Cost-Utility Analysis of Venous Thromboembolism Prophylaxis Strategies for People Undergoing Elective Total Hip and Total Knee Replacement Surgeries in the English National Health Service.

Dalia M Dawoud,Peter Barry,Sedina Lewis,Nigel Rossiter,Jagjot Kaur Chahal,Xavier L Griffin,Gerard Stansby,Carlos Sharpin,David Wonderling,Jessica Glen,Michael Reed,Beverley J Hunt

doi:10.3389/fphar.2018.01370

Abstract

Background: Major orthopedic surgery, such as elective total hip replacement (eTHR) and elective total knee replacement (eTKR), are associated with a higher risk of venous thromboembolism (VTE) than other surgical procedures. Little is known, however, about the cost-effectiveness of VTE prophylaxis strategies in people undergoing these procedures.Aim: The aim of this work was to assess the cost-effectiveness of these strategies from the English National Health Service perspective to inform NICE guideline (NG89) recommendations.Materials and Methods: Cost-utility analysis, using decision modeling, was undertaken to compare 15 VTE prophylaxis strategies for eTHR and 12 for eTKR, in addition to “no prophylaxis” strategy. The analysis complied with the NICE Reference Case. Structure and assumptions were agreed with the guideline committee. Incremental net monetary benefit (INMB) was calculated, vs. the model comparator (LMWH+ antiembolism stockings), at a threshold of £20,000/quality-adjusted life-year (QALY) gained. The model was run probabilistically. Deterministic sensitivity analyses (SAs) were undertaken to assess the robustness of the results.Results: The most cost-effective strategies were LMWH for 10 days followed by aspirin for 28 days (INMB = £530 [95% CI: -£784 to £1,103], probability of being most cost-effective = 72%) for eTHR, and foot pump (INMB = £353 [95% CI: -£101 to £665]; probability of being most cost-effective = 18%) for eTKR. There was considerable uncertainty regarding the cost-effectiveness ranking in the eTKR analysis. The results were robust to change in all SAs.Conclusions: For eTHR, LMWH (standard dose) for 10 days followed by aspirin for 28 days is the most cost-effective VTE prophylaxis strategy. For eTKR, the results are highly uncertain but foot pump appeared to be the most cost-effective strategy, followed closely by aspirin (low dose). Future research should focus on assessing cost-effectiveness of VTE prophylaxis in the eTKR population.

Highlights

Hospital-acquired venous thromboembolism (VTE), referred to as hospital-acquired thrombosis (HAT), represents a major patient safety concern (Hauck et al, 2017)
These show that the most effective option, with the highest mean qualityadjusted life-years (QALYs)-gained over lifetime per person, was the prophylaxis strategy consisting of low molecular weight heparin (LMWH) followed by aspirin
Other interventions which have a positive mean incremental NMB (INMB) compared with LMWH +anti-embolism stockings (AES) were: LMWH + AES (INMB = £36; 95% CI: -£745 to £484) and AES (INMB = £5; 95% CI: -£2,106 to £781)

Summary

Introduction

Hospital-acquired venous thromboembolism (VTE), referred to as hospital-acquired thrombosis (HAT), represents a major patient safety concern (Hauck et al, 2017). In the USA, the 5-year costs were predicted to be 1.5-fold higher for patients with HAT following major surgery ($55,956) than for hospitalized controls ($32,718; P < 0.001). Litigation costs and financial penalties on hospitals as a result of failure to prevent HAT have added to this huge cost impact (Cohoon et al, 2015; White et al, 2015). Major orthopedic surgery, such as elective total hip replacement (eTHR) and elective total knee replacement (eTKR), are associated with a higher risk of venous thromboembolism (VTE) than other surgical procedures. About the cost-effectiveness of VTE prophylaxis strategies in people undergoing these procedures

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