A comparative cost-effectiveness analysis of mechanical and pharmacological VTE prophylaxis after lower limb arthroplasty in Australia

Abstract

Background Venous thromboembolism (VTE) is a complication following surgery. Low-molecular-weight heparin (LMWH) or direct oral anticoagulants (DOACs) are efficacious but come with inherent bleeding risk. Mechanical prophylaxis, such as intermittent pneumatic compression (IPC), does not induce bleeding but may be difficult to implement beyond the immediate post-operative period. This study compared the cost and quality-adjusted life years (QALYs) saved of commonly used VTE prophylaxis regimens after lower limb arthroplasty. Methods A previously published cost-utility model considering major efficacy and safety endpoints was updated to estimate the 1-year cost-effectiveness of different VTE prophylaxis regimens. The VTE strategies assessed included apixaban, dabigatran, rivaroxaban, LMWH, IPC, IPC + LMWH and IPC + apixaban. Efficacy data were derived from studies in PubMed, and cost data came from the 2017 Australian AR-DRG and PBS pricing schemes. Results Costs for VTE prophylaxis including treatment of its associated complications over the first year after surgery ranged from AUD $644 (IPC) to AUD $956 (rivaroxaban). Across 500 simulations, IPC was the cheapest measure in 73% of simulations. In 97% of simulations, a DOAC was associated with the highest resulting QALYs. Compared to IPC, apixaban was cost-effective in 76.4% of simulations and apixaban + IPC in 87.8% of simulations. For VTE events avoided, the DOACs and IPC were on par. LMWH and LMWH + IPC were negatively dominated. Conclusions Apixaban, IPC or a sequential/simultaneous combination of both is currently the most cost-effective VTE prophylaxis regimens. The choice between them is best guided by the relative VTE and bleeding risks of individual patients.

Effectiveness of Deep Venous Thrombosis Prevention in Total Hip Arthroplasty

“…We believe that the best and lowest cost-benefit for VTE prevention is related to the systematic use of intermittent pneumatic compression. This finding is in line with the opinion of other authors who consider that the association with the use of acetylsalicylic acid (ASA) increases its preventive power, 10 especially if used within the first 24 hours after surgery. ( 11 We found divergent opinions regarding the use of this protocol, as there is a fear that its application will not be enough to prevent DVT.…”

“…In general, we found studies whose methods are similar to those adopted by Torres, Bautista and Lins, with incidences ranging from 0% to 3%. 10 )- ( 12 …”

Recommendations from the ICM-VTE: General

“…Interestingly, the cost-effectiveness of different methods depended mostly on the cost of acquisition of the drug or mechanical prophylactic device and their complications 1280 . For instance, studies comparing rivaroxaban vs. LMWH in countries with more expensive rivaroxaban acquisition including Germany (from hospital perspective) and China, favored LMWH following either THA or TKA despite the higher efficacy of rivaroxaban in preventing VTE 1256 .…”

“…They demonstrated IPCD with/without apixaban to be appropriate according to their cost-effectiveness profile. They recommended to use prophylactic measures in accordance with the bleeding/thrombosis risk of each patient 1280 .…”

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“…Our study also demonstrated high levels of unwarranted clinical variation in routine care to prevent infection and VTE after TKR and THR. The use of multiple prophylactic drugs, higher than recommended dose, and longer than recommended duration of prophylaxis, were surprising given the risks associated with inappropriate care [16,[47][48][49][50]. Prolonged VTE prophylaxis may increase the risk of bleeding; conversely when the duration or dose is insufficient, prophylaxis may be inadequate [50].…”