"Screening to identify individuals in need of primary prevention should focus on family members and deprived communities. Mass screening of the whole population may be difficult to justify as the incremental cost is much higher and incremental effectiveness is lower," report Jill Pell, from University of Glasgow, UK, and colleagues in the journal Heart.
The researchers emphasize that "the cost-effectiveness of targeted screening is not achieved at the expense of coverage, since this combined strategy identifies the vast majority of high-risk people in the general population."
The researchers compared effectiveness, cost-effectiveness, and coverage of different simulated screening strategies using cross-sectional data from the Scottish Health Survey on 3921 asymptomatic members of the general population aged 40–74 years.
High risk was defined as an ASSIGN risk score of ≥20, corresponding to a 20% or more risk for a CVD event over the subsequent 10 years and the recommended cut-off for primary prevention in Scotland, UK.
Analysis focusing on identifying people at high risk for premature CVD (in men aged 40–54 years and women aged 40–64 years) showed that mass screening of the whole population would identify the entire population at high risk. The approach would require 16 individuals to be screened for each high-risk person identified, at a cost of £370.
By comparison, targeting deprived communities would result in 17% of the total population being screened but would identify 45% of the high-risk population, identifying one high-risk individual for every 6.1 people screened, at a cost of £141.
Screening family members, ie, offspring of people who die prematurely of CVD, would mean screening 28% of the total population but would identify 61% of the high-risk population, requiring 7.4 people to be screened per high-risk person identified, at a cost of £170.
And combining both targeted approaches would enable 84% of high-risk individuals to be identified by screening only 41% of the general population.
Using incremental cost-effectiveness analysis, the authors also found that the two targeted strategies combined was better than using either in isolation, because the more effective strategy was secured for a lower cost per additional high-risk person identified.
Furthermore, extending coverage to mass screening would require an additional 58.8 people to be screened to identify each additional high-risk person, at a cost of £1358.
Writing in an accompanying editorial, M Justin Zaman and Melvyn Jones, both from University College London, supported a need for a "dual approach" to screening, emphasizing that the aim would be for more equity of outcome (reduced CV events) and not equity to access to interventions such as individual CV risk screening.
They add that the current study "adds a health economic argument to reinforce the reality that, as a society, we cannot afford to continue to funnel more and more money into wider screening of diseases caused by lifestyle without also dealing with the population-level causes of those lifestyles."
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