Venous thromboembolism:prophylaxis: LMWH may be cost-effective for abdominal and hip surgery.

Clinical bottom line (level 2b)

  1. Low molecular weight heparin was more cost-effective than unfractionated heparin, a watch-and-wait policy or no treatment at preventing post-operative venous thromboembolism.
  2. LMWH would not be cost-effective if it costs:
    • 37% more than unfractionated heparin for abdominal surgery
    • 128% more than unfractionated heparin for hip surgery
  3. Current UK prices suggest that LMWH may be cost-effective for hip surgery, but not abdominal surgery.
Bergqvist et al: British Journal of Surgery 1996; 83: 1548-1552
Expires June 2003

The study

cost-effectiveness analysis based around clinical decision tree
Setting: teaching hospital, Sweden

Patients had general abdominal surgery and were at moderate risk for DVT, or had elective hip surgery and were at high risk for DVT.

  • Viewpoint: third party, eg. HMO or NHS purchaser
  • Benefit assessment: DVT occurrence
  • Resources and costs: treatment costs based on randomised controlled trial performed in Malmo, Sweden, in Swedish 1996 Kroner. Cost of DVt treatment 17,000 Kroner
  • Sensitivity analysis: varied cost and treatment effectiveness

    • The evidence

    intervention cost
    abdominal surgery: no prophylaxis 1950 per patient
    abdominal surgery: fibrinogen scan 5710 per patient
    abdominal surgery: heparin 735 per patient
    ( 7070 Kroner per symptomatic VTE prevented; 3150 Kroner per asymptomatic VTE prevented )
    abdominal surgery: LMWH 665 per patient
    ( 6330 per symptomatic VTE prevented; 2670 per asymptomatic VTE prevented )
    hip surgery: no prophylaxis 3930 per patient
    hip surgery: fibrinogen scan 10790 per patient
    hip surgery: heparin 1730 per patient
    ( 10400 per symptomatic VTE prevented; 6730 per asymptomatic VTE prevented )
    hip surgery: LMWH 1390 per patient
    ( 7550 per symptomatic VTE prevented; 3520 per asymptomatic VTE prevented )

    Comments

    1. Seemingly high proportions of clinically detected DVT may make the analysis insecure
    2. Other viable outcomes that should have been considered are: compression stockings, pneumatic stockings, and combinations of all of the interventions.
    3. LMWH is not favoured if it costs:
      • 37% more than unfractionated heparin for abdominal surgery
      • 128% more than unfractionated heparin for hip surgery
    4. Current UK cost of heparin is 92p, tinzaparin GBP2.97. Assuming twice daily dosing of heparin vs once daily dosing of tinzaparin, LMWH costs ~60% more than unfractionated heparin, ie. use for hip but not abdominal surgery.

    Citation

    1. Bergqvist D, Lindgren B, Matzsch T: Comparison of cost of preventing postoperative deep vein thrombosis with either unfractionated or low molecular weight heparin. British Journal of Surgery 1996; 83: 1548-1552
    Contributor: Chris Ball and Clare Wotton, June 2000
    Reviewer: Alex Gallus

    Clinical Question.
    Patient moderate or high risk of DVT after surgery
    Intervention or Exposure LMWH
    Comparison unfractionated heparin
    Outcome cost-effectiveness