Cost and cost-effectiveness of a school-based education program to reduce salt intake in children and their families in China

Objective The School-based Education Program to Reduce Salt Intake in Children and Their Families study was a cluster randomized control trial among grade five students in 28 primary schools and their families in Changzhi, China. It achieved a significant effect in lowering systolic blood pressure (SBP) in all family adults by 2.3 mmHg and in elderlies (aged > = 60 years) by 9.5 mmHg. The aim of this study was to assess the cost-effectiveness of this salt reduction program. Methods Costs of the intervention were assessed using an ingredients approach to identify resource use. A trial-based incremental cost-effectiveness ratio (ICER) was estimated based on the observed effectiveness in lowering SBP. A Markov model was used to estimate the long-term cost-effectiveness of the intervention, and then based on population data, extrapolated to a scenario where the program is scaled up nationwide. Findings were presented in terms of an incremental cost per quality-adjusted life year (QALY). The perspective was that of the health sector. Results The intervention cost Int$19.04 per family and yielded an ICER of Int$2.74 (90% CI: 1.17–12.30) per mmHg reduction of SBP in all participants (combining children and adult participants together) compared with control group. If scaled up nationwide for 10 years and assumed deterioration in treatment effect of 50% over this period, it would reach 165 million families and estimated to avert 42,720 acute myocardial infarction deaths and 107,512 stroke deaths in China. This would represent a gain of 635,816 QALYs over 10-year time frame, translating into Int$1,358 per QALY gained. Conclusion Based on WHO-CHOICE criteria, our analysis demonstrated that the proposed salt reduction strategy is highly cost-effective, and if scaled up nationwide, the benefits could be substantial. Trial registration ClinicalTrials.gov NCT01821144

[1]  Franziska Wulf,et al.  Methods For The Economic Evaluation Of Health Care Programmes , 2016 .

[2]  Ian J. Brown,et al.  Dietary sources of sodium in China, Japan, the United Kingdom, and the United States, women and men aged 40 to 59 years: the INTERMAP study. , 2010, Journal of the American Dietetic Association.

[3]  Kirsten Bibbins-Domingo,et al.  Projected effect of dietary salt reductions on future cardiovascular disease. , 2010, The New England journal of medicine.

[4]  Gretchen A. Stevens,et al.  The Age-Specific Quantitative Effects of Metabolic Risk Factors on Cardiovascular Diseases and Diabetes: A Pooled Analysis , 2013, PloS one.

[5]  J. Stamler,et al.  The INTERSALT Study: background, methods, findings, and implications. , 1997, The American journal of clinical nutrition.

[6]  W. Elliott.  Population Strategies to Decrease Sodium Intake and the Burden of Cardiovascular Disease: A Cost-Effectiveness Analysis , 2011 .

[7]  Ashutosh Kumar Singh,et al.  Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015 , 2016, Lancet.

[8]  M. Sculpher,et al.  Representing uncertainty: the role of cost-effectiveness acceptability curves. , 2001, Health economics.

[9]  M. Drummond,et al.  Health Care Technology: Effectiveness, Efficiency and Public Policy@@@Methods for the Economic Evaluation of Health Care Programmes , 1988 .

[10]  Guy S. Parcel,et al.  How individuals, environments, and health behaviors interact: Social cognitive theory. , 2008 .

[11]  A. Husseini,et al.  A Cost Effectiveness Analysis of Salt Reduction Policies to Reduce Coronary Heart Disease in Four Eastern Mediterranean Countries , 2014, PloS one.

[12]  L. Goldman,et al.  The future impact of population growth and aging on coronary heart disease in China: projections from the Coronary Heart Disease Policy Model-China , 2008, BMC public health.

[13]  G. MacGregor,et al.  Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials , 2013, BMJ : British Medical Journal.

[14]  Karen Tu,et al.  Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related health care costs in Canada. , 2007, The Canadian journal of cardiology.

[15]  D. Bennett,et al.  Blood pressure and cardiovascular disease in the Asia Pacific region. , 2003, Journal of hypertension.

[16]  Dong Zhao,et al.  Epidemiological Transition of Stroke in China: Twenty-One–Year Observational Study From the Sino-MONICA-Beijing Project , 2008, Stroke.

[17]  Andrew E Moran,et al.  Global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990–2010: findings from the Global Burden of Disease Study 2010 , 2013, The Lancet. Global health.

[18]  F. Hu,et al.  National trends in hospital length of stay for acute myocardial infarction in China , 2015, BMC Cardiovascular Disorders.

[19]  Li Chen,et al.  Prevalence of cardiovascular disease risk factor in the Chinese population: the 2007-2008 China National Diabetes and Metabolic Disorders Study. , 2012, European heart journal.

[20]  Elizabeth Dunford,et al.  Target Salt 2025: A Global Overview of National Programs to Encourage the Food Industry to Reduce Salt in Foods , 2014, Nutrients.

[21]  G. MacGregor,et al.  Importance of Salt in Determining Blood Pressure in Children: Meta-Analysis of Controlled Trials , 2006, Hypertension.

[22]  Tammy O. Tengs,et al.  One thousand health-related quality-of-life estimates. , 2000, Medical care.

[23]  P. Dalal.  Burden of Stroke: Indian Perspective , 2004, International journal of stroke : official journal of the International Stroke Society.

[24]  S. Tokunaga,et al.  Analysis of hospital charges for cerebral infarction stroke inpatients in Beijing, People's Republic of China. , 2002, Health policy.

[25]  S. Basu,et al.  Dietary Salt Reduction and Cardiovascular Disease Rates in India: A Mathematical Model , 2012, PloS one.

[26]  K. Glanz,et al.  Health behavior and health education : theory, research, and practice , 1991 .

[27]  T. Blakely,et al.  Health and Economic Impacts of Eight Different Dietary Salt Reduction Interventions , 2015, PloS one.

[28]  Bradley Efron,et al.  Missing Data, Imputation, and the Bootstrap , 1994 .

[29]  Li Yang,et al.  Economic burden of cardiovascular diseases in China , 2008, Expert review of pharmacoeconomics & outcomes research.

[30]  J. Critchley,et al.  An economic evaluation of salt reduction policies to reduce coronary heart disease in England: a policy modeling study. , 2014, Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research.

[31]  Alan D. Lopez,et al.  The Global Burden of Disease Study , 2003 .

[32]  Anthony Rodgers,et al.  Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk , 2003, The Lancet.

[33]  P. McEwan.  Cost-effectiveness analysis of education and health interventions in developing countries , 2011 .

[34]  Orton,et al.  EFFECTS ON BLOOD PRESSURE OF REDUCED DIETARY SODIUM AND THE DIETARY APPROACHES TO STOP HYPERTENSION ( DASH ) DIET , 2000 .

[35]  K. Bønaa,et al.  Cost and health consequences of reducing the population intake of salt , 2000, Journal of epidemiology and community health.

[36]  C. Mathers,et al.  Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use , 2007, The Lancet.

[37]  G. MacGregor,et al.  Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality , 2014, BMJ Open.

[38]  B. Popkin,et al.  Understanding the patterns and trends of sodium intake, potassium intake, and sodium to potassium ratio and their effect on hypertension in China. , 2014, The American journal of clinical nutrition.

[39]  Lijing L. Yan,et al.  A school-based education programme to reduce salt intake in children and their families (School-EduSalt): protocol of a cluster randomised controlled trial , 2013, BMJ Open.

[40]  Dong Zhao,et al.  [The changing case-fatality of acute stroke in Beijing during 1984 to 2000]. , 2007, Zhonghua nei ke za zhi.

[41]  E. Mervaala,et al.  Sodium intake and hypertension. , 2006, Progress in cardiovascular diseases.

[42]  Alan D. Lopez,et al.  Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013 , 2016, The Lancet.

[43]  Jun Ma,et al.  School based education programme to reduce salt intake in children and their families (School-EduSalt): cluster randomised controlled trial , 2015, BMJ : British Medical Journal.

[44]  L. Goldman,et al.  The Cost-Effectiveness of Low-Cost Essential Antihypertensive Medicines for Hypertension Control in China: A Modelling Study , 2015, PLoS medicine.

[45]  Youfa Wang,et al.  Tracking of Blood Pressure From Childhood to Adulthood: A Systematic Review and Meta–Regression Analysis , 2008, Circulation.