Cardiovascular (CV) risk factors such as hypertension, hyperlipidemia and diabetes, are insufficiently managed, according to current guidelines 1. This mismanagement occurs in spite of the accepted fact that reaching the recommended target goals of the various guidelines is an effective means to reduce morbidity and mortality from atherosclerosis and vascular events 23. Reasons for this shortfall have been described in many recent studies, showing that both the American 45 and the European 67 guidelines, are not truly implemented.

As in other developed nations, the burden of disease attributable to Hypertension, heart disease and stroke in Israel is considerable. These diseases are also among the most expensive diseases to treat 8. In response to these important issues of disease burden in terms of human suffering and treatment cost, we initiated the Ashkelon Hypertension Detection and Control Program (AHDC Program): a community approach to reducing cardiovascular mortality 9. During a 10-year period (1980–1990), we operated a professional doctor-nurse screening team, who were instructed to find those at high risk in control of their risk factors, in order to reduce CV morbidity and mortality. They examined 12,202 subjects, (mean age 51 +/- 7 years, range 20–65 years) accounting for 23.4% of the total regional population. High risk subjects underwent an intensive CV risk factor control program. Subjects (3,506 or 28.6%) were found to have one or more CV risk factors (hypertension, obesity, smoking, hypercholesterolemia). During an average of 2 years, follow-up BP, weight reduction, and smoking cessation remained statistically significant. Total cholesterol was unchanged. Over this period, the standardized mortality ratio (SMR) in the area for acute MI fell from 100 to 76 (P < 0.01), for CV disease from 129 to 107 (P < 0.0001), and for hypertension from 121 to 87 (P < 0.1 NS). The project saved many life-years at no additional net cost to society, and cost-effectiveness analysis showed positive results. Our community approach with mainly non pharmacological treatment was proven to be feasible and cost-effective in reducing CV morbidity and mortality. Subsequent we conducted the Israel Blood Pressure Control (IBPC) program 10, in the year 2000 in 30 general practice clinics in Israel. After 1 year of intervention in 4848 patients according to our method 10, there was a significant increase in control of risk factors. In hypertension this percentage raised from 29.0 to 46.7%, in control of body weight from 36.7 to 43.8%, in Low Density Lipoprotein (LDL) levels from 31.2 to 41.7% while the percentage of patients with glucose levels above 200 mg/dl dropped from 5.2 to 3.1%. Encouraged by these results we decided to propose a nationwide program that could also be extended to act in cooperation with neighboring countries. This study was initiated to help attain this goal and convince the health authorities, by presenting the costs and the utilities if the Ashkelon project were to be extended nationwide.

Interventions will be based on experience from the following two programs:

The program is expected to result in their being 8,749 fewer AMIs, 8,134 fewer PVDs, 8,074 fewer CVAs, 6,765 fewer UAPs and 2,316 fewer cases of ESRD (Table 2). Around half of the estimated total of 2,242 fewer deaths will be due to the reduction in cerebrovascular strokes (1,114 fewer deaths), while there will be 543 fewer deaths from AMIs, 440 fewer deaths from ESRD and 145 fewer deaths from UAP (Table 2). These translate into a total of 35,117 life years saved, around 48.1% due to decreased CVA (Table 3). After adjusting for disabilities, around 18,726 discounted DALYs (24,433 undiscounted) are saved from reduced mortality, of whom 48.6% are due to reduced CVA, 24.6% from fewer AMIs, 20.6% from reduced ESRD and 6.3% from reduced UAP (Table 3).

A smaller quantity of DALYs (13,643 discounted and 17,801 undiscounted) will be saved from reduced morbidity. While the large majority of morbidity gains (around 61.5%) are due to decreased CVA incidence, AMI/UAP and ESRD account for a further 14.3% and 14.3% respectively (Table 3).

In total, around 32,369 discounted DALYs will be saved, around 57.9% being attributable to reduced CVA mortality. Program costs amount to $352.7 million, including $9.8 million for staff education, $19.2 million for telemedicine and operational expenses, $70.0 million for patient training during the first year of treatment, $66.8 for patient maintenance visits in subsequent years and $186.2 million for additional use of pharmaceuticals.

Averted renal dialysis and transplants accounted for the majority (70.2%) of the $ 444.4 million savings in reduced medical treatment costs. In addition there were $93.3 million savings from reduced pharmaceutical use as a result of morbidity decreases. Thus the total of treatment and drug savings ($537.7 million) exceeds treatment costs by $185.0 million (Table 4).

Coronary heart disease and Cerebrovascular Accident (CVA) prevention are priority areas for improving health, especially in developed nations. World-wide targets have been set for the reducing the major Cardiovascular (CV) risk factors: Blood Pressure (BP), diabetes, dyslipidemia, smoking and diet in relation to obesity 2829. Nationwide projects are called for in order to significantly shift any nation's risk factor profile towards proven goals. Health policy and economic decisions makers in each country will be more likely to accept such large preventive projects not only if it the project is proven to save lifes and reduce morbidity, but also if it cost-effective (ie: having a low or even negative cost-per DALYs).

Our calculations show that implementation of a nationwide program to reduce hypertension, is likely to save over two thousand lives in the next 20 years, improve the quality of life in many more people and at the same time actually save $185.0 million in health care resources alone. The study is limited in the sense that it is using current estimates of relative risk and demographics to project disease incidence many years into the future. Economic changes over the next two decades are likely to influence the cost-utility ratio in so far as they will affect lifestyles (eg: may be increased obesity) which in turn will increase or decrease incidence of the diseases in question. In addition biases exist which tend to underestimate DALYs benefits as follows:-

a) Because mortality was only attributable for AMI and UAP for a one year post-hospitalization period. Deaths after this timeframe were conservatively not attributed to coronary syndromes. Similarly deaths due to stroke were very conservatively estimated because stroke deaths were only attributed to in-hospital mortality.

b) We based life years gained on the age specific life expectancies, unadjusted for a decrease of the disease in question. For example, if the program eradicates x% of AMIs, then life years saved should be based on a life expectancies adjusted upwards because of the eradication of x% of deaths from AMIs.

c) our model based its duration of ESRD solely on data from patients receiving dialysis. It is likely that this underestimates the true amount of life years saved as it excludes data from patients who had undergone transplants and had not reverted to dialysis 20. DALYs benefits will be over or underestimated to the extent that fewer or more coronary events occur in February and March, the months on which the incidence survey was based 14. The question whether there is a need for such a nationwide program is clear form many studies 2345 which prove the need for risk factor control in order to achieve CV disease prevention. Despite this, there is growing evidence that the guidelines are not implemented enough and there is under treatment 567, poor patient compliance, physician's unawareness of the new recommendations 19, and non adherence to updating treatment and to targets of treatments 2021.

Economic-Epidemiologic analysis has become a standard method for informing health policy makers, and is also helpful for individual physicians making medical decisions 28. For each of the various CV risk factors, especially hypertension on account of the high prevalence, and the need for long-term, perhaps lifelong, treatment, quite minor changes in antihypertensive practices can have a significant impact on healthcare budgets 29.

Our first previous study, the Ashkelon Hypertension Detection and Control Program (AHDC Program), showed that a community approach to reduce cardiovascular mortality 9, during a 10-year period (1980–1990), can affect reduce CV morbidity and mortality. During an average of 6.4 years, follow-up BP, weight reduction, and smoking cessation, the standardized mortality ratio SMRs for MI, CVD and hypertensive diseases fell significantly. The project saved many life-years at no additional net cost to society. Also in our second project: the Israel Blood Pressure Control (IBPC) program 10, there was a significant increase in the percentage of patents defined as "controlled" in hypertension, Low Density Lipoprotein (LDL) levels and in the percentage of patients with diabetes.

It is important to note the impact of decreased mortality by estimating the additional Disability Adjusted Years of Life (DALYs) and not only life years added.

Each hypertension related disease encounters many measurable obstacles which patients face during their rehabilitation, which in many cases are not completely resolved. These diseases can cause pain, suffering, increasing dysfunction, temporary or permanent unemployment accompanied by attendant life stresses and major reductions in self image and in family status. In Israel, AMI patients are automatically absent from work for three months of rehabilitation as the minimum even if there are no AMI complications. This example shows that on top of the treatment and secondary prevention cost of each AMI there is also a considerable socioeconomic burden that may influence the total balance of the cost utility analysis.

Although probably underestimated the program is expected to result in 8,749 fewer AMIs, 8,134 fewer PVDs, 8,074 fewer CVAs, 6,765 fewer UAPs and 2,316 fewer cases of ESRD (Table 2). Around half of the estimated total of 2,242 fewer deaths will be due to the reduction in cerebrovascular strokes (1,114 fewer deaths), while there will be 543 fewer deaths from AMIs, 440 fewer deaths from ESRD and 145 fewer deaths from UAP. These translates into a total of 35,117 life years saved.

For CVA the whole socioeconomic benefits are even more likely to have been underestimated, as the program may also prevent work disability. The 1.7 relative risk of strokes in hypertensive patients 19 translates into a potential 41.2% reduction of strokes and stroke sequlae in successfully treated hypertensive cases. A further source of underestimation of DALYs saved is that our model based its duration of ESRD solely on data from patients receiving dialysis. It is likely that this underestimates the true amount of life years saved as it excludes data from patients who had undergone transplants and had not reverted to dialysis 20.

We feel that, consideration should be given to extending such a potentially cost-effective project (which saves life years, morbidity and resources) to a nationwide basis, in order to encompass as many people as possible.

Our study shows that a national health education program to reduce cardiovascular risk factors, over the next 20 years, should succeed in decreasing the risk in one-half of AMI and UAP by 16.0%, CVA by 41.2%, CRF by 50.0% and PVD by 42.6%. The implementation of such a program nationwide is likely to save over two thousand lives, improve the quality of life in many more people and at the same time actually save $185.0 million in health care resources alone. It is conceivable that it may be extended not only throughout our country, but also to neighboring countries.

AHDC Ashkelon Hypertension Detection and Control

AMI Acute Myocardial Infarction

BP Blood Pressure

CV Cardiovascular

CVA Cerebrovascular Accident

DALYs Disability Adjusted Life Years

ESRD End stage renal disease

GDP Gross domestic product

HSV Health Status Valuation

IBPC Israel Blood Pressure Control

MOH Ministry of Health

LDL Low Density Lipoprotein

PVD Peripheral vascular disease

UAP Unstable Angina Pectoris

The author(s) declare that they have no competing interests.

CY instigated the project, designed, researched and wrote the introduction and discussion sections of the manuscript. GG designed, researched, built the model and wrote the methods and results sections of the manuscript.

RV instigated, designed and researched the project and commented on drafts of the paper. DD instigated, designed and researched the project and commented on drafts of the paper. DG instigated, designed and researched the project and commented on drafts of the paper.

See Tables: 5, 6 and 7.