Cost-Effectiveness of Salt Substitute and Salt Supply Restriction in Eldercare Facilities
Authors: Lai Xiaozhen , Yuan Yifang , Wang Hongxia , Zhang Ruijuan , Qiao Qianku , Feng Xiangxian , Jin Aoming , Li Huijuan , Li Jiayu , Si Lei , Gao Pei , Jan Stephen , Fang Hai , Wu Yangfeng ,   DECIDE-Salt Research Group, Chen Junshi , Neal Bruce , Labarthe Darwin , Elliott Paul , Zhao Minghui , Niu Wenyi , Gao Runlin , Liang Xiaofeng , Huo Yong , Ma Changsheng , Sun Yihong , Tang Xun , Zhao Wei , Sui Zhun , Wang Jinwei , Zhao Xingshan , Du Xin , Sun Weiping , Xie Gaoqiang , Wang Fengzhi , Zhu Shulan , Feng Lin , Yuan Jianhui , Duan Peifen , Han Yanbo , Cui Xiaorui , Li Decheng , Gao Peng , Cao La’e , Cheng Lili , Zhang Lili , JI Lidong , Yu Wenjie , Zhang Hui , Wang Sujuan , Zhuo Ran , Hang Jing , Yang Li , QI Xiaoqin , Hu Senke , Wang Yanxi , Wang Yuqi , Shen Yang , Chang Huan 
Published: February 2024

ImportanceSalt substitution has been reported to be a cost-saving sodium reduction strategy that has not yet been replicated in different contexts.ObjectiveTo estimate the cost-effectiveness of sodium reduction strategies within the DECIDE-Salt trial.Design, Setting, and ParticipantsThe DECIDE-Salt trial cluster randomized in a 1:1:1:1 ratio 48 eldercare facilities in China into 4 groups for evaluation of 2 sodium reduction strategies for 2 years: 1 with both strategies, 2 with either strategy, and 1 with neither strategy. The trial was conducted from September 25, 2017, through October 24, 2020.InterventionsThe 2 intervention strategies were replacing regular salt with salt substitute and progressively restricting salt supply to kitchens.Main Outcomes and MeasuresThe main outcomes included per-participant costs of intervention implementation and medical treatments for hypertension and major adverse cardiovascular events (MACEs) against mean reductions in systolic blood pressure, hypertension prevalence, MACE incidence, and mortality. The incremental cost-utility ratio was then assessed as the additional mean cost per quality-adjusted life-year gained. Analyses were conducted separately for each strategy, comparing groups assigned and not assigned the test strategy. Disease outcomes followed the intention-to-treat principle and adopted different models as appropriate. One-way and probabilistic sensitivity analyses were conducted to explore uncertainty, and data analyses were performed between August 13, 2022, and April 5, 2023.ResultsA total of 1612 participants (1230 males [76.3%]) with a mean (SD) age of 71.0 (9.5) years were enrolled. Replacing regular salt with salt substitute reduced mean systolic blood pressure by 7.14 (95% CI, 3.79-10.48) mm Hg, hypertension prevalence by 5.09 (95% CI, 0.37-9.80) percentage points, and cumulative MACEs by 2.27 (95% CI, 0.09-4.45) percentage points. At the end of the 2-year intervention, the mean cost was $25.95 less for the salt substitute group than the regular salt group due to substantial savings in health care costs for MACEs (mean [SD], $72.88 [$9.11] vs $111.18 [$13.90], respectively). Sensitivity analysis showed robust cost savings. By contrast, the salt restriction strategy did not show significant results. If the salt substitution strategy were rolled out to all eldercare facilities in China, 48 101 MACEs and 107 857 hypertension cases were estimated to be averted and $54 982 278 saved in the first 2 years.Conclusions and RelevanceThe findings of this cluster randomized clinical trial indicate that salt substitution may be a cost-saving strategy for hypertension control and cardiovascular disease prevention for residents of eldercare facilities in China. The substantial health benefit savings in preventing MACEs and moderate operating costs offer strong evidence to support the Chinese government and other countries in planning or implementing sodium intake reduction and salt substitute campaigns.Trial RegistrationClinicalTrials.gov Identifier: NCT03290716