Azza Shoaibi

A Cost Effectiveness Analysis of Salt Reduction Policies to Reduce Coronary Heart Disease in Four Eastern Mediterranean Countries

Background Coronary Heart Disease (CHD) is rising in middle income countries. Population based strategies to reduce specific CHD risk factors have an important role to play in reducing overall CHD mortality. Reducing dietary salt consumption is a potentially cost-effective way to reduce CHD events. This paper presents an economic evaluation of population based salt reduction policies in Tunisia, Syria, Palestine and Turkey. Methods and Findings Three policies to reduce dietary salt intake were evaluated: a health promotion campaign, labelling of food packaging and mandatory reformulation of salt content in processed food. These were evaluated separately and in combination. Estimates of the effectiveness of salt reduction on blood pressure were based on a literature review. The reduction in mortality was estimated using the IMPACT CHD model specific to that country. Cumulative population health effects were quantified as life years gained (LYG) over a 10 year time frame. The costs of each policy were estimated using evidence from comparable policies and expert opinion including public sector costs and costs to the food industry. Health care costs associated with CHDs were estimated using standardized unit costs. The total cost of implementing each policy was compared against the current baseline (no policy). All costs were calculated using 2010 PPP exchange rates. In all four countries most policies were cost saving compared with the baseline. The combination of all three policies (reducing salt consumption by 30%) resulted in estimated cost savings of

Forecasting prevalence of type 2 diabetes mellitus in Palestinians to 2030: validation of a predictive model

235,000,000 and 6455 LYG in Tunisia;

Analysing falls in coronary heart disease mortality in the West Bank between 1998 and 2009

39,000,000 and 31674 LYG in Syria;

Health system challenges of cardiovascular disease and diabetes in four Eastern Mediterranean countries.

6,000,000 and 2682 LYG in Palestine and

Salt reduction as a population-based intervention for the prevention of coronary heart diseases: an economic assessment

1,3000,000,000 and 378439 LYG in Turkey. Conclusion Decreasing dietary salt intake will reduce coronary heart disease deaths in the four countries. A comprehensive strategy of health education and food industry actions to label and reduce salt content would save both money and lives.

Making the future ours in the occupied Palestinian territory

Background Projections of the prevalence of diabetes mellitus are mostly based on changes in population demographics. Inclusion of the time trends of the prevalence of obesity and other risk factors could improve the accuracy of the projections and help with the assessment of policy options for prevention. We therefore report the validation of a mathematical model for predicting the prevalence of diabetes. Methods We created a mathematical model in which time trends in population, obesity, and smoking can be integrated, using a Markov approach, to estimate the future prevalence of diabetes. The parameters for the model were derived from publications, except for the incidence of diabetes, which was estimated with DISMOD II (version 1.01), a computer program that can be used to check the consistency of estimates of incidence, prevalence, duration, and case fatality from the baseline estimate of the prevalence of diabetes. We developed the model for the Palestinian population using data that were available for 2000–10. The model was validated by comparison of the predicted and actual prevalence of diabetes. The baseline point was obtained from the Palestinian Demographic Health Survey 2000. We used the Palestinian Family Health Survey 2004, Palestinian Family Health Survey 2006, and Stepwise Survey 2010 to validate the actual prevalence of diabetes. These are national surveys, each with more than 6000 participants. This study was approved by the Institute of Community and Public Health Ethical Review Committee, West Bank. Findings In 2000, the estimated prevalence of diabetes mellitus was 11·5% (95% CI 9·5–13·5) in Palestinian people aged 25 years or older; by 2010, it had increased to 14·5% (12·2–16·7). In this period, prevalence in men rose from 11·7% (9·7–13·6) to 15·9% (13·4–18·1) and in women from 11·4% (9·3–13·3) to 13·2% (11·1–15·2). In 2004, the prevalence reported in the Palestinian Family Health Survey was 10·6% (8·7–12·5) versus an estimated 11·4% (9·7–13·4); in 2006, these values were 11·8% (9·8–13·8) and 12·3% (10·6–14·6), respectively. Comparison of the estimated and reported prevalence showed a good match for 2004, 2006, and 2010. The forecasts for prevalence of diabetes are 20·8% (18·0–23·2) for 2020 and 23·4% (20·7–25·8) for 2030. If the prevalence of obesity starts to fall by 5%, starting in 2010, a 13% reduction in the prevalence of diabetes could be achieved by 2030. Interpretation The estimates of the prevalence of diabetes in 2000–10 obtained with our model were fairly similar to those reported in independent surveys of prevalence in the occupied Palestinian territory. The burden of diabetes is now a huge public health challenge, and according to our model will increase substantially in the next two decades. Therefore, obesity and other risk factors for diabetes need urgent action to address them. Funding European Communitys Seventh Framework Programme.

A population-based approach for implementing change from opt-out to opt-in research permissions

Objectives To analyse coronary heart disease (CHD) mortality and risk factor trends in the West Bank, occupied Palestinian territory between 1998 and 2009. Design Modelling study using CHD IMPACT model. Setting The West Bank, occupied Palestinian territory. Participants Data on populations, mortality, patient groups and numbers, treatments and cardiovascular risk factor trends were obtained from national and local surveys, routine national and WHO statistics, and critically appraised. Data were then integrated and analysed using a previously validated CHD model. Primary and secondary outcome measures CHD deaths prevented or postponed are the main outcome. Results CHD death rates fell by 20% in the West Bank, between 1998 and 2009. Smoking prevalence was initially high in men, 51%, but decreased to 42%. Population blood pressure levels and total cholesterol levels also decreased. Conversely, body mass index rose by 1–2 kg/m2 and diabetes increased by 2–8%. Population modelling suggested that more than two-thirds of the mortality fall was attributable to decreases in major risk factors, mainly total cholesterol, blood pressure and smoking. Approximately one-third of the CHD mortality decreases were attributable to treatments, particularly for secondary prevention and heart failure. However, the contributions from statins, surgery and angioplasty were consistently small. Conclusions CHD mortality fell by 20% between 1998 and 2009 in the West Bank. More than two-third of this fall was due to decreases in major risk factors, particularly total cholesterol and blood pressure. Our results clearly indicate that risk factor reductions in the general population compared save substantially more lives to specific treatments for individual patients. This emphasizes the importance of population-wide primary prevention strategies.

Contrasting cardiovascular mortality trends in Eastern Mediterranean populations: Contributions from risk factor changes and treatments

This paper presents evidence from research into health system challenges of cardiovascular disease (CVD) and diabetes in four Eastern Mediterranean countries: the occupied Palestinian territory, Syria, Tunisia and Turkey. We address two questions. How has the health system in each country been conceptualised and organised to manage the provision of care for those with CVD or diabetes? And what were key concerns about the institutional ability to address this challenge? Research took place from 2009 to 2010, shortly before the political upheavals in the region, and notably in Syria and Tunisia. Data collection involved a review of key documents, interviews with key informants and brief data collection in clinics. In analysing the data, we adopted the analytical schema proposed by Walt and Gilson, distinguishing content, actors, context and process. Key findings from each country highlighted concerns about fragmented provision and a lack of coordination. Specific concerns included: the lack of patient referral pathways, functioning health information systems and investment in staff. Regarding issues underlying these ‘visible’ problems in managing these diseases, we highlight implications of the wider systemic pressure for reform of health-sector finance in each country, based on neoliberal models.

Priority setting for prevention and control of coronary heart disease in the occupied Palestinian territory: a pilot study

Background The incidence of coronary heart diseases is increasing in the occupied Palestinian territory (oPt) and hence poses a growing challenge for treatment. Reduction in the intake of dietary salt is a potentially cost-effective approach to reduce the burden of coronary heart diseases. Here, we report the results of an economic assessment of three interventions of salt reduction in the oPt. Methods We did the analysis from a societal perspective of three salt-reduction interventions—population-wide health promotion campaigns, mandatory labelling of food packaging, and mandatory reduction of salt content of processed food. These interventions were assessed individually, and in combinations of two and all three together. We estimated the costs of policies using past experiences, expert opinion, and hospital records, and costs of health care with a standardised unit cost for treatments. We considered the financial implications for the food industry and public sectors. The total cost of implementation of each policy was compared with the do-nothing scenario. We used data reported in reviews of epidemiological studies as estimates of the expected reduction of the current sodium salt consumption attributable to each policy. The expected change in salt intake was then converted into a change in mean population blood pressure based on estimates reported in a meta-analysis. The change in blood pressure was used to estimate the number of deaths prevented or postponed in 10 years, using the Palestinian IMPACT policy model for coronary heart disease. The estimates were compared with the number of deaths from coronary heart disease that would have been expected in relation to the number in the baseline year. This policy model is an epidemiological model that was used to analyse mortality associated with coronary heart disease and risk factor trends in the West Bank, oPt, between 1998 and 2009, and project mortality trends for the future. We used Microsoft Excel 2010 for our analyses. Findings All policies resulted in a reduction in salt intake of 5–30%, leading to changes of 1–20 mm Hg in systolic blood pressure. All scenarios were cost effective compared with the do-nothing scenario. The cost-effectiveness of the scenarios for per life-year gained was

Use of evidence to support healthy public policy: a policy effectiveness-feasibility loop

134·57–1430·62 (purchasing power parity at 2010 exchange rates). Policies for the labelling of food and use of the three interventions together were the most cost effective. These two scenarios were estimated to save costs (