Justifying Total Costs of Extended Venothromboembolism Prophylaxis After Colorectal Cancer Surgery
- 84 Downloads
Current guidelines recommend extended venothromboembolism (VTE) prophylaxis for most patients following colorectal cancer surgery, but provider uptake has been limited. The purpose of this study was to identify thresholds for when such extended prophylaxis (ePpx) may be value-appropriate.
All colorectal cancer postoperative discharges were identified within a private payer administrative database (MarketScan® 2010–2014, IBM Truven Health Analytics). Outcomes of interest were VTE event rate, mortality, and overall costs of care. The data along with published literature were used as parameter estimations for a decision analysis model with probabilistic sensitivity analysis.
We identified 22,463 colorectal cancer surgical patients (4.0% with ePpx) that served as the parameter estimates for the decision model with a VTE event rate of 0.2%. Decision analysis demonstrated that prescribing ePpx was dominated by usual practice with the former having higher probability-adjusted incremental costs ($1078.68 per person) and lower probability-adjusted benefits (− 0.000098 quality adjusted life years). Broad sensitivity analysis found that probability of a VTE event, bleeding case fatality rate, and probability of an ePpx-associated bleeding event were the primary effectors of the model. VTE event rates of greater than 3.0% benefited from prescribing ePpx to all patients.
Very few patients are discharged on ePpx following colorectal cancer surgery despite its endorsement by national guidelines. A decision analysis model does not support the use of ePpx except in cases of markedly high VTE rates. Clinical guidance could be improved by further recognizing the role of risk stratification in the determination of high-risk patients requiring ePpx.
KeywordsSurgery Colorectal cancer Economic evaluation Cost-benefit analysis Venous thrombosis Decision trees
I.L. received salary support for the preparation of this manuscript from a National Cancer Institute T32 Institutional Training Grant (5T32CA126607) and a Research Foundation of the American Society of Colon and Rectal Surgeons Resident Research Initiation Grant (GSRRIG-031).
Study design—I.L.L., S.R.D., and B.S. Data collection—I.L.L., J.K.C., and S.R.D. Data analysis and interpretation—I.L.L. and B.S. Manuscript drafting—I.L.L. Manuscript critical revision—J.K.C., S.R.D., and B.S.
Compliance with Ethical Standards
The following study design and analysis were approved by the Johns Hopkins University School of Medicine Institutional Review Board and meet requirements of the Second Panel on Cost-Effectiveness Reporting Standards.
Conflict of Interest
The authors declare that they have no conflict of interest.
- 6.Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. Prevention of vte in nonorthopedic surgical patients: Antithrombotic therapy and prevention of thrombosis, 9th ed: american college of chest physicians evidence-based clinical practice guidelines. CHEST J. 2012;141(2_suppl):e227S–e277S.Google Scholar
- 9.Kakkar V V, Balibrea JL, Martínez-González J, Prandoni P, CANBESURE Study Group. Extended prophylaxis with bemiparin for the prevention of venous thromboembolism after abdominal or pelvic surgery for cancer: the CANBESURE randomized study. J Thromb Haemost. 2010 Jun;8(6):1223–9.CrossRefPubMedGoogle Scholar
- 10.Akl EA, Kahale LA, Hakoum MB, Matar CF, Sperati F, Barba M, et al. Parenteral anticoagulation in ambulatory patients with cancer. Cochrane Database Syst Rev. 2017 Sep 11;(6):CD009447.Google Scholar
- 12.Kalka C, Spirk D, Siebenrock K-A, Metzger U, Tuor P, Sterzing D, et al. Lack of extended venous thromboembolism prophylaxis in high-risk patients undergoing major orthopaedic or major cancer surgery. Electronic Assessment of VTE Prophylaxis in High-Risk Surgical Patients at Discharge from Swiss Hospitals (ESSENTIAL). Thromb Haemost. 2009 May 12;Google Scholar
- 14.Srinivasaiah N, Arsalani-Zadeh R, Monson JR. Thrombo-prophylaxis in colorectal surgery: A National Questionnaire Survey of the members of the Association of Coloproctology of Great Britain and Ireland. Color Dis. 2012;14(7).Google Scholar
- 20.Rasmussen MS, Jørgensen LN, Wille-Jørgensen P. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane database Syst Rev. 2009 Jan 21;(1):CD004318.Google Scholar
- 22.Briggs A, Sculpher M, Claxton K. Decision Modeling for Health Economic Evaluation. Oxford, England: Oxford University Press; 2006.Google Scholar
- 23.Food and Drug Administration. Required Warnings for Cigarette Packages and Advertisements (21 CFR Part 1141). Fed Regist. 2010;75(218):69524–65.Google Scholar
- 24.National Center for Environmental Economics. Frequently Asked Questions on Mortality Risk Valuation [Internet]. Washington, DC; 2010.Google Scholar
- 25.Appelbaum B. As U.S. Agencies Put More Value on a Life, Businesses Fret. New York Times. 2011 Feb 16;Google Scholar
- 29.Data U.S. Bureau of Labor Statistics FRED: Federal Reserve Economic. Consumer Price Index for All Urban Consumers: Medical Care. Federal Reserver Bank of St. Louis. [Internet]. 2018 [cited 2018 Apr 10]. Available from: https://fred.stlouisfed.org/series/CPIMEDNS. Accessed 10 Apr 2018
- 30.Rasmussen MS, Jorgensen LN, Wille-Jørgensen P, Nielsen JD, Horn A, Mohn AC, et al. Prolonged prophylaxis with dalteparin to prevent late thromboembolic complications in patients undergoing major abdominal surgery: a multicenter randomized open-label study. J Thromb Haemost. 2006 Nov;4(11):2384–90.CrossRefPubMedGoogle Scholar