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Cost-effectiveness of Prophylactic Anticoagulation Prolonged After Hospital Discharge Following General Surgery

Cost-effectiveness of Prophylactic Anticoagulation Prolonged After Hospital Discharge Following... Abstract Objective: To evaluate the net clinical benefit and the economic burden of prophylactic anticoagulation prolonged after hospital discharge following general surgery. Design: A cost-effectiveness analysis representing the risks of developing symptomatic venous thromboembolism beyond the hospital stay, the risks of major bleeding, and the efficacy of treatment. Data were drawn from the literature. Subjects: A hypothetical cohort of 10 000 patients discharged from the hospital after general surgery (gastrointestinal, gynecologic, urologic, or vascular surgery). Interventions: We compared 2 strategies: (1) prolonged self-administered prophylactic low-dose low-molecular-weight heparin during 4 weeks after discharge from the hospital and (2) anticoagulant therapy with heparin started immediately after the first clinically overt venous thromboembolism. Main Outcome Measures: The number of venous thromboembolisms prevented, the number of major bleeding events induced, and the average direct costs. Results: Prophylactic low-molecular-weight heparin was an effective therapy. Depending on the rate of venous thromboembolism (0.06% to 0.18% per week), this strategy prevented 19 to 58 venous thromboembolisms for a cohort of 10 000 patients treated, more than the number of anticoagulation-related complications (n=10). Its marginal costs, however, exceeded $2.5 million (US dollars) for 10 000 patients. As the weekly rate of venous thromboembolism increased, prophylactic low-molecular-weight heparin became more cost-effective, with a marginal cost-effectiveness ratio per venous thromboembolism prevented ranging from $135 903 (rate of venous thromboembolism, 0.06% per week) to 45 353 (rate of venous thromboembolism, 0.18% per week). Conclusion: Although prolonged prophylactic anticoagulation after hospital discharge for general surgery is effective in preventing venous thromboembolism, we believe that its marginal costs are too high to recommend its indiscriminate use.Arch Surg. 1996;131:694-697 References 1. Nurmohamed MT, Rosendaal FR, Büller HR, et al. The efficacy and safety of low molecular weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis . Lancet . 1992:340:152-156.Crossref 2. Leizorovicz A, Haugh MC, Chapuis FR, Samana MM, Boissel JP. Low molecular weight heparin in prevention of perioperative thrombosis . BMJ . 1992;305: 913-920.Crossref 3. Clagett PG, Anderson FA, Heit J, Levine MN, Wheeler HB. Fourth Consensus Conference on Antithrombotic Therapy: prevention of venous thromboembolism . Chest . 1995:108 ( (suppl) ):312S-334S.Crossref 4. Huber O, Bounameaux H, Borst F, Rohner A. Postoperative pulmonary embolism after hospital discharge: an underestimated risk . Arch Surg . 1992;127: 310-313.Crossref 5. Scurr JH, Coleridge-Smith PD, Hasty JH. Deep venous thrombosis: a continuing problem . BMJ . 1988:297:28.Crossref 6. Clarke-Pearson DL, Jelovsek FR, Creasman WT. Thromboembolism complicating surgery for cervical and uterine malignancy: incidence, risk factors, and prophylaxis . Obstet Gynecol . 1983;61:87-94. 7. Clarke-Pearson DL, Synan IS, Coleman RE, Hinshaw W, Creasman WT. The natural history of postoperative thromboemboli in gynecologic oncology: a prospective study of 382 patients . Am J Obstet Gynecol . 1984:148:1051-1054.Crossref 8. Kakkar VV, Cohen AT, Edmonson RA, et al, on behalf of the Thromboprophylaxis Collaborative Group. Low molecular weight versus standard heparin for prevention of venous thromboembolism after major abdominal surgery . Lancet . 1993;341:259-265.Crossref 9. Goldhaber SZ, Morpurgo M, for the WHO/International Society and Federation of Cardiology Task Force. Diagnosis, treatment and prevention of pulmonary embolism . JAMA . 1992;268:1727-1733.Crossref 10. Sonnenberg FA, Beck JR. Markov models in medical decision making: a practical guide . Med Decis Making . 1993;13:322-328.Crossref 11. Anderson FA, Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism: the Worcester DVT Study . Arch Intern Med . 1991;151:933-938.Crossref 12. Menzin J, Colditz GA, Regan MM, Richner RE, Oster G. Cost-effectiveness of enoxaparin vs low-dose warfarin in the prevention of deep vein thrombosis after total hip replacement surgery . Arch Intern Med . 1995;155:757-764.Crossref 13. Alpert JS, Smith R, Carlson CJ, Ockene IS, Dexter L, Dalen JE. Mortality in patients treated for pulmonary embolism . JAMA . 1976;236:1477-1480.Crossref 14. Snider DE, Caras GJ, Koplan JP. Preventive therapy with isoniazid . JAMA . 1986; 255:1579-1583.Crossref 15. Fitzgerald JM, Gafni A. A cost-effectiveness analysis of the routine use of isoniazid prophylaxis in patients with a positive Mantoux skin test . Am Rev Respir Dis . 1990;142:848-853.Crossref 16. Fedson DS, Shapiro ED, LaForce FM, et al. Pneumococcal vaccine after 15 years of use . Arch Intern Med 1994;154:2531-2535.Crossref 17. Gustafsson C, Asplund K, Britton M, Norrving B, Olsson B, Marké LA. Cost-effectiveness of primary stroke prevention in atrial fibrillation: Swedish national perspective . BMJ . 1992;305:1457-1459.Crossref 18. Wells PS, Lensing AWA, Hirsh J. Graduated compression stockings in the prevention of postoperative venous thromboembolism: a meta-analysis . Arch Intern Med . 1994;154:67-72.Crossref 19. Sarasin FP, Bounameaux H. Antithrombotic strategy after total hip replacement: a cost-effectiveness analysis comparing prolonged oral anticoagulants with screening for deep vein thrombosis. Arch Intern Med. In press. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Cost-effectiveness of Prophylactic Anticoagulation Prolonged After Hospital Discharge Following General Surgery

Archives of Surgery , Volume 131 (7) – Jul 1, 1996

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Publisher
American Medical Association
Copyright
Copyright © 1996 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1996.01430190016003
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Abstract

Abstract Objective: To evaluate the net clinical benefit and the economic burden of prophylactic anticoagulation prolonged after hospital discharge following general surgery. Design: A cost-effectiveness analysis representing the risks of developing symptomatic venous thromboembolism beyond the hospital stay, the risks of major bleeding, and the efficacy of treatment. Data were drawn from the literature. Subjects: A hypothetical cohort of 10 000 patients discharged from the hospital after general surgery (gastrointestinal, gynecologic, urologic, or vascular surgery). Interventions: We compared 2 strategies: (1) prolonged self-administered prophylactic low-dose low-molecular-weight heparin during 4 weeks after discharge from the hospital and (2) anticoagulant therapy with heparin started immediately after the first clinically overt venous thromboembolism. Main Outcome Measures: The number of venous thromboembolisms prevented, the number of major bleeding events induced, and the average direct costs. Results: Prophylactic low-molecular-weight heparin was an effective therapy. Depending on the rate of venous thromboembolism (0.06% to 0.18% per week), this strategy prevented 19 to 58 venous thromboembolisms for a cohort of 10 000 patients treated, more than the number of anticoagulation-related complications (n=10). Its marginal costs, however, exceeded $2.5 million (US dollars) for 10 000 patients. As the weekly rate of venous thromboembolism increased, prophylactic low-molecular-weight heparin became more cost-effective, with a marginal cost-effectiveness ratio per venous thromboembolism prevented ranging from $135 903 (rate of venous thromboembolism, 0.06% per week) to 45 353 (rate of venous thromboembolism, 0.18% per week). Conclusion: Although prolonged prophylactic anticoagulation after hospital discharge for general surgery is effective in preventing venous thromboembolism, we believe that its marginal costs are too high to recommend its indiscriminate use.Arch Surg. 1996;131:694-697 References 1. Nurmohamed MT, Rosendaal FR, Büller HR, et al. The efficacy and safety of low molecular weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis . Lancet . 1992:340:152-156.Crossref 2. Leizorovicz A, Haugh MC, Chapuis FR, Samana MM, Boissel JP. Low molecular weight heparin in prevention of perioperative thrombosis . BMJ . 1992;305: 913-920.Crossref 3. Clagett PG, Anderson FA, Heit J, Levine MN, Wheeler HB. Fourth Consensus Conference on Antithrombotic Therapy: prevention of venous thromboembolism . Chest . 1995:108 ( (suppl) ):312S-334S.Crossref 4. Huber O, Bounameaux H, Borst F, Rohner A. Postoperative pulmonary embolism after hospital discharge: an underestimated risk . Arch Surg . 1992;127: 310-313.Crossref 5. Scurr JH, Coleridge-Smith PD, Hasty JH. Deep venous thrombosis: a continuing problem . BMJ . 1988:297:28.Crossref 6. Clarke-Pearson DL, Jelovsek FR, Creasman WT. Thromboembolism complicating surgery for cervical and uterine malignancy: incidence, risk factors, and prophylaxis . Obstet Gynecol . 1983;61:87-94. 7. Clarke-Pearson DL, Synan IS, Coleman RE, Hinshaw W, Creasman WT. The natural history of postoperative thromboemboli in gynecologic oncology: a prospective study of 382 patients . Am J Obstet Gynecol . 1984:148:1051-1054.Crossref 8. Kakkar VV, Cohen AT, Edmonson RA, et al, on behalf of the Thromboprophylaxis Collaborative Group. Low molecular weight versus standard heparin for prevention of venous thromboembolism after major abdominal surgery . Lancet . 1993;341:259-265.Crossref 9. Goldhaber SZ, Morpurgo M, for the WHO/International Society and Federation of Cardiology Task Force. Diagnosis, treatment and prevention of pulmonary embolism . JAMA . 1992;268:1727-1733.Crossref 10. Sonnenberg FA, Beck JR. Markov models in medical decision making: a practical guide . Med Decis Making . 1993;13:322-328.Crossref 11. Anderson FA, Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism: the Worcester DVT Study . Arch Intern Med . 1991;151:933-938.Crossref 12. Menzin J, Colditz GA, Regan MM, Richner RE, Oster G. Cost-effectiveness of enoxaparin vs low-dose warfarin in the prevention of deep vein thrombosis after total hip replacement surgery . Arch Intern Med . 1995;155:757-764.Crossref 13. Alpert JS, Smith R, Carlson CJ, Ockene IS, Dexter L, Dalen JE. Mortality in patients treated for pulmonary embolism . JAMA . 1976;236:1477-1480.Crossref 14. Snider DE, Caras GJ, Koplan JP. Preventive therapy with isoniazid . JAMA . 1986; 255:1579-1583.Crossref 15. Fitzgerald JM, Gafni A. A cost-effectiveness analysis of the routine use of isoniazid prophylaxis in patients with a positive Mantoux skin test . Am Rev Respir Dis . 1990;142:848-853.Crossref 16. Fedson DS, Shapiro ED, LaForce FM, et al. Pneumococcal vaccine after 15 years of use . Arch Intern Med 1994;154:2531-2535.Crossref 17. Gustafsson C, Asplund K, Britton M, Norrving B, Olsson B, Marké LA. Cost-effectiveness of primary stroke prevention in atrial fibrillation: Swedish national perspective . BMJ . 1992;305:1457-1459.Crossref 18. Wells PS, Lensing AWA, Hirsh J. Graduated compression stockings in the prevention of postoperative venous thromboembolism: a meta-analysis . Arch Intern Med . 1994;154:67-72.Crossref 19. Sarasin FP, Bounameaux H. Antithrombotic strategy after total hip replacement: a cost-effectiveness analysis comparing prolonged oral anticoagulants with screening for deep vein thrombosis. Arch Intern Med. In press.

Journal

Archives of SurgeryAmerican Medical Association

Published: Jul 1, 1996

References