Cost-effectiveness of low-molecular-weight heparin in the treatment of proximal deep vein thrombosis
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OBJECTIVE: To estimate the cost-effectiveness of low-molecular-weight heparin (LMWH) in the treatment of proximal lower extremity deep venous thrombosis.
DESIGN: Cost-effectiveness analysis that includes the treatment of the index case and simulated 3-month follow-up.
SETTING: Acute care facility.
PATIENTS AND PARTICIPANTS: Hypothetical cohorts of 1,000 patients who present with proximal deep venous thrombosis.
MEASUREMENTS AND MAIN RESULTS: The outcomes were recurrent thrombosis, mortality, direct medical costs, and marginal cost-effectiveness ratios from the payer’s perspective. At the base-case and under most assumptions in the sensitivity analysis, the LMWH and the selective UH/LMWH strategies dominate the UH strategy i.e., they result in fewer cases of recurrent thrombosis and fewer deaths, and they save resources. The savings occur primarily by decreasing the length of stay. The LMWH strategy resulted in lower costs as compared with the UH strategy when the proportion of patients treated at home was more than 14%. Treating 1,000 patients with the LMWH strategy as compared with the UH/LMWH strategy would result in 10 fewer cases of recurrent thrombosis, 1.2 fewer deaths, at an additional cost of $96,822; the cost-effectiveness ratio was $9,667 and $80,685 per recurrent thrombosis or death prevented, respectively.
CONCLUSIONS: Treatment with LMWH leads to savings and better outcomes as compared with UH in patients with lower extremity deep venous thrombosis. The selective UH/LMWH strategy is an alternative option.
- Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism: a statement for healthcare professionals. Council on Thrombosis (in consultation with the Council on Cardiovascular Radiology), American Heart Association. Circulation. 1996;93:2212–45. CrossRef
- Prandoni P, Lensing AW, Cogo A, et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med. 1996;125:1–7. CrossRef
- Raschke RA, Reilly BM, Guidry JR, Fontana JR, Srinivas S. The weight-based heparin dosing nomogram compared with a “standard care” nomogram: a randomized controlled trial. Ann Intern Med. 1993;119:874–81. CrossRef
- Hirsh J, Warkentin TE, Raschke R, Granger C, Ohman EM, Dalen JE. Heparin and low-molecular-weight heparin: mechanisms of action, pharmacokinetics, dosing considerations, monitoring, efficacy, and safety. Chest. 1998;114:489S-510S. CrossRef
- Hyers TM. Venous thromboembolism. Am J Respir Crit Care Med. 1999;159:1–14. CrossRef
- Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease. Chest. 1998;114:561S-578S. CrossRef
- Ginsberg JS. Management of venous thromboembolism. N Engl J Med. 1996;335:1816–28. CrossRef
- Siragusa S, Cosmi B, Piovella F, Hirsh J, Ginsberg JS. Low-molecular-weight heparins and unfractionated heparin in the treatment of patients with acute venous thromboembolism: results of a meta-analysis. Am J Med. 1996;100:269–77. CrossRef
- Lensing AW, Prins MH, Davidson BL, Hirsh J. Treatment of deep venous thrombosis with low-molecular-weight heparins. A meta-analysis. Arch Intern Med. 1995;155:601–7. CrossRef
- Leizorovicz A, Simonneau G, Decousus H, Boissel JP. Comparison of efficacy and safety of low molecular weight heparins and unfractionated heparin in initial treatment of deep venous thrombosis: a meta-analysis. BMJ. 1994;309:299–304. CrossRef
- Levine M, Gent M, Hirsh J, et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med. 1996;334:677–81. CrossRef
- Koopman MM, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tasman Study Group. N Engl J Med. 1996;334:682–7. CrossRef
- The Columbus Investigators. Low-molecular weight heparin in the treatment of patients with venous thromboembolism. N Engl J Med. 1997;337:657–62. CrossRef
- Simonneau G, Sors H, Charbonnier B, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. The THESEE Study Group. Tinzaparine ou Heparine Standard: Evaluations dans l’Embolie Pulmonaire. N Engl J Med. 1997;337:663–9. CrossRef
- Levine MN, Raskob G, Landefeld S, Kearon C. Hemorrhagic complications of anticoagulant treatment. Chest. 1998;114:511S-523S. CrossRef
- Weitz JI. Low-molecular weight heparins. N Engl J Med. 1997;337:688–98. CrossRef
- Hull RD, Raskob GE, Rosenbloom D, et al. Treatment of proximal vein thrombosis with subcutaneous low-molecular-weight heparin vs intravenous heparin: an economic perspective. Arch Intern Med. 1997;157:289–94. CrossRef
- van den Belt AG, Bossuyt PM, Prins MH, Gallus AS, Buller HR. Replacing inpatient care by outpatient care in the treatment of deep venous thrombosis—an economic evaluation. TASMAN Study Group. Thromb Haemost. 1998;79:259–63.
- Drummond MF, Davies L. Economic analysis alongside clinical trials: revisiting the methodological issues. Int J Technol Assess Health Care. 1991;7:561–73. CrossRef
- Ellwein LB, Drummond MF. Economic analysis alongside clinical trials: bias in the assessment of economic outcomes. Int J Technol Assess Health Care. 1996;12:691–7. CrossRef
- Sox HC, Blatt MA, Higgins MC, Marton KI. Medical Decision Making. Mass: Butterworths; 1988.
- Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Press; 1996.
- Haddix AC, Teutsch SM, Shaffer PA, Dunet DO. Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation. New York, NY: Oxford University Press; 1996.
- Jobe AC, Mansfield CJ. Health policy and economics. In: Mengel MB, Holleman WL, eds. Fundamentals of Clinical Practice: A Textbook on the Patient, Doctor, and Society. New York, NY: Plenum Medical Book Company; 1997. 297–322. CrossRef
- van den Belt AG, Prins MH, Lensing AWA, et al. Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism (Cochrane Review). In: The Cochrane Library, Issue 3. Oxford, UK: Update Software; 1998.
- Hull RD, Raskob GE, Hirsh J, et al. Continuous intravenous heparin compared with intermittent subcutaneous heparin in the initial treatment of proximal-vein thrombosis. N Engl J Med. 1986;315:1109–14. CrossRef
- Gould MK, Dembitzer AD, Doyle RL, Hastie TJ, Garber AM. Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis: a meta-analysis of randomized, controlled trials. Ann Intern Med. 1999;130:800–9. CrossRef
- Douketis JD, Kearon C, Bates S, Duku EK, Ginsberg JS. Risk of fatal pulmonary embolism in patients with treated venous thromboembolism. JAMA. 1998;279:458–62. CrossRef
- Hommes DW, Bura A, Mazzolai L, Buller HR, ten Cate JW. Subcutaneous heparin compared with continuous intravenous heparin administration in the initial treatment of deep vein thrombosis: a meta-analysis. Ann Intern Med. 1992;116:279–84. CrossRef
- Warkentin TE, Levine MN, Hirsh J, et al. Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med. 1995;332:1330–5. CrossRef
- Carson JL, Kelley MA, Duff A, et al. The clinical course of pulmonary embolism. N Engl J Med. 1992;326:1240–5. CrossRef
- Goldhaber SZ. Pulmonary embolism. N Engl J Med. 1998;339:93–103. CrossRef
- Lilienfeld DE, Godbold JH, Burke GL, Sprafka JM, Pham DL, Baxter J. Hospitalization and case fatality for pulmonary embolism in the twin cities: 1979–1984. Am Heart J. 1990;120:392–5. CrossRef
- Siddique RM, Siddique MI, Rimm AA. Trends in pulmonary embolism mortality in the US elderly population: 1984 through 1991. Am J Public Health. 1998;88:478–80. CrossRef
- Shen VS, Pollak EW. Fatal pulmonary embolism in cancer patients: is heparin prophylaxis justified? South Med J. 1980;73:841–3. CrossRef
- Kniffin WD Jr, Baron JA, Barrett J, Birkmeyer JD, Anderson FA Jr. The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly. Arch Intern Med. 1994;154:861–6. CrossRef
- AbuRahma AF, Boland JP, Witsberger T. Diagnostic and therapeutic strategies of white clot syndrome. Am J Surg. 1991;162:175–9. CrossRef
- Stanton PE Jr, Evans JR, Lefemine AA, et al. White clot syndrome. South Med J. 1988;81:616–20. CrossRef
- King DJ, Kelton JG. Heparin-associated thrombocytopenia. Ann Intern Med. 1984;100:535–40. CrossRef
- Warkentin TE, Kelton JG. A 14-year study of heparin-induced thrombocytopenia. Am J Med. 1996;101:502–7. CrossRef
- Osterkorn D, Schramm W, Szucs T. Health care economics evaluation of inpatient treatment of venous thrombosis with unfractionated heparin versus subcutaneous low molecular weight heparin at home. Med Klin. 1996;91:607–9.
- Teo CP, Lim HL, Kueh YK. Cost effectiveness and ease of administration of low molecular weight heparin in deep vein thrombosis. Thromb Haemost. 1994;72:328–9. Letter.
- Sarasin FP, Eckman MH. Management and prevention of thromboembolic events in patients with cancer-related hypercoagulable states: a risky business. J Gen Intern Med. 1993;8:476–86. CrossRef
- Hull RD, Feldstein W, Pineo GF, Raskob GE. Cost effectiveness of diagnosis of deep vein thrombosis in symptomatic patients. Thromb Haemost. 1995;74:189–96.
- Oudkerk M, van Beek EJ, van Putten WL, Buller HR. Cost-effectiveness analysis of various strategies in the diagnostic management of pulmonary embolism. Arch Intern Med. 1993;153:947–54. CrossRef
- Hillner BE, Philbrick JT, Becker DM. Optimal management of suspected lower-extremity deep vein thrombosis: an evaluation with cost assessment of 24 management strategies. Arch Intern Med. 1992;152:165–75. CrossRef
- Bergqvist D, Jendteg S, Johnsen L, Persson U, Odegaard K. Cost of long-term complications of deep venous thrombosis of the lower extremities: an analysis of a defined patient population in Sweden. Ann Intern Med. 1997;126:454–7. CrossRef
- Hawkins DW, Langley PC, Krueger KP. Pharmacoeconomic model of enoxaparin versus heparin for prevention of deep vein thrombosis after total hip replacement. Am J Health Syst Pharm. 1997;54:1185–90.
- Lloyd AC, Aitken JA, Hoffmeyer UK, Kelso EJ, Wakerly EC, Barber ND. Economic evaluation of the use of nadroparin in the treatment of deep-vein thrombosis in Switzerland. Ann Pharmacother. 1997;31:842–6.
- Bergqvist D, Jendteg S, Lindgren B, Matzsch T, Persson U. The economics of general thromboembolic prophylaxis. World J Surg. 1988;12:349–55. CrossRef
- Udvarhelyi IS, Colditz GA, Rai A, Epstein AM. Cost-effectiveness and cost-benefit analyses in the medical literature: are the methods being used correctly? Ann Intern Med. 1992;116:238–44. CrossRef
- Gould MK, Dembitzer AD, Sanders GD, Garber AM. Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. A cost-effectiveness analysis. Ann Intern Med. 1999;130:789–99. CrossRef
- Rodger M, Bredeson C, Wells PS, Beck J, Kearns B, Huebsch LB. Cost-effectiveness of low-molecular-weight heparin and unfractionated heparin in treatment of deep vein thrombosis. CMAJ. 1998;159:931–8.
- Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prevention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med. 1998;338:409–15. CrossRef
- Hull RD, Feldstein W, Stein PD, Pineo GF. Cost-effectiveness of pulmonary embolism diagnosis. Arch Intern Med. 1996;156:68–72. CrossRef
- Bergqvist D, Benoni G, Bjorgell O, et al. Low-molecular-weight heparin (enoxaparin) as prophylaxis against venous thromboembolism after total hip replacement. N Engl J Med. 1996;335:696–700. CrossRef
- Cost-effectiveness of low-molecular-weight heparin in the treatment of proximal deep vein thrombosis
Journal of General Internal Medicine
Volume 15, Issue 2 , pp 108-115
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- heparin, low molecular weight
- cost-benefit analysis
- Industry Sectors
- Author Affiliations
- 1. East Carolina University School of Medicine, General Internal Medicine, 600 Moye Blvd., PCMH-Teaching Annex Room 389, 27858-4354, Greenville, NC
- 2. University of Alabama at Birmingham and Birmingham Veterans Administration Medical Center, Birmingham, Alabama