A Cost-Effectiveness Analysis of the Alternative Approaches to the Prophylaxis of Venous Thromboembolism

Abstract

<p>Up until the last decade, physicians were content to base management decisions in postoperative surgical patients on the clinical diagnosis of deep vein thrombosis (DVT). Subsequently, multiple studies have demonstrated the insensitivity of clinical diagnosis. Pulmonary embolism (PE) is the most common preventable cause of in-hospital death, which no doubt reflects the insensitivity of clinical diagnosis. Multiple randomized trials indicate that low-dose subcutaneous (sc) heparin and intravenous (IV) dextran are effective for preventing death due to pulmonary embolism in postoperative general surgical patients. Other approaches effective against venous thromboembolism are: intermittent pneumatic leg compression (IPLC) and screening with ¹²⁵I-fibrinogen leg scanning. We have performed a cost-effective analysis in 1,000 patients over the age of forty years undergoing major elective surgery comparing the prophylactic approaches described above with the "no-programme" situation (early ambulation but no other active prophylaxis). The total cost (Canadian dollars) and total effects (deaths from pulmonary embolism averted) are as follows: s.c. heparin $35,714 for 7 lives saved; IPLC $55,803 for 7 lives saved; IV dextran $137,235 for 6 lives saved; leg scanning $396,599 for 7 lives saved; and the "no-programme" situation $53,472 for 8 lives lost. The "no-programme" situation is clearly cost-ineffective. Incremental cost-effectiveness analysis indicates that s.c. heparin is the most cost-effective, followed by IPLC. Dextran and leg scanning, although effective, are both expensive; therefore s.c. heparin or IPLC prophylaxis are preferred.</p>