos/1.5 billion USD) and, finally, atrial fibrillation (8.4 billion pesos/532 million USD). In addition, the heart conditions included impose a substantial wellbeing loss. Of the 1.63 million disability adjusted life years (DALYs), adjusted for comorbidities, there are 902,081 healthy years lost
Category | HF | MI | AF | HTN | Total (unadjusted) | Total (adjusted for comorbidities)c |
Health system costs | 7556 | 22,903 | 8111 | 5385 | 43,955 | 43,955 |
28% | 59% | 97% | 24% | 45% | 46% | |
Productivity losses | 19,457 | 16,145 | 246 | 17,316 | 53,164 | 52,441 |
72% | 41% | 3% | 76% | 55% | 54% | |
Income for gone by individualsa | 8259 | 11,874 | 143 | 7731 | 28,008 | 27,611 |
31% | 30% | 2% | 34% | 29% | 29% | |
Income for gone by businessesa | 848 | 1050 | 73 | 7983 | 9954 | 9725 |
3% | 3% | 1% | 35% | 10% | 10% | |
Opportunity cost of informal care by family/friends | 7155 | 631 | 7786 | 7774 | ||
26% | 2% | 8% | 8% | |||
Tax revenue forgone by governmentb | 3194 | 2591 | 30 | 1602 | 7416 | 7332 |
12% | 7% | 0% | 7% | 8% | 8% | |
Total cost (millionpesos) | 27,013 | 39,048 | 8357 | 22,701 | 97,119 | 96,395 |
A Theresult from absenteeism, reduced employment participation, and premature mortality.
B Due to reduced income of individuals with heart conditions and their carers.
C Comorbidities 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.
SC | TM | STS | |
Total costs (pesos) | 169,971 | 432,4890 | 422,164 |
Total QALYs | 3.99 | 5.91 | 5.63 |
Net monetary benefit | 930,090 | 1,194,500 | 1,127,625 |
Incremental costs (pesos) | 262,518 | 252,193 | |
Incremental QALYS | 1.91 | 1.63 | |
Incremental cost (pesos) per QALY | 137,232 | 154,466 | |
Incremental net monetary benefit | 264,410 | 197,535 |
due to disability (YLD) and over 723,306 years of life lost due to premature mortality (YLL).
A Markov model was constructed in TreeAge Pro©2015 to evaluate the cost effectiveness of STS and TM compared with usual care for a hypothetical cohort of patients discharged in the last 28 days following HF related hospitalizations. The model considered two different permanent health states, ‘alive at home’ and ‘dead’ as well as two temporary health states for ‘hospitalized due to HF’ and ‘hospitalized for all other causes’. Over the 30-year time horizon, the estimated discounted cumulative costs for the TM and STS interventions were 262,518 and 252,193 pesos higher than standard care (SC) respectively, but generated an additional 1.91 and 1.63 QALYs, respectively. This resulted in an estimated incremental cost effectiveness ratio (ICER) of 137,232 pesos/QALY and 154,466 pesos/QALY for TM and STS respectively compared to SC (Table 2), noting a willingness to pay (WTP) threshold of 137,727---413,181 pesos/QALY, which is based on one to three times the GDP per capita of Mexico.2 The incremental net monetary benefit was 264,410 pesos for TM vs SC and 197,535 pesos for STS vs SC (see Appendix for further information).