Cost-effectiveness of group medical visits and microfinance interventions versus usual care to manage hypertension in Kenya: a secondary modelling analysis of data from the Bridging Income Generation with Group Integrated Care (BIGPIC) trial

Background The Bridging Income Generation with Group Integrated Care (BIGPIC) trial in rural Kenya that integrating usual care with group medical visits or microfinance interventions reduced systolic pressure and cardiovascular risk in participants. We aimed to estimate the incremental cost-effectiveness three BIGPIC interventions for a modelled cohort and by sex, as well as the cost of implementing interventions. Methods For this analysis, we used data collected during the BIGPIC trial, a four-group, cluster-randomised conducted in the western Kenyan catchment area of the Academic Model Providing Access to Healthcare. enrolled participants from 24 rural health facilities in rural western Kenya aged 35 years or older with increased blood pressure or diabetes. Participants were assigned to receive either usual care, group medical microfinance, or a combination of group medical visits and microfinance (GMV-MF). Our model estimated incremental cost-effectiveness of the three BIGPIC interventions via seven health states (ie, a hypertensive five chronic cardiovascular-disease states, and a death state) by simulating transitions between health states hypothetical cohort of individuals with hypertension on the basis of QRISK3 scores. In every cycle, participants accrued costs and disability-adjusted life-years (DALYs) associated with their health state. Incremental effectiveness ratios (ICERs) were calculated for the entire modelled cohort and by sex by dividing the incremental cost by the incremental effectiveness of the next most expensive intervention. The main outcome of this was ICERs for each intervention evaluated. This analysis is registered at ClinicalTrials.gov (NCT02501746). Findings Between Feb 6, 2017, and Dec 29, 2019, 2890 people were recruited to the BIGPIC 2020 (69<middle dot>9%) of 2890 participants were female and 870 (30<middle dot>1%) were male. At baseline, mean score was 11<middle dot>5 (95% CI 11<middle dot>1-11<middle dot>9) for the trial population, 11<middle dot>9 (11<middle dot>5-12<middle dot>2) for male participants, and (11<middle dot>0-11<middle dot>6) for female participants. For the population of Kenya, group medical visits were estimated US$7 more per individual than usual care and result in 0<middle dot>005 more DALYs averted (ICER $1455 per DALY averted). Microfinance was estimated to cost $19 more than group medical visits but was only estimated to avert 0<middle dot>001 DALYs. Relative to group medical visits, GMV-MF was estimated to cost $29 more and avert 0<middle dot>009 more ($3235 per DALY averted). Relative to usual care, GMV-MF was estimated to cost $37 more and avert 0<middle dot>014 DALYs ($2601 per DALY averted). In the first year of the intervention, usual care was estimated to be the expensive intervention to implement ($87 per participant; $10 238 per health-facility catchment area [HFCA]), then group medical visits ($99 per participant; $12 268 per HFCA), then microfinance ($120 per participant; $14 172 per HFCA), with GMV-MF estimated to be the most expensive intervention to implement ($139 per participant; $16 913 per HFCA). Interpretation Group medical visits and GMV-MF were estimated to be cost-effective strategies to improve pressure control in rural Kenya. However, which intervention to pursue depends on resource availability. makers should consider these factors, in addition to sex differences in programme effectiveness, when selecting optimal implementation strategies.