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Defining High Risk: Cost-Effectiveness of Extended-Duration Thromboprophylaxis Following Major Oncologic Abdominal Surgery

  • 2013 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Purpose

Extended-duration thromboprophylaxis (EDTPPX) is the practice of prescribing antithrombotic therapy for 21 days after discharge, commonly used in surgical patients who are at high risk for venothromboembolism (VTE). While guidelines recommend EDTPPX, criteria are vague due to a paucity of data. The criteria can be further informed by cost-effectiveness thresholds. This study sought to determine the VTE incidence threshold for the cost-effectiveness of EDTPPX compared to inpatient prophylaxis.

Methods

A decision tree was used to compare EDTPPX for 21 days after discharge to 7 days of inpatient prophylaxis with base case assumptions based on an abdominal oncologic resection without complications in an otherwise healthy individual. Willingness to pay was set at $50,000/quality-adjusted life year (QALY). Sensitivity analyses were performed to assess uncertainty within the model, with particular interest in the threshold for cost-effectiveness based on VTE incidence.

Results

EDTPPX was the dominant strategy when VTE probability exceeds 2.39 %. Given a willingness to pay threshold of $50,000/QALY, EDTPPX was the preferred strategy when VTE incidence exceeded 1.22 and 0.88 % when using brand name or generic medication costs, respectively.

Conclusions

EDTPPX should be recommended whenever VTE incidence exceeds 2.39 %. When post-discharge estimated VTE risk is 0.88–2.39 %, patient preferences about self-injections and medication costs should be considered.

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Author information

Authors and Affiliations

  1. Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Box SURG, Rochester, NY, 14642, USA

    James C. Iannuzzi, Aaron S. Rickles, Kristin N. Kelly, Fergal J. Fleming, John R. T. Monson & Katia Noyes

  2. Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA

    James G. Dolan

Authors
  1. James C. Iannuzzi
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  2. Aaron S. Rickles
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  3. Kristin N. Kelly
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  4. Fergal J. Fleming
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  5. James G. Dolan
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  6. John R. T. Monson
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  7. Katia Noyes
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Correspondence to James C. Iannuzzi.

Additional information

Discussion

Dr. Kimberly M. Brown (Galveston, TX): The authors have completed an interesting study of an important question relating to the use of extended thromboprophylaxis in GI cancer patients. It is clear that EDTPPX is more likely to benefit certain patients, and this paper illuminates a specific threshold of risk beyond which the most cost-effective strategy is to provide EDTPPX.

1. Given that the work of Bradley et al. demonstrated cost-effectiveness of unfractionated heparin, please give a rationale as to why that strategy was not included in your analysis.

2. In the discussion, the authors criticize vague definitions of “high risk” and lack of a risk prediction model as contributing factors to poor compliance, but the results of their study depend on being able to calculate a patient's risk in order to determine cost-effectiveness (should one try to operationalize the conclusions of this paper). How would one determine the risk of a given patient in order to apply the proposed algorithm?

3. Symptomatic DVT/PE rates are different for laparoscopic vs. open abdominal surgery. Please clarify what years of NSQIP data were used and whether the codes for lap and open were separate during the time period. Did you consider both lap and open cases?

4. In the conclusions, the authors state that the findings of the paper should inform guidelines regarding colorectal surgery. Please comment as to if or how these findings should be applied to other abdominal surgery patients.

Closing Discussant

Dr. James Iannuzzi: Thank you for your comments and questions. The work of Bradley et al. was focused on evaluating a wide range of thromboprophylactic regimens including warfarin and aspirin that are not currently recommended for post-discharge thromboprophylaxis. While current ACCP guidelines do recommend either low weight molecular heparin or unfractionated heparin, the clinical trials leading to these guidelines focused on low molecular weight heparin only. Unfractionated heparin may remain a viable low-cost option; however, it is not a favored approach with a minority of colorectal surgeons using it for extended prophylaxis (unpublished data). We restricted our analysis to the most commonly used post-discharge thromboprophylactic agent with the purpose of determining when it is best utilized in congruence with the clinical trials that led to current guidelines.

Determining patient risk for individualized care is a growing trend in surgical care that likely increased medical efficiency. While previously no risk stratification is available for determining post-discharge VTE risk, we have recently developed just such a risk score aimed at the post-surgical discharge VTE risk prediction. The range of risk where extended-duration thromboprophylaxis is cost-effective includes the average VTE rates following major abdominal surgery, which bolsters current recommendations for its use in this population. However, individual patients may have lower risk and be spared extended-duration thromboprophylaxis, while others may clearly be at high risk making the decision easy. This paper demonstrates that intermediate-risk patients may benefit from extended-duration thromboprophylaxis, but including their preferences about shots and availability of generic drugs may be even more important and should be included in the decision making process.

In our paper, we considered both laparoscopic and open cases together in aggregate. Controversy continues to rage over whether there is a true difference in VTE based on operative approach. The studies utilized for baseline estimates of VTE rate were derived from NSQIP from 2005 to 2009; however, subsequent studies including 2010 data have corroborated these estimates.

While our initial conclusions were geared towards colorectal patients, our findings are generalizable to the wider cohort of major abdominal surgeries as the utility estimates and baseline parameters were derived from widely generalizable values. The risk scores that then inform an individualized patient approach also are non-specific and include all general surgery cases. We thus have now concluded that our findings can be applied to all major abdominal GI resections.

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Iannuzzi, J.C., Rickles, A.S., Kelly, K.N. et al. Defining High Risk: Cost-Effectiveness of Extended-Duration Thromboprophylaxis Following Major Oncologic Abdominal Surgery. J Gastrointest Surg 18, 60–68 (2014). https://doi.org/10.1007/s11605-013-2373-4

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  • DOI: https://doi.org/10.1007/s11605-013-2373-4

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