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Scientific Articles   |    
The Cost-Effectiveness of Extended-Duration Antithrombotic Prophylaxis After Total Hip Arthroplasty
Chris Skedgel, MDE1; Ron Goeree, MA2; Sue Pleasance, BScN1; Kara Thompson, MSc1; Bernie O'Brien, PhD3; David Anderson, MD1
1 Department of Medicine, Dalhousie University, Centre for Clinical Research, Room 207, 5790 University Avenue, Halifax, NS B3H 1V7, Canada. E-mail address for C. Skedgel: chris.skedgel@cdha.nshealth.ca
2 Program for Assessment of Technology in Health (PATH), St. Joseph's Hospital, 25 Main Street West, Suite 2000, Hamilton, ON L8P 1H1, Canada
3 Deceased
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Nova Scotia Health Research Foundation (PSO-Project-2003-339). At the time of the study, one author was a Research Scholar of the Faculty of Medicine, Dalhousie University. Neither the authors nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Centre for Clinical Research, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Apr 01;89(4):819-828. doi: 10.2106/JBJS.F.00092
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Abstract

Background: Although the risk of thromboembolism after total hip arthroplasty continues beyond hospital discharge, the cost-effectiveness of extending prophylaxis beyond hospitalization is unclear. We compared the cost-effectiveness of an extended duration of antithrombotic prophylaxis following total hip arthroplasty, with use of low-molecular-weight heparin or warfarin administered for twenty-eight days beyond hospital discharge, in terms of incremental cost per quality-adjusted life year gained.

Methods: The economic analysis was structured around a decision tree characterizing the consequences of extended prophylaxis choices following total hip arthroplasty. The health benefits of extended antithrombotic prophylaxis, measured as the reduction in symptomatic venous thromboembolic events and deaths for each treatment alternative, were determined through a systematic review of the literature. Gains in quality-adjusted life years were based on the distribution of life years remaining for all patients undergoing total hip arthroplasty in Canada in 2003, weighted by utilities derived from the literature. The cost analysis, in 2006 Canadian dollars, took a direct payer perspective with a ninety-day time horizon.

Results: There was a net gain in quality-adjusted life years in both cohorts that received extended prophylaxis relative to the cohort that received no extended prophylaxis (7.5 quality-adjusted life years per 1000 patients treated with low-molecular-weight heparin and 5.5 quality-adjusted life years per 1000 patients treated with warfarin), although these gains were not significant. The net treatment costs per 1000 patients treated were $799,104 with low-molecular-weight heparin and $72,236 with warfarin. In comparison with the cohort that received no extended prophylaxis, the cost-effectiveness of low-molecular-weight heparin was $106,454 per quality-adjusted life year gained and the cost-effectiveness of warfarin was $13,115 per quality-adjusted life year gained.

Conclusions: There is insufficient economic evidence to support extended thromboprophylaxis with low-molecular-weight heparin following total hip arthroplasty. Although the cost-effectiveness of warfarin was potentially quite favorable, this finding was based on limited clinical evidence. Further research is required to clarify the benefits of extended prophylaxis, particularly with warfarin.

Level of Evidence: Economic and decision analysis, Level I. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Chris D. Skedgel
    Posted on June 22, 2007
    Cost-effectiveness of LMWH: A response to Shoaib and colleagues
    Dalhousie University

    As Dr. Shoaib and colleagues correctly point out, our economic analysis suggested extended antithrombotic prophylaxis with low-molecular- weight heparin (LMWH) could meet a $50,000 per QALY gained threshold with home care rates of less than 10%. At the figure Shoaib et al quote (6.5%), our model estimates the cost-effectiveness of LMWH would be roughly $35,000 per QALY gained, relative to no further prophylaxis. However, while we accept that LMWH has the potential to be cost-effective at such rates, we still feel this is an optimistic result. First, in their own words, the cohort Shoaib et al refer to was pre-screened to exclude patients in whom, among other factors, “self administration was not possible.” Our analysis considered LMWH used as routine antithrombotic prophylaxis in all patients following total hip arthroplasty. Second, as warfarin appears to be an effective alternative, it is important to consider the incremental cost-effectiveness of LMWH relative to warfarin. Based on home care rates of 6.5% for both LMWH administration and warfarin monitoring, the incremental cost-effectiveness of LMWH relative to warfarin would be approximately $107,000 per QALY gained.

    The discrepancy between our baseline estimates of home care rates and Shoaib et al’s highlights the uncertainty around the ability to self- administer in such a cohort. Further research is required to clarify this important parameter.

    Amer Shoaib
    Posted on June 05, 2007
    Cost effective levels of patient self administration of low molecular weight heparins are achievable
    robert jones and agnes hunt hospital, oswestry

    We read with interest the recent paper, by Skedgel et al(1) regarding economic decision making, with reference to extended thromboprophylaxis after total hip arthroplasty. The authors refer to Lapidus et al(2) who states 38.4% of low molecular heparin (LMWH) patients required a community nurse for administration. For cost effectiveness the number requiring a community nurse must be less than 10%.

    We reviewed the last 100 major lower limb arthroplasties by a single surgeon in two centres over the last year. Our practice is that LMWH is given for five weeks by self administration or by a patient advocate. Advice is given at preassesment/ consenting with instruction in injection technique after surgery. Warfarin is used if the patient is already on the drug pre-operatively, poor compliance is suspected, or self administration not possible. 92% of cases had LMWH (6.5% of these ultimately needing external help, especially if housed in short-term respite care). Advanced age, over 80 years, did not appear to be a limiting factor. Intuitively a patient deemed competent for major elective surgery should be deemed likely to succeed with this regime.

    The cost-effectiveness of LMWH is therefore achievable with appropriate information, teaching and ward knowledge. Indeed most companies offer these facilities to staff and patients free of charge, which must surely be included in the equation as an indirect saving.

    1 Skedgel C, Goeree R, Pleasance S, Thompson K, O'Brien B, Anderson D. The cost-effectiveness of extended-duration antithrombotic prophylaxis after total hip arthroplasty.J Bone Joint Surg Am. 2007 Apr;89(4):819-28.

    2 Lapidus L, Borretzen J, Fahlen M, Thomsen HG, Hasselblom S, Larson L, Nordstrom H, Stigendal L, Waller L. Home treatment of deep vein thrombosis. An out-patient treatment model with once-daily injection of low-molecular-weight heparin (tinzaparin) in 555 patients. Pathophysiol Haemost Thromb.2002; 32:59 -66

    Mr Amer Shoaib BSc.(Hons), FRCS( Tr and Orth) (1) Mr Narlaka Jayesekera MRCS (2) Dr Monika Oktaba (2) Mr Richard T. Roach BSc.(Hons), FRCS(Tr and Orth) (1,2)

    (1) Robert Jones and Agnes Hunt Hospital, Oswestry (2) Princess Royal Hospital, Telford, Shropshire, UK.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

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