Justifying Total Costs of Extended Venothromboembolism Prophylaxis After Colorectal Cancer Surgery



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.

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Funding Source

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).

Author information




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.

Corresponding author

Correspondence to Ira L. Leeds.

Ethics declarations

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.

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The authors declare that they have no conflict of interest.

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Appendix 1

Table 3 Impact inventory for cost-effectiveness analysis comparing ePpx versus current standard of care
Table 4 Quality-adjusted life year calculation

Appendix 2


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Leeds, I.L., Canner, J.K., DiBrito, S.R. et al. Justifying Total Costs of Extended Venothromboembolism Prophylaxis After Colorectal Cancer Surgery. J Gastrointest Surg 24, 677–687 (2020). https://doi.org/10.1007/s11605-019-04206-z

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  • Surgery
  • Colorectal cancer
  • Economic evaluation
  • Cost-benefit analysis
  • Venous thrombosis
  • Decision trees