Clinical Context
First-degree relatives of individuals with premature coronary heart disease (CHD before age 55 in men, 65 in women) carry substantially elevated cardiovascular risk—both from shared genetic susceptibility and shared lifestyle/environmental factors. Despite this elevated risk, family members often aren’t systematically screened or engaged in prevention efforts. The index patient’s cardiac event represents a “teachable moment” for the entire family, when awareness of heart disease risk is heightened and motivation for change may be optimal.
Traditional cardiovascular prevention focuses on individuals identified through routine screening or after their own clinical events. Family-based approaches offer advantages: shared meals and environments mean family-wide dietary changes are more sustainable than individual efforts, exercise can become family activity, and mutual support enhances behavior change. The family unit as the intervention target may provide efficiency beyond individual-level interventions.
The PROLIFIC trial tested a structured lifestyle modification program targeting families of patients with premature CHD. This cost-effectiveness analysis examines whether the intervention provides value for money—a critical question for healthcare systems deciding whether to implement such programs at scale.
Study Summary (PICO Framework)
Summary:
In family members of premature CHD patients, a 2-year family-based structured lifestyle program with non-physician health worker support and active follow-up significantly improved QALYs and reduced BP, glucose, HbA1c, cholesterol, and waist circumference compared to usual care with one-time counseling, at an ICER of $11,352/QALY—well below cost-effectiveness thresholds.
| PICO | Description |
|---|---|
| Population | Adults ≥18 years: first-degree relatives and spouses of premature CHD patients. |
| Intervention | Structured lifestyle intervention: risk screening, behavior change support by non-physician health workers, primary care linkage, active 2-year follow-up. |
| Comparison | Usual care: one-time lifestyle counseling + annual screening (no structured follow-up). |
| Outcome | QALY gain 0.014, incremental cost $157.50/person. ICER $11,352/QALY. Significant reductions: SBP, FPG, HbA1c, cholesterol, waist circumference. Cost-effective under 3x GDP/capita threshold. |
Clinical Pearls
1. The family as the intervention unit amplifies impact. Treating families rather than individuals means dietary changes affect everyone sharing meals, exercise becomes a group activity, and social support for behavior change is built into the home environment. This ecological approach may produce larger, more sustained effects than individual-level interventions that fight against unchanged home environments.
2. Non-physician health workers delivered effective behavior change support. The intervention used non-physician health workers (likely community health workers or trained counselors) rather than physicians for behavior change support. This task-shifting approach reduces costs while potentially providing more culturally appropriate, accessible, and frequent contact than physician-delivered care. It’s a scalable model for resource-constrained settings.
3. The ICER of $11,352/QALY is highly cost-effective by standard thresholds. WHO considers interventions cost-effective if the ICER is below 3 times GDP per capita, and highly cost-effective if below 1 times GDP per capita. At $11,352/QALY, this intervention would be considered cost-effective in essentially any country and highly cost-effective in most middle- and high-income settings. This economic case supports implementation at scale.
4. Broad risk factor improvements suggest comprehensive metabolic benefit. The intervention improved blood pressure, fasting glucose, HbA1c, cholesterol, and waist circumference—essentially the full spectrum of cardiometabolic risk factors. This suggests the lifestyle changes addressed fundamental metabolic health rather than targeting isolated risk factors. Comprehensive improvement predicts greater cardiovascular risk reduction than any single factor improvement.
Practical Application
Systematically identify and engage family members of CHD patients: When a patient presents with premature CHD, consider their family as a high-risk population deserving targeted prevention. Offer to screen first-degree relatives for cardiovascular risk factors. Use the index event as a motivator: “Your family member’s heart attack means you and other family members are at higher risk—let’s check and address your risk factors.”
Implement family-based rather than individual-only interventions: When prescribing lifestyle changes, engage the whole household. Dietary counseling should address family meals, not just the patient’s individual intake. Exercise prescriptions can include family walks or activities. This approach is more sustainable and addresses the shared environment driving risk.
Use non-physician staff for behavior change support where possible: Physicians have limited time for intensive behavior change counseling. Develop or connect with programs using health coaches, community health workers, dietitians, or trained counselors for the ongoing support that lifestyle change requires. This extends reach while controlling costs.
Track multiple risk factors to demonstrate comprehensive benefit: When monitoring intervention success, assess the full cardiometabolic panel: BP, glucose/HbA1c, lipids, weight/waist circumference. Comprehensive improvement motivates continued adherence and demonstrates value to patients and payers.
How This Study Fits Into the Broader Evidence
The PROLIFIC trial adds to evidence for family-based cardiovascular prevention. Prior studies in the US and Europe have shown that family history-based risk stratification identifies high-risk individuals who benefit from targeted prevention. Family-based dietary interventions (like the DASH diet delivered to families) have shown sustained BP reductions. This trial extends the evidence to a structured, comprehensive, cost-effective program in a developing country context (India).
Lifestyle intervention cost-effectiveness has been demonstrated in multiple settings. The Diabetes Prevention Program showed that intensive lifestyle intervention to prevent diabetes was cost-effective or cost-saving when implemented by community health workers. Weight management programs, smoking cessation, and cardiac rehabilitation all show favorable cost-effectiveness. PROLIFIC adds family-based CVD prevention to this portfolio of economically justified interventions.
The challenge globally is implementation at scale. Cost-effectiveness analyses provide the economic justification, but health system implementation requires training, infrastructure, and payment mechanisms for community health worker programs. PROLIFIC’s design—using non-physician staff and linkage to primary care—offers a potentially scalable model.
Limitations to Consider
The QALY gain (0.014) is modest at the individual level, though population-level impact accumulates. Within-trial cost-effectiveness analysis captures only 2-year costs and outcomes; lifetime projections would show greater benefit as risk factor reductions prevent future events. Conducted in India, generalizability to other healthcare systems requires context adaptation. Risk factor improvements are surrogate outcomes; hard cardiovascular events weren’t assessed in this timeframe.
Bottom Line
The PROLIFIC trial demonstrated that a family-based structured lifestyle intervention for relatives of premature CHD patients improved multiple cardiovascular risk factors and quality-adjusted life years at an incremental cost of $11,352 per QALY—highly cost-effective by international standards. Using non-physician health workers for behavior change support and targeting families rather than individuals provides an efficient, scalable prevention model. For clinicians seeing patients with premature CHD, systematically engaging family members in cardiovascular prevention represents an evidence-based, cost-effective opportunity to multiply preventive impact.
Source: Ashis Samuel John, et al. “Within-Trial Cost-Effectiveness Analysis of a Family-Based Structured Lifestyle Modification Intervention Program for Cardiovascular Risk Reduction: Results from the PROLIFIC Trial.” Read article here.
