Elsevier

The Lancet

Volume 391, Issue 10126, 24–30 March 2018, Pages 1224-1236
The Lancet

Review
Cardiovascular, respiratory, and related disorders: key messages from Disease Control Priorities, 3rd edition

https://doi.org/10.1016/S0140-6736(17)32471-6Get rights and content

Summary

Cardiovascular, respiratory, and related disorders (CVRDs) are the leading causes of adult death worldwide, and substantial inequalities in care of patients with CVRDs exist between countries of high income and countries of low and middle income. Based on current trends, the UN Sustainable Development Goal to reduce premature mortality due to CVRDs by a third by 2030 will be challenging for many countries of low and middle income. We did systematic literature reviews of effectiveness and cost-effectiveness to identify priority interventions. We summarise the key findings and present a costed essential package of interventions to reduce risk of and manage CVRDs. On a population level, we recommend tobacco taxation, bans on trans fats, and compulsory reduction of salt in manufactured food products. We suggest primary health services be strengthened through the establishment of locally endorsed guidelines and ensured availability of essential medications. The policy interventions and health service delivery package we suggest could serve as the cornerstone for the management of CVRDs, and afford substantial financial risk protection for vulnerable households. We estimate that full implementation of the essential package would cost an additional US$21 per person in the average low-income country and $24 in the average lower-middle-income country. The essential package we describe could be a starting place for low-income and middle-income countries developing universal health coverage packages. Interventions could be rolled out as disease burden demands and budgets allow. Our outlined interventions provide a pathway for countries attempting to convert the UN Sustainable Development Goal commitments into tangible action.

Introduction

Adults today are most likely to die from a cardiovascular, respiratory, or related disorder (CVRD), with 43% of overall deaths and 49% of adult deaths estimated, by WHO, to be due to CVRDs in 2015 (figure 1).1 Most CVRDs are preventable or, if they do occur, can be treated to improve longevity and reduce disability. The ability to secure resources for optimal risk reduction and treatment, and to ensure consistent and persistent therapeutic compliance, is a challenge even for high-income countries (HICs). In low-income and middle-income countries (LMICs), limited capacity to detect these silent diseases and provide early treatment contributes to the rapid emergence of advanced complications and premature death.

Cardiovascular, Respiratory, and Related Disorders, the fifth volume of the 3rd edition of Disease Control Priorities (DCP-3 CVRDs), covers three of the four major non-communicable diseases (NCDs) prioritised by the UN high-level meeting on prevention and control of NCDs in 2011:2 cardiovascular diseases (CVDs; ischaemic heart disease and its risk factors—ie, obesity, physical inactivity, tobacco, high blood pressure, and abnormal lipids—and stroke, peripheral artery disease, structural heart disease, and congestive heart failure), respiratory diseases, and diabetes. We also include kidney disease as a related condition (see appendix for complete list of conditions). Cancers and mental health, also typically grouped among NCDs, are covered in other volumes of DCP-3.3, 4, 5 CVRDs are closely related, some (eg, hypertension or hyperlipidaemia) serving as precursors, whereas others are sequelae (eg, heart failure or peripheral artery disease), and therefore they share prevention and management measures. Panel 1 summarises the key messages from DCP-3's volume 5 and provides a framework for systematically addressing CVRDs in LMICs.

We discuss the overarching burden of CVRDs, including the reasons LMICs face disproportionately high premature mortality and disability rates. We summarise the effectiveness of and cost-effectiveness evidence for relevant health interventions and policies, and propose a costed essential package of 36 interventions that are feasible for low-income countries (LICs) and lower-middle-income countries to adapt and implement.

Section snippets

High risk of death, disability, and impoverishment

The world's population is ageing. For most of the 20th century, 5% or fewer people reached the age of 65 years; nowadays, people older than 65 years constitute 10% of the world's population, and this proportion is expected to increase to more than 15% by 2030.7 Combined with population growth, population ageing has led to an overall increase in the number of people dying from CVRDs, because although the propensity for these diseases starts in utero, their substantive effects are seen in

Cost-effectiveness of interventions for CVRDs

We reviewed the cost and cost-effectiveness of various CVRD clinical interventions and related policies, with the goal of creating a package of CVRD interventions for LMICs.51 We reviewed the published literature on the cost of the provision of preventive care and treatment for cardiovascular and metabolic diseases,52 and the cost-effectiveness of CVRD interventions in LMICs. Guidelines for reporting cost-effectiveness results were not uniform, and to accurately interpret the results, reference

Pathways to addressing CVRDs in LMICs

After the UN highlighted the growing and detrimental effect of NCDs on the health and wealth of nations,2 WHO produced a Global Action Plan for the Prevention and Control of NCDs.70 Of the eight voluntary targets set to help countries reduce NCD mortality, six focus on prevention; specifically, interventions that improve diet and reduce smoking, obesity, and physical inactivity. To assist countries in meeting WHO targets, we offer a set of policies and interventions that form an essential

Conclusions

We offer a range of effective and cost-effective policies and interventions to reduce the high and mounting global health burden of CVRDs. We reviewed the evidence for CVRD interventions to assemble a DCP-3 essential package of the most effective policies and services that could be implemented in LMICs. Modelled studies suggest that countries can expect a high return on investment from prevention and control of CVRDs, especially from the implementation of population prevention policies that

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