To The Editor:
We read with interest the recent paper "The Cost-Effectiveness of
Extended-Duration Antithrombotic Prophylaxis After Total Hip
Arthroplasty" (2007;89:819-28), by Skedgel et al., regarding economic
decision-making, with reference to extended thromboprophylaxis after total hip
arthroplasty. The authors refer to a study by Lapidus et al.1, who
stated that 38.4% of patients receiving low-molecular-weight heparin required
a community nurse for administration. For cost-effectiveness, the number
requiring a community nurse must be <10%.
We reviewed the last 100 major lower-limb arthroplasties by a single
surgeon in two centers over the last year. Our practice is that
low-molecular-weight heparin is given for five weeks by self-administration or
by a patient advocate. Advice is given at the time of preoperative assessment
and/or at the time of consenting to the treatment, with instruction given in
the injection technique after surgery. Warfarin is used if the patient is
already on the drug preoperatively, poor compliance is suspected, or
self-administration is not possible. Ninety-two percent of the patients had
low-molecular-weight heparin (with 6.5% of them ultimately needing external
help, especially if they were living in a short-term rehabilitation facility).
An advanced age of more than eighty 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 low-molecular-weight heparin is therefore
achievable with appropriate information, teaching, and awareness among the
staff. Indeed, most companies offer these services to staff and patients free
of charge, which must surely be included in the equation as an indirect
saving.