Cost-Effectiveness of Cardiac Surgery in the Developing World

Cardiac surgery is needed, but too expensive.” A sentence so often heard, yet a sentence so unsupported. The third edition of Disease Control Priorities (DCP3) lists 44 essential surgical procedures based on their cost-effectiveness in low- and middle-income countries, highlighting their favourable cost-effectiveness compared to several other public health priorities (e.g., antiretrovirals for HIV/AIDS and oral rehydration therapy for diarrhoea). However, DCP3 explicitly mentions not including cardiac surgery due to lack of cost-effectiveness analyses (CEA), despite recognising the significant burden of disease.
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On November, 16th 2018, Cardarelli et al. published “Cost-effectiveness of Humanitarian Pediatric Cardiac Surgery Programs in Low- and Middle-Income Countries” and depicted the impact of the William Novick Cardiac Alliance during humanitarian paediatric cardiac surgery missions in 10 centers in China, Macedonia, Honduras, Iran, Iraq, Libya, Nigeria, Pakistan, Russia, and Ukraine. 446 paediatric patients were operated on with a mean age of 3.7 years.
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The estimated cost per surgery was $6,831 and the largest program service expenses were the estimated wages by the volunteers and donated medicines and disposables. These represented nearly 60% of all expenses. Other significant service costs included team travel and boarding, contracted medical services, and clinical staff salaries and benefits. The remaining costs included smaller amounts spent in one-time contracts, shipping costs, other medical expenses, and bank fees.
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On average, cost-effectiveness of the intervention was $171 per DALY averted, approximating ophthalmic surgery ($136) and common general surgical procedures ($82), and more favourable than common maternal and child health interventions and public health interventions such as oral rehydration therapy and HIV/AIDS antiretroviral therapy (Figure). The authors note that some limitations exist that can potentially affect the actual cost per DALY averted, but emphasise the limited difference of the overall outcome.
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Cost-effectiveness of Surgery in Low- and Middle-income Countries A Systematic Review
Figure from “Cost-effectiveness of Surgery in Low- and Middle-income Countries: A Systematic Review” by Grimes et al.
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The paper highlights the high cost-effectiveness of paediatric cardiac surgical care through humanitarian efforts, and is the first paper undermining the myth of unfavourable cost-effectiveness thereof. Future research in LMIC centers ought to delineate whether facilities that are in place and work at high volume (i.e., use economies of scale) can further reduce costs per DALY averted and identify just how cost-effective (paediatric) cardiac surgery in LMICs is.
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Nearly six billion people live without access to cardiac surgical care, and as many as 18 million people die every year to cardiovascular diseases. Many cardiac conditions, including most ischaemic, congenital, and rheumatic heart disease require surgery at a given time during their lifetime. Congenital and rheumatic heart disease in children are particularly in need, yet individual costs (and lack of health insurance) and lack of access to care remain important barriers.
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And so the question remains: is cardiac surgery actually too expensive? Or do the DALYs averted and socioeconomic impact outweigh the high upfront cost of establishing cardiac services in low- and middle-income countries?

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