Do Cost Limitations of Extended Prophylaxis After Surgery Apply to Ulcerative Colitis Patients?

Abstract

BACKGROUND:Colorectal surgery patients with ulcerative colitis are at increased risk of postoperative venous thromboembolism. Extended prophylaxis for thromboembolism prevention has been used in colorectal surgery patients, but it has been criticized for its lack of cost-effectiveness. However, the cost-effectiveness of extended prophylaxis for postoperative ulcerative colitis patients may be unique. OBJECTIVE:This study aimed to assess the costeffectiveness of extended prophylaxis in postoperative ulcerative colitis patients.DESIGN: A decision analysis compared costs and benefits in postoperative ulcerative colitis patients with and without extended prophylaxis over a lifetime horizon. SETTING:Assumptions for decision analysis were identified from available literature for a typical ulcerative colitis patient's risk of thrombosis, age at surgery, type of thrombosis, prophylaxis risk reduction, bleeding complications, and mortality. MAIN OUTCOME MEASURES:Costs ($) and benefits (quality-adjusted life year) reflected a societal perspective and were time-discounted at 3%. Costs and benefits were combined to produce the main outcome measure, the incremental cost-effectiveness ratio ($ per qualityadjusted life year). Multivariable probabilistic sensitivity analysis modeled uncertainty in probabilities, costs, and disutilities.

Tofacitinib Is Associated With Increased Risk of Postoperative Venous Thromboembolism in Patients With Ulcerative Colitis

“…36 An international consensus guideline, published 37,38 When the risk of VTE chemoprophylaxis and costs have been assessed, the use of extended chemoprophylaxis for all patients with UC has not been supported. 39 It is of note that within the cost-effectiveness analysis by Leeds et al, the risk of VTE used in the study is far less (estimated to be 1.1% with a SD of 2.5%) than the rate identified in this study (8.3% for unexposed patients and 22% for exposed patients), indicating that the results of their analysis may not be applicable to patients with UC undergoing surgery with a higher risk of VTE events. Overall, our work demonstrates that patients on tofacitinib before surgery are likely to be at elevated risk, and therefore, as supported by both the American Society of Colon and Rectal Surgeons guidelines and international consensus paper, extended chemoprophylaxis may be warranted in this population.…”

Low Dose Rivaroxaban as Extended Prophylaxis Reduces Postdischarge Venous Thromboembolism in Patients With Malignancy and Inflammatory Bowel Disease

“…Although nomograms have been proposed to identify those at highest risk with IBD, 29 others have found extended prophylaxis not to be cost-effective in scenarios where the VTE rate was less than 1.5% and extended prophylaxis costs more than $300. 30 Similar to our study design, Najjar et al 31 performed a pre- and postintervention analysis using low-molecular-weight heparin (enoxaparin) and reduced rates of postdischarge VTE from 2.5% to 0% in the setting of abdominal surgery and IBD. Although the authors recognize the many institutional barriers to implementing extended prophylaxis, patient compliance remains a major hurdle with at-home subcutaneous injections.…”