Research and Development Agenda
The cost-effectiveness data reviewed in this chapter indicate that the best use of resources for personal-level interventions for preventing CVD mediated by high blood pressure, cholesterol, and bodyweight would be combination medications targeted to those at high absolute risk. This strategy represents a considerable departure from existing paradigms, such as hypertension treatment. Research and development is therefore required in several areas to develop, implement, and evaluate this strategy. This research could include several themes as follows:
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Refine absolute risk-based treatment in developing country settings:
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Evaluate optimal communications to the public and to health professionals that explain the rationale for this new paradigm and its advantages over traditional paradigms, such as hypertension treatment. One barrier to adopting preventive therapy based on absolute risk has been its relative complexity compared with dichotomous diagnosis-based strategies, such as hypertension-no hypertension.
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Develop simple methods for predicting absolute risk using straightforward, inexpensive, direct measures, such as physical examination, clinical history, and on-site tests. These methods would likely involve low-cost algorithms completed by a multipurpose health care worker involving, for example, the collection of data on age, sex, tobacco use, blood pressure, waist circumference, and urine dipstick results. The development of different levels of screening protocol may also be needed in certain settings.
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Calibrate existing algorithms for different disease rates and cardiovascular profiles in developing countries.
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Develop treatment algorithms that can easily be adopted in resource-poor settings by, for example, multipurpose health care workers.
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Develop methods for predicting absolute risk on the basis of the probability of lost healthy life years as well as the probability of a clinical event. This strategy could mean developing an index of healthy life years at risk from a cardiovascular event in the next five years, which would require taking case fatalities into consideration and discounting. A major barrier to adopting a strategy based on absolute risk has been the absence of a time-based measure and, hence, the equal value placed on preventing an event at a young and at an old age.
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Develop and evaluate combination treatments:
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Carry out new research on the ideal combinations for different patient groups and populations at different stages of the health transition. Local initiatives would be needed to determine the ideal combination of medications based principally on cost, tolerability, and ability to lower risk-factor levels. One default set of interventions could be an angiotensin-converting enzyme inhibitor (for example, enalapril or lisinopril); a diuretic (such as hydrochlorothiazide or chlothalidone); a statin (for instance, simvastatin or lovastatin); and low-dose aspirin.
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Measure the potential costs and benefits of adding other active agents, such as vitamins or diabetic medications.
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Quantify the extent of improved access, acceptability, and tolerability for people with symptomatic vascular disease who have established indications for those medications.
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Evaluate the benefits and costs in developing countries with large-scale clinical trials and demonstration projects, both among patients who have established indications (compared with usual care) and among those who do not have clear indications but are still at high risk (compared with a placebo).
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Evaluate the advantages and disadvantages of a polypill versus unit-of-use packs and other novel delivery strategies.
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Investigate weight-loss initiatives:
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Develop strategies to improve the effectiveness of personal interventions to reduce bodyweight in developing countries.
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Evaluate the use of gastric surgery for weight loss in the extremely obese in selected settings.
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Assess technology:
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Screen which technologies should be transferred to developing countries on the basis of cost-effectiveness criteria.
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Design new technologies specifically for use by community health workers (for example, point-of-care devices).
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Review public and personal health services:
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Carry out a critical evaluation of community health workers versus trained health professionals in delivering simplified screening and treatment regimens.
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Provide guideline assistance for CVD prevention and management to regional and country-specific ministers of health and policy makers.
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Support demonstration projects to determine the limitations for managing chronic conditions in resource-poor settings.
