Venous thromboembolism: compression stockings were most cost-effective.

Clinical bottom line (level 2b)

  1. Using compression stockings alone was the most cost-effective way of preventing venous thromboembolism- it was cheaper than doing nothing.
  2. The next most cost-effective options were pneumatic stockings combined with compression stockings, followed by heparin alone.
Oster et al: American Journal of Medicine 1987; 82: 889-899
Expires December 2003

The study

cost-effectiveness analysis using a clinical decision analysis
Setting: university hospital, USA

systematic review of all English language randomised controlled trials (1976-1984) on venous thromboembolism prophylaxis in patients undergoing abdominothoracic, gynaecological or prostatic surgery with objective measurement of subsequent VTE (deep vein thrombosis diagnosed by venogram or radiolabeled fibrinogen uptake study. Pulmonary embolism diagnosed by ventilation-perfusion scan, pulmonary angiography or autopsy)

  • Viewpoint: third party, eg. HMO or NHS purchaser
  • Benefit assessment: deep vein thrombosis or pulmonary embolism
  • Resources and costs: no details given
  • Sensitivity analysis: varied cost and effectiveness of treatment

    • The evidence

    intervention cost
    cost per patient (1984 US$) 109
    ( extra cost per VTE prevented: -210 )
    stockings 75.1
    ( extra cost per VTE: 180 )
    heparin 140
    ( extra cost per VTE: 430 )
    pneumatic compression 149
    ( extra cost per VTE: 430 )
    heparin and dihydroergotamine 164
    ( extra cost per VTE: 320 )
    heparin and stockings 149
    ( extra cost per VTE: 200 )
    pneumatic compression and stockings 126
    ( extra cost per VTE: 77 )

    Effect of sensitivity analysis: Analysis was resistant to doubling to halving the costs- no change in the order. NB. actual amount saved is unimportant- the order matters.
    • heparin- 2500 units given s/c two hours pre-op, then 5000 units every 12 hours post-op for five days
    • intermittent pneumatic compression- rhythmic extremity compression bilaterally, prior to induction, continued for 16 hours post-op
    • graduated pressure stockings- applied one day pre-op and worn until the patient was fully ambulatory or discharged
    • heparin and dihydroergotamine- 2500 units heparin and 0.5 mg dihydroergotamine given s/c two hours pre-op, then 5000 units heparin and 0.5 mg dihydroergotamine every 12 hours post-op for five days

    Comments

    1. LMWH were not included in this analysis and may significantly alter results of analysis.
    2. Unclear as to whether all patients receiving any operation benefit or whether only patients undergoing major surgery were involved. Little information given about type of surgery or patients.
    3. The study does not mention cost of increased bleeding and wound hematomas.

    Citation

    1. Oster G, Tuden RL, Colditz GA: Prevention of venous thromboembolism after general surgery: cost-effectiveness analysis of alternative approaches to prophylaxis. American Journal of Medicine 1987; 82: 889-899
    Search Terms: thromboembol* and cost or econom* in Cochrane
    Contributor: Chris Ball and Clare Wotton, June 2000
    Reviewer:

    Clinical Question.
    Patient undergoing surgery
    Intervention or Exposure venous thromboembolism prophylaxis
    Outcome cost-effectiveness