In this study, multiple data sources were used to estimate the economic burden of the disease. The most important data source used to estimate direct medical costs were the information extracted from the medical records of the patients with CVDs.

This type of costs is directly attributable to patients admitted to various types of health care facilities (Ministry of Health, Social Security, and private sector), as well as treatment costs, including different services, such as diagnostic, medical, and rehabilitation services [26]. To estimate direct costs, the costs of standard diagnostic services, such as electrocardiograms, echocardiography, exercise testing, nuclear heart scan, and angiography, were included. Sampling was performed among patients who had undergone open-heart surgery, angioplasty, and medication. Sample sizes for the three groups (undergone open-heart surgery, angioplasty, and medication) were 135, 251, and 221 people, respectively. Sampling was performed using simple random sampling method and Cochrane-Orcutt Procedure, which is applicable for a limited population, was used. The main drugs for CVDs were also extracted by reviewing 65 patients’ medical records and interviews with CVDs specialists. In this section, direct payments were considered as the patients’ OOP expenditure, which can be due to the difference between the patient’s share of the cost and share of the insurance cost, which was recorded as the patient’s share of the costs in their medical record.

Indirect costs are a combination of the costs incurred to the patients and their families, such as the cost of medical travel, cost of time lost, and cost of patient in-home care [27].

Time costs are calculated based on the mean number of days lost due to receiving health care services and hospitalization in the hospital. In this study, time costs were calculated by multiplying the number of hospitalization days by the average daily wage. Data for an average daily wage were obtained from the report of the Ministry of Cooperatives, Labor, and Social Welfare of Iran in 2018.

The human capital approach was used as the primary method for the estimation of premature death costs in this study. In previous studies, HCA was used for the estimation of premature death due to non-communicable diseases, such as CVDs [28, 29]. Total numbers of deaths due to CVDs during last 5 years were obtained from documents of the hospital and deputy of the health of ARUMS. The data adopted to the data of the Institute for Health Metrics and Evaluation (IHME) and Global Burden of Disease (GBD), and then, registered.

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