Objectives  
Screening for cardiovascular disease (CVD) risk is potentially cost-effective; however, its net health impact by socioeconomic status (SES) likely depends on (1) who is screened, (2) the socioeconomic profile of risk factors, and (3) the criteria for prescribing preventive medication. We conducted a dominance-based distributional cost-effectiveness analysis of CVD risk screening strategies in Sri Lanka to compare their equity-efficiency trade-offs.

Methods 
Using nationally representative data, we modeled 4 strategies of opportunistic CVD risk screening at public outpatient clinics and the current screening program (comparator). We measured SES with an assets index. For each strategy, we simulated costs, quality-adjusted life-years (QALYs) and the distribution of QALYs net of health opportunity costs by SES. Assuming aversion to pro-rich inequality, we used generalized concentration curve dominance to rank these distributions and calculated equally distributed equivalent net QALYs for each.

Results 
The most cost-effective (lowest incremental cost-effectiveness ratio) strategy was opportunistic (vs invited) screening at age ≥ 40 (vs ≥35) with statins prescribed at CVD risk ≥10% (vs ≥20%) and antihypertensives at blood pressure ≥130/80 mm Hg (vs ≥140/90) for those risks and people with diabetes. Given net QALYs generated by SES and aversion to pro-rich inequality, this strategy dominated all others (except one), and it generated more equally distributed equivalent net QALYs. This strategy dominated another with a similar incremental cost-effectiveness ratio that added statins for people with diabetes.

Conclusions 
Dominance-based distributional cost-effectiveness analysis identified modifications to CVD risk screening in Sri Lanka that would likely improve equity while remaining efficient.