Cost-effectiveness of early placement of vena cava filters to prevent symptomatic pulmonary embolism in patients with contraindications to prophylactic anticoagulant

Abstract

Introduction: Vena cava filters have been used as a primary means to prevent symptomatic pulmonary embolism (PE) in trauma patients who cannot be anticoagulated after severe injury, but the economic implications for this practice remain unclear. Methods: Using a healthcare system perspective to analyze the a priori primary outcome of the da Vinci trial, we report the cost-effectiveness of using vena cava filters as a primary means to prevent PE in patients who have contraindications to prophylactic anticoagulation after major trauma. Results: Of the 240 patients enrolled, complete, prospectively collected, hospital cost data during the entire hospital stay − including costs for the filter, medical/nursing/allied health staff, medical supplies, pathology tests, and radiological imaging − were available in 223 patients (93%). Patients allocated to the filter group ( n = 114) were associated with a reduced risk of PE (0.9%) compared to those in the control group ( n = 109, 5.5%; p = 0.048); and the filter’s benefit was more pronounced among those who could not be anticoagulated within 7 days (filter: 0% vs control: 16%, Bonferroni-corrected p = 0.02). Overall, the cost needed to prevent one PE was high (AUD $379,760), but among those who could not be anticoagulated within 7 days, the costs to prevent one PE (AUD $36,156; ~ USD $26,032) and gain one quality-adjusted life-year (AUD $30,903; ~ USD $22,250) were substantially lower. Conclusion: The cost of using a vena cava filter to prevent PE for those who have contraindications to prophylactic anticoagulation within 3 days of injury is prohibitive, unless such contraindications remain for longer than 7 days. (Australian New Zealand Clinical Trials Registry no.: ACTRN12614000963628)

Monitoring anti-Xa Levels to Optimize Low-Molecular-Weight-Heparin Thromboprophylaxis in High-Risk Hospitalized Patients: A Stratified Meta-Analysis

“…Given the substantial financial (>US$ 35,000) and non-financial costs of VTE in high-risk hospitalized patients, 27,28 titrating the dose or frequency of LMWH by monitoring anti-Xa levels (∼US$25.3/test) would appear to be a cost-effective strategy compared with many other interventions that are in clinical use to prevent VTE. 29,30 COVID-19 infection is known to be associated with an increased risk of VTE 31 but the best strategy to prevent the burden of VTE in this type of patients remains uncertain. Observational evidence suggested that a higher dose of LMWH is needed to achieve adequate peak anti-Xa levels (.2-.5 IU/ml) in COVID-19 patients; 32 and in at least one study, a prompt correction of LMWH doses according to the first anti-Xa measurement was independently associated with a lower risk of COVID-19-related deaths (adjusted OR .04, 95%CI 0.002-.90; P = .043).…”

“…Given the substantial financial (>US$ 35,000) and non-financial costs of VTE in high-risk hospitalized patients, 27,28 titrating the dose or frequency of LMWH by monitoring anti-Xa levels (∼US$25.3/test) would appear to be a cost-effective strategy compared with many other interventions that are in clinical use to prevent VTE. 29,30…”

Long-term outcomes after using retrievable vena cava filters in major trauma patients with contraindications to prophylactic anticoagulation

“…Although vena cava filters have been used for either primary or secondary prevention of symptomatic PE in major trauma patients for several decades, their long-term costeffectiveness and safety outcomes in these high-risk patients remain contentious [1,5,[10][11][12][13], primarily due to a lack of reliable data from RCTs. Our previous economic analysis based on 90-day follow-up data from patients who had contraindications to prophylactic anticoagulation within three days of trauma admission showed that the cost of using vena cava filters to prevent symptomatic PE in trauma was prohibitive (even though it was indeed effective but was not explicitly reported in our primary manuscript: 1/122 in the filter group vs 7/118 in the control group; p = 0.033) [9], and such strategy could only be considered cost-effective when restricted to those who had a prolonged period (> 7 days) of contraindications to prophylactic anticoagulation (€24,586 to prevent one symptomatic PE and €21,014 to gain one quality-adjusted-life-year).…”

“…In this study, one Australian dollar was converted to 0.68 Euro dollar (€) when reporting the cost in Euro currency. The details of our economic costing were described in our economic analysis sub-study [ 5 ].…”

“…In addition to substantial detrimental effects on patients’ short- and long-term functional and psychosocial capacity [ 2 , 3 ], symptomatic PE after major trauma is also costly with an attributable hospitalization cost of over A$40,000 [ 4 ]. On the other hand, vena cava filters are expensive [ 5 ] and associated with serious complications [ 6 ]. Although a number of long-term complications of vena cava have been well described by observational studies [ 6 , 7 ], whether these complications are related to the issue of confounding when the filters were used in a sicker cohort of trauma patients and left in situ for a prolonged period of time, is uncertain.…”