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Volume
3:
No. 1, January 2006
ORIGINAL RESEARCH
A Cost Evaluation of the Georgia Stroke and Heart Attack Prevention Program
David B. Rein, PhD, Roberta T. Constantine, PhD, Diane Orenstein, PhD, Hong Chen,
MS, Patricia Jones, RN, CDE, J. Nell Brownstein, PhD, Rosanne Farris, PhD, RD
Suggested citation for this article: Rein DB, Constantine RT,
Orenstein D, Chen H, Jones P, Brownstein JN, et al. A cost evaluation of the
Georgia Stroke and Heart Attack Prevention Program. Prev Chronic Dis
[serial online] 2006 Jan [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2006/
jan/05_0143.htm.
PEER REVIEWED
Abstract
Introduction
Hypertension is a leading cause of stroke, coronary artery disease, heart
attack, and heart and kidney failure in the United States, all of which
contribute to the rising costs of health care. The Georgia Stroke and Heart
Attack Prevention Program is an education and direct service program for low-income patients with hypertension. This project evaluated the
cost-effectiveness of the program compared with the following two alternative
scenarios: no treatment for high blood pressure and the typical hypertension
treatment received in the private sector nationwide (usual care).
Methods
We estimated the preventive treatment costs and number of adverse health events
averted (hemorrhagic and ischemic stroke, heart disease, and kidney failure)
associated with the Georgia Stroke and Heart Attack Prevention Program in two
Georgia health districts. We used program cost and service usage data obtained
from the Georgia Department of Human Resources and probabilities and costs of
expected adverse events published in peer-reviewed sources. We compared
program costs and number of expected adverse health events averted with those
expected from 1) no preventive care and 2) usual care for high blood
pressure.
Results
The Georgia Stroke and Heart Attack Prevention Program was less costly and
resulted in better health outcomes than either no preventive care or usual
care. Compared with no preventive care in the two districts, the
program was estimated to result in 54% fewer expected adverse events; compared
with usual care, the program was estimated to result in 46% fewer expected
adverse events. Combining the costs of preventive treatment with the costs of
expected adverse events, the Georgia Stroke and Heart Attack Prevention
Program cost an average of $486 per patient annually, compared with average
annual costs of $534 for no care and $624 for usual care.
Conclusion
Maintaining a publicly financed stroke and heart attack prevention program
is more cost-effective and results in greater health benefits than other
plausible scenarios. Because the benefits of this program accrue to both the
state and federal governments through reduced Medicaid and indigent care
expenditures, both the state and federal governments have a financial incentive
to support the program.
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Introduction
Hypertension is a leading cause of stroke, coronary artery disease, heart
attack, and heart and kidney failure in the United States. Currently, 50
million Americans have hypertension and another 45 million have
prehypertension
(blood pressure of 120–139 mm Hg [systolic] or 80–89 mm Hg [diastolic])
(1). More than 70% of U.S. adults with hypertension do not have it
under control (2,3). Hypertension is particularly common among African
Americans, who have a 30% higher prevalence of hypertension than whites (1). As
might be expected, African Americans experience hypertension-related deaths at
younger ages than whites and have higher rates of stroke, left ventricular
hypertrophy, and heart attack (3). Some but not all of these differences
are explained by the lower socioeconomic status (SES) of African Americans,
because lower SES is also strongly related to uncontrolled blood pressure (4).
As many as 30% of all deaths among African American men and 20% of all deaths
among African American women can be attributed to high blood pressure (5).
Aggressive treatment of hypertension, which usually involves medication,
significantly decreases the risk of coronary artery disease, congestive heart
failure, stroke, and resulting disability. For example, a 12-point to 13-point
reduction in blood pressure can lower the risk of heart attack by 21%,
stroke by 37%, and total cardiovascular deaths by 25% (6). Results of recent
large hypertension trials demonstrated that inexpensive thiazide-type
diuretics are superior in preventing one or more major forms of cardiovascular
disease (7). Unfortunately, low-income individuals without prescription
drug coverage are significantly more likely to skip doses to save money or
make their hypertension medication prescriptions last longer. In one recently
observed population, systemic hypertension was adequately controlled among
only 38% of those who paid for their medication themselves (8).
The Georgia Stroke and Heart Attack Prevention Program (SHAPP) is an
education and direct service program for low-income patients with
hypertension. The program is based on the Chronic Care Model, a framework for
identifying the essential elements of a health care system and involving
patients in their own care (9). SHAPP patient services are provided through the
county health departments and include screening, referral to
physicians, diagnosis, and treatment. Treatment protocols are based on Joint
National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure recommendations (10). Individual patients are assigned to
nurses who act as case managers. SHAPP nurses then coordinate the wide array
of treatment services including physical and family history assessments,
diagnostic testing, lifestyle counseling and education, medication, and
patient monitoring (follow-up visits for medication, blood pressure
assessment, and any needed testing) as stipulated by the SHAPP protocol.
Information on patient medical and family history, physical characteristics,
and risk factors is collected. Diagnostic testing is done to determine
baseline and follow-up blood pressure levels. Lifestyle counseling includes
advice on diet, weight, smoking cessation, alcohol consumption, and physical
activity and information about signs and symptoms of stroke and heart attack.
Nurses track medication side effects and monitor patients to ensure they keep
clinic appointments and adhere to medication schedules. SHAPP
also supplies prescription drugs at low or no cost according to a treatment
protocol.
According to the Centers for Disease Control and Prevention’s (CDC’s)
Behavioral Risk Factor Surveillance System (BRFSS), 1.7 million Georgians had
hypertension in 2004. Of those, 469,800 were low income, uninsured, or
underinsured and were potentially eligible for the SHAPP program. (Eligibility
is based on both income and hypertension severity.) However, given the small
enrollment in SHAPP (15,819 clients in fiscal year 2003), there is likely a
much a greater need in Georgia for SHAPP services than the program is
currently able to meet.
Reducing hypertension can lead to marked reductions (10) in the risk of
several high-consequence adverse events such as hemorrhagic stroke (11),
ischemic stroke, heart disease (12), and kidney failure (13). However, one
recent study suggests that less intensive interventions that rely only on patients to manage their own hypertension care are relatively ineffective (14).
Comparatively, SHAPP is a higher-intensity intervention guided by the premise
that providing low-cost preventive services to medically indigent patients
provides benefits to patients and savings to the state. SHAPP
patients who control their blood pressure could reduce their risks for adverse
events, thus prolonging and improving the quality of their lives and lowering
the annual medical costs borne by the state for high-cost hospital care and
procedures. Although advocates of SHAPP have long suspected that the program
results in cost savings, the association among SHAPP services, patient
outcomes, and medical costs has never been formally evaluated. In this
article, we discuss a limited, first-time evaluation of the costs and benefits of SHAPP
to determine whether this promising practice results in enhanced patient health
and reduced medical costs for the state.
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Methods
Selection of districts
We collected administrative data on the costs and hypertension control
outcomes of SHAPP in two Georgia health districts with high rates of blood
pressure control for fiscal year 2003 (July 1, 2002–June 30, 2003). Blood
pressure control is defined by the Georgia Department of Human
Resources (DHR) as a reading of less than 140/90 mm Hg, based on the average
of at least two blood pressure readings taken on the most recent visit.
The selection and number of the districts studied was guided by several
factors. The primary goal of the study was to examine the critical components
of SHAPP in sites with high success rates so that lessons could be shared with
other hypertension control programs. In addition to analyzing costs, the full
study included focus groups with patients, interviews with clinic and
administrative staff, and an examination of the medical records. Time and
funding limitations allowed for only two districts to be studied. The two
districts were selected based on their success in controlling hypertension,
use of different computer systems, geographic diversity between districts,
demographic diversity among counties within the districts, and the mix of
patients managed solely by the health department with patients managed jointly
by the health department and private physicians. Although the characteristics
of SHAPP districts and clinics vary widely, the intention is for SHAPP to
perform at the same level in all districts. This analysis represents the upper boundary of the potential effectiveness of the SHAPP
program.
Impact of SHAPP compared with plausible alternatives
After examining administrative data for each district, we extrapolated the
number of adverse health events — hemorrhagic stroke (11), ischemic stroke,
heart disease (12), and kidney failure (13) — that would be expected given the
level of blood pressure control within each district, and we assigned costs to
these events. We then compared cost and health outcomes of SHAPP with two simulated
plausible alternatives: 1) no care and 2) the typical treatment received
in the private sector nationally (referred to as usual care). We chose
no care to represent the lower boundary that Georgia’s SHAPP patients
would receive in the absence of the program, and we chose usual care to
represent the upper boundary. If SHAPP were eliminated, its patients could be
expected to receive no care (the worst-case scenario) or usual care
(the best-case scenario).
Patients who received no care would be expected to have no costs
related to blood pressure control, but they would also be expected to have a
higher number of adverse events. Our analysis evaluated whether the number of
expected adverse events prevented by SHAPP was sufficient to justify the
additional cost of SHAPP preventive treatment.
Next, we compared SHAPP patients with a scenario in which patients who had
characteristics identical to SHAPP patients received usual care. SHAPP
patients and patients who received usual care would be expected to differ in
the following ways: 1) cost of treatment, 2) level of hypertension control
outcomes, and 3) the probability of receiving treatment. Nationally, only 58%
of people with hypertension receive any regular preventive care, compared with
100% of SHAPP patients, assuming SHAPP patients seek care and are eligible for
the program (1). This analysis evaluated whether SHAPP resulted in less costly
treatment as well as fewer expected adverse health events than usual care. Advocates
have suggested that SHAPP is both less expensive for and more effective at
controlling blood pressure than care provided in private settings because SHAPP uses evidence-based protocols whereas private providers may
substitute alternative protocols; SHAPP uses fewer new, more costly (and not
necessarily more effective) prescription drugs; and SHAPP substitutes nurse
practitioners for physicians to manage patient care. SHAPP could be more
beneficial than usual care by offering full coverage to all patients who are
eligible and seek treatment, by providing services at lower costs, or by
achieving better outcomes.
SHAPP data and costs
We examined typical direct and indirect SHAPP program costs using
methodology recommended by the National Panel on Cost-Effectiveness
Analysis in Health and Medicine convened by the U.S. Public Health Service
(15). Total program costs include the cost of services (e.g., diagnostic
testing, patient visits), medications, and overhead costs. Overhead costs
include personnel costs (e.g., salary, benefits) and operating costs (e.g.,
pharmacy, clinical). Total annual SHAPP clinical costs were supplied for two
selected counties in District 1 and District 2. For each district, data were
obtained from one county in which the study occurred and in another county
selected randomly.
The Georgia DHR supplied the following data
for the selected counties: 1) the number of patients treated and the
percentage of patients who achieved controlled blood pressure; 2) the costs of
prescription drugs, postage, and overhead; and 3) the cost of clinical
services. To estimate clinical costs per patient, we divided the annual total
costs per county by the total number of SHAPP patients treated in each county. We
assumed that the costs identified in the selected counties were representative
of the overall per-patient costs in each health district.
The percentage of SHAPP patients treated with prescription drugs was
calculated by dividing the number of patients who received any prescription
drug in each district by the number of patients in that district. The cost per
patient for prescribed drugs was calculated by dividing the total annual
prescription drug cost in each district by the number of patients who received
any drugs. Postage costs per patient were calculated by dividing aggregate
postage costs (to mail prescriptions to SHAPP clinics) in each district by the
number of patients in each district. Government overhead costs for SHAPP
statewide were provided by Georgia DHR for all SHAPP patients statewide. These
costs included personnel costs (salary and benefits) and operating costs
(pharmacy and clinical). This total cost was converted to a per-person cost by
dividing it by the number of statewide SHAPP participants, and this cost was
then applied to patients in the respective districts. SHAPP’s annual treatment
cost per patient was calculated as the sum of per-patient clinical,
prescription drug, postage, and state overhead costs.
Comparison treatment costs
For comparison purposes, estimates of the number of patients receiving
treatment and the expected level of hypertension control for patients who
receive treatment were obtained from reported national hypertension trends
derived from the third National Health and Nutrition Examination Survey (NHANES
III) (1). Because no exact definition exists of what treatment in the private
sector entails, we assumed that such treatment was based on the Seventh Report
of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 7) guidelines, which would be comparable
to SHAPP treatment (3). Therefore, we defined usual care (for people who
received treatment) as the average number of annual hypertension visits for
SHAPP participants (3.71 visits), combined with the same drug treatment used
by SHAPP patients in District 1.
The cost of usual care was estimated by multiplying the average number of
annual hypertension visits for SHAPP participants (3.71 visits) by the Centers
for Medicaid and Medicare Services (CMS) Medicare reimbursement rate for
office visits ($80). To this we added the average per-person drug costs
observed in the SHAPP program. We assumed no postage or state
overhead costs for usual care. Because not all patients with hypertension
receive care, we then multiplied this total per-patient cost for those who
receive care by the estimated proportion of patients who receive any treatment
(1). Table 1 presents a comparison of costs and outcomes for patients in
District 1 and District 2 and for patients nationally.
We noted that prescription costs per patient were higher in District 1. On
further examination of the data, we found that even though drug costs per type
of prescription were consistent statewide, District 1 used a greater quantity
of some drugs such as hydrocortothiazide, hydralazine, and fosinopril. In
contrast, per-patient clinical services were more costly in District 2. Although most reported procedure codes are the same in both
districts, the data show that some differences in service use exist. Overall, patients in
District 2 used more clinical services such as phone consultation, preventive
counseling, and laboratory test reviews than patients in District 1. Also, the
cost per procedure was routinely more expensive per unit of service in
District 2 than District 1. Focus groups with patients and key informant
interviews with administrators and staff in both districts indicated that each SHAPP district offers the same basic set of services. The observed differences
in costs between the two districts studied, however, indicate that SHAPP
implementation varies among districts; the technology used to capture and
report cost and usage data may vary as well.
Outcomes
We defined SHAPP effectiveness as the proportion of patients with
controlled blood pressure in each health district, based on statistics from
Georgia DHR annual reports. Using these reported levels of blood pressure
control, we then estimated the number of adverse events expected in each
health district based on the results of a published statistical model by Flack
and colleagues (12). The model was designed to estimate the annual probability
of hemorrhagic and ischemic stroke and heart disease for individuals in three
categories of blood pressure treatment and control: 1) treated and controlled,
2) treated but uncontrolled, and 3) untreated and uncontrolled (12). We used
this model to make estimates because time and funding limitations prevented us
from observing adverse outcomes or measuring associated costs directly. The
Flack study was selected for modeling purposes because it provided the most
recent and comprehensive information related to the SHAPP study. It examined
the effect of inadequate blood pressure control on selected cardiovascular
disease outcomes and analyzed related costs for the U.S. population with
hypertension. In addition, the study developed a sophisticated model, provided
incidence rates for cardiovascular disease morbidity and mortality, and
integrated hypertension statistics from NHANES III and cost estimates for
stroke, congestive heart failure, and myocardial infarction (12). NHANES III
was conducted in 1999–2000; the published results were the most recent
available at the time of the Flack study.
We calculated the cost-effectiveness of SHAPP by comparing two other
treatment possibilities — no treatment and usual care — based on expected
adverse outcomes observed in the absence of a public program. The proportions
of the U.S. population with treated and controlled, treated but uncontrolled,
and untreated and uncontrolled blood pressure were taken from a published analysis of NHANES
III surveillance data for 1999–2000 (1) (Table 2). The probability of
hemorrhagic stroke based on treatment and control of blood pressure was
taken from the published results of a randomized controlled study of more than
45,000 participants in the Netherlands that provided population-based
estimates; the goal of this study was to examine the outcomes (i.e., number of strokes) associated with
insufficient treatment of hypertension (11). The
probability of ischemic stroke was derived by applying the ratio of ischemic
strokes to hemorrhagic strokes identified in the 2001 Medical Expenditure
Panel Study (MEPS) (16) to the probabilities of hemorrhagic stoke identified
in the Netherlands study. The probability of kidney failure was derived from
two separate studies of hypertension-related adverse events, the second of
which studied hypertension-related renal failure (13,17). Rates of heart
disease and the costs of each expected adverse event were obtained from the
Flack simulation model of cardiovascular disease associated with
uncontrolled blood pressure (12). Costs for stroke and heart attack reported
in the Flack study represent estimates of inpatient and outpatient costs
during 1 year
after the adverse event. Inpatient costs represent the majority of costs and
were obtained from the National Inpatient Profile (a database derived from the
National Hospital Discharge Survey); outpatient costs included typical
follow-up care, medications, laboratory tests, and office visits (12). The
cost of treating congestive heart failure was obtained from the economic
burden-of-illness estimates from the American Heart Association (12).
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Results
The SHAPP program achieved blood pressure control rates of 68.1% in
District 1 and 59.7% in District 2 (Table 1). The average control rate for all
SHAPP districts is 54%, with a range of 41% to 68% (data not shown). The
comparative national control rate was 53% for patients in treatment,
translating to a 31% control rate for all patients nationally when accounting
for individuals who do not seek treatment (Table 2) (1). Annual preventive
treatment costs per patient were $132.36 in District 1 and $260.39 in District
2. The average number of clinical services between the two districts and the
same pharmaceutical care that was used in District 1 would cost $322 per patient in
the private sector. However, because only 58% of patients with hypertension
nationally receive preventive treatment, the estimated national annual
per-patient cost for treated patients with hypertension ($187.04) was between
the annual costs per patient in the two districts.
Because SHAPP achieved higher blood pressure control rates and offered care
to all patients who were eligible and sought treatment, SHAPP patients in both
districts were expected to experience lower rates of hemorrhagic stroke,
ischemic stroke, heart disease, and kidney failure compared with both other
treatment scenarios (no care and usual care) (Table 3). Patients in District 1
were expected to experience roughly 10 fewer expected adverse events than if
they had received no treatment and seven fewer than if they had received usual care. Patients in District 2 were expected to experience
roughly 30 fewer expected adverse events than if they had received no
treatment and 21 fewer than if they had received usual care.
The differences in the number of expected adverse outcomes translated into
substantial differences in costs among the three scenarios. Total expected
annual costs for SHAPP patients, including both preventive treatment and care
related to expected adverse outcomes in District 1, were estimated at $289,617
for no treatment, $323,095 for usual care, and $209,800 for SHAPP treatment.
In District 2, costs were estimated at $870,451 for no treatment, $971,070 for usual care, and $848,254 for SHAPP treatment (Table 4). In each county, SHAPP was the least expensive of the three treatment scenarios. Total expected
costs for SHAPP patients in District 1 were 27.5% below the costs of no
treatment, and 35.1% below the costs of treatment offered only through the
private sector. In District 2, where treatment costs were higher, total costs
of SHAPP were 2.6% below the costs of no treatment and 12.7% below the costs
of treatment offered only through the private sector. When examining both
districts to provide a more global picture of SHAPP, we found that
implementation of the SHAPP program resulted in both lower costs and greater potential
health benefits than either of the alternative treatment
scenarios. SHAPP saved costs and provided greater health benefits when
compared with both no treatment for hypertension and usual care (Table 5).
SHAPP costs differed between the two health districts. Table 1 shows that
although District 1 reported lower costs per patient overall than District 2,
District 1 prescribed medications to a greater proportion (94%) of clients
than District 2 (63%). District 1 also paid more for medications ($49.56 per
patient) than District 2 ($15.19 per patient). In contrast, District 1 used
fewer clinical services per patient (8.0) than District 2 (12.6) and paid less
for the services.
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Discussion
SHAPP is an education and direct service program that appears to save costs
for the state of Georgia. SHAPP resulted in lower costs and better health
outcomes than either no treatment or treatment offered at the average level
expected nationally. For the two districts examined, SHAPP was found to be
preferable to the other two options because it resulted in both better blood
pressure control levels (which are expected to translate into fewer
adverse health events), lower treatment costs for those who receive treatment,
and lower overall costs per eligible patient. These results were supported by
blood pressure control rates of 68.1% in District 1 and 59.7% in District 2.
Both these rates exceed the national average control rate for patients in
treatment (53%) and for all patients with hypertension, including the
untreated (31%). The average control rate for SHAPP during this study period
was 54%. Although the SHAPP districts that were evaluated had higher control
rates, we believe that these rates can be reached by other districts.
SHAPP still saved costs when expected adverse outcomes were considered,
although the cost savings covered a narrow range of direct medical costs. Had
we included lost productivity and deaths associated with the expected adverse
events that SHAPP prevented, the benefits of SHAPP compared with the benefits
of other treatment options would likely appear even more substantial. This cost
analysis was one element of an initial program evaluation that also included both
medical record review and focus groups with patients as well as key informant
interviews with administrative and clinical staff. This evaluation also
identified important components that contribute to high blood pressure control
rates: intense patient monitoring, follow-up, access to medication, and
counseling.
This study is limited by several factors. First, because of funding and
time constraints, only two districts were examined. Also, districts with high
blood pressure control rates were analyzed because the primary objectives of
the study were to examine program components that contributed to successful
blood pressure outcomes and to communicate results to other hypertension
programs. Limited information on adverse events among SHAPP patients was
available, and no actual outcomes in the population were observed. All
expected adverse events were inferred from the medical literature using the
probability of adverse events based on different levels of blood pressure
control. The conclusions are accurate to the extent that populations observed
in other studies reflect the characteristics of the SHAPP population.
Populations in other studies used for this analysis vary in their similarity
to the SHAPP population. When selecting parameter values for the model, we
balanced demographic similarity with data completeness, fit of the parameter,
and size of the study. For example, Klungel et al used data from a study of
more than 45,000 individuals and thus had the statistical power to observe
differences that would be missed by other smaller studies. In addition,
Klungel et al examined precisely the measure we sought: the probability of
stroke given uncontrolled and controlled hypertension.
Second, medical costs for private-sector care were estimated based on
service usage observed in SHAPP. Thus, the results may overestimate the
effectiveness of the SHAPP statewide. A better approach for estimation would
include direct observation of the costs of preventive services in the private
sector and comparison of private-sector costs with SHAPP costs. In addition, a
more comprehensive approach would be to examine SHAPP on a statewide basis, including
districts with varying rates of success. Future models should
use more complicated simulations that vary the number of assumptions.
On the other hand, the costs assigned in this study were conservative,
particularly prescription costs. A more precise estimate of private-sector
costs would likely make SHAPP appear more cost-effective because SHAPP
provides protocol-driven, evidence-based treatment, and most treatment is
provided by nurses instead of physicians. We have no way of knowing how SHAPP
patients would use services in the absence of the program, so we must rely on
hypothetical scenarios for comparison. Finally, because we used data from two
higher-performing SHAPP districts, this study identified the upper range of
program effectiveness. However, hypertension control rates representing all
SHAPP districts (ranging from 41% to 68%) exceed the rates of hypertension
control observed nationally in NHANES (31%).
This study evaluated the costs and benefits of SHAPP based on observed data
on program costs and outcomes and on similar data published in the medical
literature translated into adverse events in other settings. These findings
show that SHAPP treatment is more cost-effective than no treatment or
treatment offered only through the private sector. Compared with the two other
plausible scenarios tested, SHAPP resulted in the lowest medical costs and the
best patient health outcomes. Given these conclusions, we hypothesize that
SHAPP’s full coverage of patients is preferable to both no patient care and
the average amount of care expected nationally both in terms of costs and
health outcomes. It is important to view these results in the context of the
growing expense of health care and the importance of implementing prevention
programs that are successful and reduce costs.
However, it is also important to keep the limitations of the study in mind.
Promising practices at the state level too often are left unexplored because
of a lack of funding or an inability to acquire data. This evaluation provides
preliminary evidence of the effectiveness of an intervention based on the
Chronic Care Model to control hypertension among disadvantaged individuals,
but limited time and resources led to a simple simulation that used data from
a limited number of locations and relied on several assumptions. We recommend
more extensive and more formal evaluations of SHAPP and other hypertension
interventions based on the Chronic Care Model to better understand how these
interventions work and to more precisely measure program success.
Because SHAPP costs are borne by the taxpayer and at least some portion of
private care is paid for by consumers, it is important to consider who would
bear the costs of caring for adverse outcomes if SHAPP were
eliminated. First, because patients in SHAPP are indigent, they would be far
more likely to receive no care than the average amount of care received
nationally if the program were eliminated. This analysis suggests that such a
change would result in a substantial increase of expected adverse events and
deaths. Because most SHAPP patients do not carry private insurance, the higher
cost of caring for these adverse events would likely fall on already
overextended public hospitals, the state Medicaid program, and federally
funded indigent care programs. Thus, the elimination of SHAPP would likely
result in higher costs for both the state and federal governments, making it
financially prudent for Georgia to maintain the program. The higher costs of
not providing care due to the occurrence of adverse events far exceed the
costs of treating hypertension and preventing those events. More importantly,
SHAPP provides access to vital services for indigent Georgians to address this
critical, life-threatening health issue.
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Author Information
Corresponding Author: Diane Orenstein, PhD, Division for Heart Disease and
Stroke Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control and Prevention,
4770 Buford Hwy, Mail Stop K-47, Atlanta, GA 30341. Telephone: 770-488-8003. E-mail: dro1@cdc.gov.
Author Affiliations: David B. Rein, PhD, Roberta T. Constantine, PhD, Hong Chen,
MS, Research Triangle Institute International, Waltham, Mass; Patricia Jones,
RN, CDE, Georgia Division of Public Health, Chronic Disease Prevention and
Health Promotion Branch, Atlanta, Ga; J. Nell Brownstein, PhD, Rosanne
Farris PhD, RD, Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta, Ga.
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