RESUMEN
Medical patients represent the majority of hospitalized patients, and at least 75% of fatal pulmonary emboli occur in this group. Medical patients are at significant risk of thromboembolic disease, yet few are considered for thromboprophylaxis. Recent studies have identified the risk factor profiles in this group of patients, and a risk assessment model for medical patients has been developed. Risk stratification will help to ensure that patients receive appropriate thromboprophylaxis. It is clear that patients with severe chronic respiratory disease, congestive heart failure, and infectious disease are at high risk of symptomatic venous thromboembolism (VTE), particularly pulmonary embolism. Heparin-based prophylaxis significantly reduces the incidence of VTE. Low-molecular-weight heparin offers a safe and cost-effective alternative to unfractionated heparin in medical patients; to date, enoxaparin is the only low-molecular-weight heparin licensed for thromboprophylaxis in this indication.
Asunto(s)
Fibrinolíticos/uso terapéutico , Trombosis/tratamiento farmacológico , Ensayos Clínicos como Asunto , Análisis Costo-Beneficio , Cuidados Críticos , Costos de los Medicamentos , Enoxaparina/uso terapéutico , Fibrinolíticos/economía , Insuficiencia Cardíaca/complicaciones , Heparina/uso terapéutico , Costos de Hospital , Humanos , Incidencia , Infecciones/complicaciones , Metaanálisis como Asunto , Embolia Pulmonar/tratamiento farmacológico , Embolia Pulmonar/economía , Embolia Pulmonar/epidemiología , Embolia Pulmonar/etiología , Embolia Pulmonar/prevención & control , Insuficiencia Respiratoria/complicaciones , Factores de Riesgo , Accidente Cerebrovascular/complicaciones , Terapia Trombolítica , Tromboflebitis/tratamiento farmacológico , Tromboflebitis/economía , Tromboflebitis/epidemiología , Tromboflebitis/etiología , Tromboflebitis/prevención & control , Trombosis/epidemiología , Trombosis/etiología , Trombosis/prevención & controlAsunto(s)
Cuidados Críticos , Productos de Degradación de Fibrina-Fibrinógeno/metabolismo , Embolia Pulmonar/diagnóstico , Tromboflebitis/diagnóstico , Análisis Costo-Beneficio , Cuidados Críticos/economía , Humanos , Valor Predictivo de las Pruebas , Embolia Pulmonar/sangre , Embolia Pulmonar/economía , Tromboflebitis/sangre , Tromboflebitis/economíaRESUMEN
The aim of the present study was to evaluate the effects of different treatment plans (compression only, early surgery, low-dose subcutaneous heparin [LDSH], low-molecular-weight heparin [LMWH], and oral anticoagulant [OC] treatment) in the management of superficial thrombophlebitis (STP), by considering efficacy and costs in a 6-month, randomized, follow-up trial. Patients with STP, with large varicose veins without any suspected/documented systemic disorder, were included. Criteria for inclusion were as follows: presence of varicose veins; venous incompetence (by duplex); a tender, indurated cord along a superficial vein; and redness and heat in the affected area. All patients were ambulatory. Exclusion criteria were obesity, cardiovascular or neoplastic diseases, bone/joint disease, problems requiring immobilization, and age > 70 years. Patients with superficial thrombophlebitis without varicose veins and patients under treatment with drugs at referral were also excluded. Color duplex (CD) was used to detect concomitant deep vein thrombosis (DVT) and to evaluate the extension or reduction of STP at 3 and 6 months. Venography was not used. Of 562 patients included, 3.5% had had a recent DVT in the same limb affected by SVT and 2.1% in the contralateral limb. In six patients DVT was present in both limbs. These patients were treated with anticoagulants and excluded from the follow-up. After 3 and 6 months the incidence of STP extension was higher in the elastic compression and in the saphenous ligation groups (p < 0.05). There was no significant difference in DVT incidence at 3 months among the treatment groups. Stripping of the affected veins was associated with the lowest incidence of thrombus extension. The cost for compression alone was the lowest and the cost including LMWH was the highest. The average cost was 1,383 US$. However the highest social cost (lost working days, inactivity) was observed in subjects treated only with stockings.
Asunto(s)
Tromboflebitis/terapia , Absentismo , Administración Oral , Anticoagulantes/administración & dosificación , Anticoagulantes/economía , Anticoagulantes/uso terapéutico , Vendajes/economía , Costo de Enfermedad , Costos y Análisis de Costo , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Heparina/administración & dosificación , Heparina/economía , Heparina/uso terapéutico , Heparina de Bajo-Peso-Molecular/administración & dosificación , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Incidencia , Inyecciones Subcutáneas/economía , Pierna/irrigación sanguínea , Ligadura , Masculino , Persona de Mediana Edad , Vena Safena/cirugía , Tromboflebitis/tratamiento farmacológico , Tromboflebitis/economía , Tromboflebitis/cirugía , Resultado del Tratamiento , Ultrasonografía Doppler en Color , Ultrasonografía Doppler Dúplex , Várices/tratamiento farmacológico , Várices/economía , Várices/cirugía , Várices/terapia , Insuficiencia Venosa/tratamiento farmacológico , Insuficiencia Venosa/economía , Insuficiencia Venosa/cirugía , Insuficiencia Venosa/terapia , Trombosis de la Vena/complicaciones , Trombosis de la Vena/diagnóstico por imagenRESUMEN
Deep vein thromboses of the legs, which have been treated with low molecular weight heparin (LMWH), show significantly less thromboembolic recurrencies, less extension of the thrombus, fewer bleedings and a lower mortality than standard heparin (UFH). The differences are, however, small. LMWH is considerably more expensive. The advantage of LMWH lies in the possibility that it can be subcutaneously injected and thus given on an outpatient basis. This makes the treatment much easier and reduces the treatment costs by 50%.
Asunto(s)
Heparina de Bajo-Peso-Molecular/administración & dosificación , Heparina/administración & dosificación , Tromboflebitis/tratamiento farmacológico , Atención Ambulatoria/economía , Análisis Costo-Beneficio , Heparina/efectos adversos , Heparina/economía , Heparina de Bajo-Peso-Molecular/efectos adversos , Heparina de Bajo-Peso-Molecular/economía , Humanos , Ensayos Clínicos Controlados Aleatorios como Asunto , Recurrencia , Tromboflebitis/economía , Tromboflebitis/etiología , Resultado del TratamientoRESUMEN
Low-molecular-weight heparins, nowadays already widely used for the prevention of thromboembolism, have now also become available for the treatment of deep-vein thrombosis. This article should serve to explain the rationale for this development and to demonstrate the clinically relevant advantages of the use of low-molecular-weight heparins. After briefly describing the characteristic properties of heparins the most relevant studies comparing the use of low-molecular-weight heparin versus unfractionated heparin for the treatment of thromboembolism are discussed. In conclusion, clinical trials suggest that low-molecular-weight heparins given subcutaneously can replace the hitherto standard intravenous application of unfractionated heparin in the initial treatment of deep-vein thrombosis, granting equal or even better efficacy and potentially lower rates of adverse side effects. Furthermore, the simplicity of this therapeutic regime allows for treatment of patients at home, thus offering patients' mobility and also reducing the cost of treatment.
Asunto(s)
Heparina de Bajo-Peso-Molecular/administración & dosificación , Tromboflebitis/tratamiento farmacológico , Atención Ambulatoria/economía , Ensayos Clínicos como Asunto , Análisis Costo-Beneficio , Heparina/administración & dosificación , Heparina/efectos adversos , Heparina/economía , Heparina de Bajo-Peso-Molecular/efectos adversos , Heparina de Bajo-Peso-Molecular/economía , Humanos , Embolia Pulmonar/tratamiento farmacológico , Embolia Pulmonar/economía , Autoadministración/economía , Tromboflebitis/economíaRESUMEN
Foreign phlebologists from Austria, Sweden and Switzerland have been demonstrating successfully for years that alternative approaches to the traditional treatment of DVT exist. At the outpatient clinic for vascular diseases in Essen, 520 patients with acute deep vein thrombosis have been treated since January 1996, approximately 85% of which on an outpatient basis. The results are quite encouraging. No complications had to be faced. 188 patients were highly satisfied with the fact that they could stay at home, could return to work considerably sooner than after being referred to hospital, not to speak of an absolutely convincing reduction of therapeutical costs. On the other hand, the therapeutical concept demands high flexibility, adequate equipment and an effective communication network between patient, specialist, family doctor and clinic, and should be used by experienced vascular specialists only.
Asunto(s)
Atención Ambulatoria , Tromboflebitis/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Atención Ambulatoria/economía , Anticoagulantes/administración & dosificación , Anticoagulantes/economía , Vendajes/economía , Análisis Costo-Beneficio , Europa (Continente) , Femenino , Alemania , Humanos , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente/economía , Tromboflebitis/economía , Resultado del TratamientoRESUMEN
Out-patient or home treatment of acute proximal deep venous thrombosis (DVT) has not made its way yet. In this article, we review the data published on this form of management with regard to effectiveness and costs. We find that more than 80% of patients with DVT need not be admitted to the hospital and that the rate of secondary hospitalization is < 2%. Home treatment requires professional assistance in 15 to 74% of cases, while out-patient management with elastic leg compression and deliberate ambulation goes completely without it. The effect on objectivity assessed clinical symptoms, absence from work and patients' acceptance is significantly better and the costs are 2.5- to 3.2-fold lower with home or outpatient treatment than with treatment in the hospital. However, we found outpatient treatment associated with a reduced general well-being resulting from a probably frightening information which mentioned the possibility of experiencing an eventually fatal pulmonary embolism despite treatment. Management with deliberate ambulation in compression hosiery lead to a slower relief of subjective leg symptoms than initial immobilisation. We conclude that outpatient treatment of DVT is highly cost-effective. The problems still encountered are of a psychological nature and also have to do with treatment by leg compression and ambulation. These measures have to be optimized.
Asunto(s)
Atención Ambulatoria/economía , Tromboflebitis/economía , Enfermedad Aguda , Vendajes/economía , Análisis Costo-Beneficio , Ambulación Precoz/economía , Servicios de Atención de Salud a Domicilio/economía , Humanos , Admisión del Paciente/economía , Ensayos Clínicos Controlados Aleatorios como Asunto , Suiza , Tromboflebitis/terapiaRESUMEN
The classical clinical signs of deep vein thrombosis (DVT) are unspecific and may be found in several other conditions besides DVT. Therefore, patients suspicious of DVT are subjected to elaborate invasive or noninvasive evidence-based procedures that actually confirm DVT in only 20% to 30% of patients in this setting. However, simple laboratory tests and noninvasive strategies to exclude and diagnose DVT are becoming available in the clinical emergency setting of outpatients. In the presented literature, a sound basis is provided for quantifying clinical judgment for the diagnosis of acute proximal DVT. The number of positive clinical findings at time of first suspicion of DVT appears to correlate directly with the probability of acute proximal DVT. The modified clinical model of Landefeld and Wells for DVT allows reasonable accurate classification of patients into low, moderate, and high probability for suffering DVT. The rapid automated enzyme-linked immunoabsorbant assay (ELISA) VIDAS D-dimer presently available can be rapidly performed in daily practice and emergency situations and is accurate to a high degree, especially in ruling out ongoing venous thromboembolic processes. The sequential use of the rapid ELISA VIDAS D-dimer test and compression ultrasonography in a well-designed clinical setting using a simple clinical model predicts a significant improvement due to a high sensitivity near 100% for the exclusion and diagnosis of DVT in the majority of outpatients with suspect DVT. A prospective decision analysis management study is proposed to exclude and diagnose DVT based on the rapid ELISA VIDAS D-dimer test and compression ultrasonography within the context of a ready-to-use simple clinical model. The proposed simple model of a rational diagnosis of deep vein thrombosis (RADIA DVT) has to be tested in a large multicenter study of more than 1,000 outpatients with suspected DVT. This model would be less expensive, easy to perform, and likely yield a significant simplification and improvement of highly accurate evidence-based exclusion or diagnosis of DVT on the basis of which clear-cut indications of anticoagulation could be appropriately initiated or safely withheld.
Asunto(s)
Productos de Degradación de Fibrina-Fibrinógeno/análisis , Tromboflebitis/diagnóstico , Ultrasonografía , Ensayo de Inmunoadsorción Enzimática , Costos de la Atención en Salud , Humanos , Flebografía , Valor Predictivo de las Pruebas , Tromboflebitis/sangre , Tromboflebitis/economíaAsunto(s)
Productos de Degradación de Fibrina-Fibrinógeno/análisis , Tromboflebitis/diagnóstico , Ultrasonografía , Técnicas de Laboratorio Clínico/economía , Análisis Costo-Beneficio , Ensayo de Inmunoadsorción Enzimática/economía , Humanos , Tromboflebitis/sangre , Tromboflebitis/economía , Ultrasonografía/economíaRESUMEN
Enoxaparin, a low molecular weight heparin, has been demonstrated to be effective in the prophylaxis and treatment of deep vein thrombosis (DVT) in the general population. This study presents an analysis of the costs of subcutaneous (SQ) enoxaparin compared with intravenous (IV) heparin. Data were gathered on six spinal cord injured (SCI) patients in an acute freestanding rehabilitation center who were initially treated with SQ enoxaparin (n=3) or IV heparin (n=3) for a proximal DVT. No patients in either group developed further clinical complications. Comparison of the total costs of each treatment was performed, including the direct cost of the drug, as well as some of the costs of administration. Although the cost of enoxaparin per unit dose is higher, the total costs of enoxaparin are slightly lower, because its labor and administration costs are less. Subcutaneous enoxaparin is a safe, cost-effective, and less labor-intensive treatment, and can be of substantial benefit in the treatment of DVT in SCI patients in the rehabilitation setting.
Asunto(s)
Anticoagulantes/economía , Enoxaparina/economía , Traumatismos de la Médula Espinal/economía , Tromboflebitis/economía , Adulto , Anticoagulantes/administración & dosificación , Análisis Costo-Beneficio , Costos y Análisis de Costo , Enoxaparina/administración & dosificación , Femenino , Heparina/administración & dosificación , Heparina/economía , Humanos , Infusiones Intravenosas , Inyecciones Subcutáneas , Masculino , Persona de Mediana Edad , Proyectos Piloto , Centros de Rehabilitación/economía , Estudios Retrospectivos , Traumatismos de la Médula Espinal/complicaciones , Tromboflebitis/tratamiento farmacológicoRESUMEN
The frequency of clinical recurrence and pulmonary embolism in patients with acute deep venous thrombosis is reduced to the same extent by hospital treatment (with unfractionated heparin) as by treatment at home (with low-molecular-weight heparin). Very few data on subjective parameters of effectiveness have been published. We performed a prospective randomized trial comparing outpatient with in-hospital treatment in 28 patients. Six clinical and quality-of-life related parameters of effectiveness were assessed quantitatively: clinical course (with a score system), pain of venous congestion of the calf muscles (with Lowenberg's test), subjective perception of pain and general well-being (with visual analogue scales), satisfaction with the care provided, and absence from work. Subjective effectiveness was compared with the costs of each form of treatment. Outpatient treatment was significantly more effective than in-hospital treatment with regard to the objective parameters. It was, however, associated with less well-being and more pain than in-hospital treatment. The discrepancy is explained by eventually insufficient adjuvant treatment measures (which consisted of external leg compression by stockings and forced walking) and by anxiety brought on by the information that potentially lethal pulmonary embolism could occur despite anticoagulant therapy. Outpatient treatment was less costly. On the average and per patient it was CHF 3944 less expensive than treatment in hospital. An estimation reveals that the Swiss health care system would save about CHF 25 million per year if the 85% of patients with deep-vein thrombosis suitable for home care were given this form of treatment. We conclude that outpatient management is subjectively cost-effective but should be optimised to eliminate certain drawbacks associated with it.
Asunto(s)
Atención Ambulatoria/economía , Heparina de Bajo-Peso-Molecular/uso terapéutico , Heparina/uso terapéutico , Admisión del Paciente/economía , Tromboflebitis/economía , Adulto , Anciano , Análisis Costo-Beneficio , Femenino , Heparina/efectos adversos , Heparina/economía , Heparina de Bajo-Peso-Molecular/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Programas Nacionales de Salud/economía , Dimensión del Dolor , Estudios Prospectivos , Embolia Pulmonar/tratamiento farmacológico , Embolia Pulmonar/economía , Calidad de Vida , Suiza , Tromboflebitis/tratamiento farmacológicoRESUMEN
BACKGROUND: Several low-molecular-weight heparins (LMWHs) are now approved for use in the United States for the prophylaxis of venous thromboembolism. They are used in Europe for the treatment of deep venous thrombosis (DVT) and pulmonary embolism. This review examines the evidence addressing the question "Should LMWHs replace unfractionated heparin (UFH) in the treatment of adults with DVT?" METHODS: We performed a MEDLINE search using the key words "low-molecular-weight heparin" from the years 1990 to 1998, and the results were assessed using the JAMA Users' Guides to the Medical Literature system. RESULTS: Low-molecular-weight heparins are at least as safe and effective as unfractionated heparin in the treatment of patients with DVT. They are probably more effective and safer. They are more convenient to use and are associated with lower overall costs. CONCLUSIONS: Based on efficacy, safety, convenience, and cost, LMWHs are clearly superior to UFH in the treatment of DVT in primary care. Studies that confirm an expected improvement in patient-oriented outcomes (e.g., mortality and quality of life) need to be done.
Asunto(s)
Heparina de Bajo-Peso-Molecular/uso terapéutico , Heparina/uso terapéutico , Tromboflebitis/tratamiento farmacológico , Adulto , Medicina Basada en la Evidencia , Costos de la Atención en Salud , Heparina/economía , Heparina de Bajo-Peso-Molecular/economía , Humanos , Recurrencia , Tromboflebitis/economía , Tromboflebitis/prevención & controlRESUMEN
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are major complications associated with total knee arthroplasty. The American College of Chest Physicians recommends twice-daily, fixed-dose low-molecular-weight heparin (LMWH) as routine prophylaxis in this patient population. This study represents a cost analysis of ardeparin and enoxaparin, the two LMWHs currently available for this indication in the United States. Costs for treating DVT, PE, and major bleeding episodes were derived from values reported in the literature. Both ardeparin and enoxaparin were found to produce significant cost savings when used routinely as DVT prophylaxis after knee replacement surgery compared with no prophylaxis. Based on the currently available data, enoxaparin 40 mg once daily appears to be the least costly LMWH for routine pharmacoprophylaxis of DVT in patients undergoing knee replacement surgery.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Enoxaparina/economía , Fibrinolíticos/economía , Heparina de Bajo-Peso-Molecular/economía , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/prevención & control , Tromboflebitis/economía , Tromboflebitis/prevención & control , Enoxaparina/uso terapéutico , Fibrinolíticos/uso terapéutico , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Embolia Pulmonar/economía , Embolia Pulmonar/prevención & control , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Total joint replacements are high-risk procedures for development of deep venous thrombosis (DVT) and pulmonary embolism (PE), therefore, routine pharmacological prophylaxis should be instituted in all cases. Cost-containment has become an important factor with the present changes in health care. This report presents an economic model for DVT prophylaxis after total hip and total knee arthroplasty (THA & TKA) that approximates closely to the current standards in orthopedic practice, and encourages the balance of clinical and economic considerations in patient care management. METHODS: A simplified cost-effectiveness (cost-minimization) analysis, from the consumer's perspective, between Warfarin and Enoxaparin for DVT prophylaxis after THA and TKA, for a total of 15 days, in both inpatient and outpatient settings was used. The costs of drugs, laboratory, and home care services were evaluated through surveying three different providers in each category and obtaining the mean value for each of the services supplied. All providers were located within the Louisville, KY, metropolitan area. Data collection took place in October 1996. RESULTS: The main outcome measure was the difference in cost between the two drugs when all factors associated with therapy were considered. The overall cost of DVT prophylaxis with Enoxaparin was somewhat less expensive ($925.38) when compared to Warfarin ($971.77). CONCLUSIONS: Within the limitations of this study Enoxaparin was slightly more cost-effective than Warfarin for venous thromboembolism prophylaxis after total hip and knee arthroplasty.
Asunto(s)
Anticoagulantes/uso terapéutico , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Enoxaparina/uso terapéutico , Tromboflebitis/prevención & control , Warfarina/uso terapéutico , Anticoagulantes/economía , Análisis Costo-Beneficio , Costos y Análisis de Costo , Enoxaparina/economía , Humanos , Tromboflebitis/economía , Tromboflebitis/etiología , Warfarina/economíaRESUMEN
This paper examines the relative cost-effectiveness of enoxaparin and warfarin as prophylactic therapy for the prevention of deep vein thrombosis (DVT) in patients undergoing knee replacement surgery in a managed care setting. Although enoxaparin is more expensive than warfarin, it is also more effective in the prevention of DVT after knee replacement surgery. To date there has been no comprehensive assessment of the cost-effectiveness of the alternative agents used for this purpose. This evaluation is undertaken using a decision model that contrasts enoxaparin and warfarin regimens. The model takes explicit account of the incidence of proximal DVT, distal DVT, pulmonary embolism (PE), and major bleeds. The probabilities of clinical events are taken from data from a published randomized, controlled, clinical trial. Key assumptions are that PEs derive only from asymptomatic proximal DVTs and that a false-positive diagnosis of DVT is made in 10% of cases. Unit resource cost data are taken from pharmacoeconomic studies of DVT prophylaxis in hip replacement surgery. The analysis focuses on the actual or expected cost of prophylactic treatment using enoxaparin as opposed to warfarin and, as appropriate measures of cost-effectiveness, the cost per DVT event avoided and the cost per incidence of PE avoided. The expected cost of warfarin prophylaxis is $105 less per patient than that of enoxaparin. In terms of expected cost per DVT event avoided, enoxaparin prophylaxis is $2525 less than for warfarin; in terms of expected cost per PE avoided, it is $87,201 less. Enoxaparin is more cost-effective than warfarin in terms of both DVT events and PEs avoided in patients who have undergone knee replacement surgery.
Asunto(s)
Anticoagulantes/economía , Anticoagulantes/uso terapéutico , Artroplastia de Reemplazo de Rodilla , Enoxaparina/economía , Enoxaparina/uso terapéutico , Tromboflebitis/economía , Tromboflebitis/prevención & control , Warfarina/economía , Warfarina/uso terapéutico , Costos y Análisis de Costo , Humanos , Modelos Económicos , Tromboflebitis/sangreRESUMEN
Two clinical trials in patients with acute deep venous thrombosis have indicated that the outpatient management with fixed-dose, subcutaneous low-molecular-weight heparin is at least as effective and safe as inpatient treatment with unfractionated intravenous heparin with respect to recurrent venous thromboembolism and major bleeding. We performed an economic evaluation alongside one of these trials to assess the cost consequences of the outpatient management strategy. Data were collected through case record forms, complemented by a prospective questionnaire in 78 consecutive patients, interviews with health care providers, and hospital data bases. Our study demonstrated that seventy-five percent of patients allocated to low-molecular-weight heparin received treatment either entirely at home or after a brief hospital stay. Fifteen percent of these patients required professional domiciliary care. Within-centre comparisons of resource utilisation in terms of natural units showed that outpatient management with low-molecular-weight heparin reduced the average number of hospital days in the initial treatment period in nine centres by 59 percent (95% CI: 43 to 71 percent) accompanied by a limited increase in outpatient and professional domiciliary care. The average reduction in hospital days at the end of follow up was 40 percent (95% CI: 25 to 54 percent). A cost-minimisation analysis, focusing on resource utilisation directly related to the treatment of deep venous thrombosis and associated costs in one centre demonstrated a cost reduction of 64 percent (95% CI: 56 to 72 percent) with the outpatient management with low-molecular-weight heparin. These data suggest that outpatient management of patients with proximal venous thrombosis using low-molecular-weight heparin reduces resource utilisation and total treatment cost. Implementation should be preceded by a cautious evaluation of a potential cost shifting and organisational prerequisites.
Asunto(s)
Atención Ambulatoria/economía , Anticoagulantes/administración & dosificación , Heparina de Bajo-Peso-Molecular/administración & dosificación , Heparina/administración & dosificación , Tromboflebitis/tratamiento farmacológico , Tromboflebitis/economía , Administración Cutánea , Ensayos Clínicos como Asunto , Costos y Análisis de Costo , Estudios de Evaluación como Asunto , Humanos , Infusiones IntravenosasRESUMEN
Subcutaneous low-molecular-weight heparin (LMWH) is at least as safe and effective as classical intravenous heparin therapy for the treatment of proximal vein thrombosis. Anticoagulant monitoring and intravenous administration are not required with LMWH treatment, therefore this therapy may offer economic advantages. An economic evaluation of these therapeutic approaches was performed comparing the costs and effectiveness. The evaluation was aimed at helping decision-makers to maximize the health of the population served, subject to available resources. The American-Canadian Thrombosis Study was a multicentre, randomized, double-blind clinical trial that compared treatment by initial continuous intravenous infusion of heparin (followed by 3 months of warfarin therapy) with a once-daily dose of subcutaneous LMWH, tinzaparin sodium (followed by 3 months of warfarin treatment) in patients with acute proximal deep vein thrombosis. In the LMWH-treated group, the cost incurred for 100 patients was $399,403 (Canadian) or $335,687 (US) with a frequency of objectively documented recurrent venous thromboembolism of 2.8%. In the intravenous heparin-treated group, the cost incurred for 100 patients was $ 414,655 (Canadian) or $ 375,836 (US), with a frequency of objectively documented recurrent venous thromboembolism of 6.9%. These results show a cost saving of $ 15,252 (Canadian) or $ 40,149 (US) with the use of LMWH. Multiple sensitivity analyses did not alter the findings of the study which indicated that LMWH therapy is at least as safe and effective but less costly than intravenous heparin treatment. The potential for outpatient therapy in up to 37% of patients who are receiving LMWH would substantially augment the cost-saving. The cost-effectiveness findings presented in this paper are based on the assumption that all costs are covered by a single payer. Outpatient management in many countries will shift the healthcare costs from the healthcare payer to the patient, increasing the economic burden to the patient.
Asunto(s)
Anticoagulantes/economía , Heparina de Bajo-Peso-Molecular/economía , Heparina/economía , Tromboflebitis/economía , Anticoagulantes/administración & dosificación , Costos y Análisis de Costo , Método Doble Ciego , Estudios de Evaluación como Asunto , Heparina/administración & dosificación , Heparina de Bajo-Peso-Molecular/administración & dosificación , Humanos , Infusiones Intravenosas , Inyecciones Subcutáneas , Tromboflebitis/tratamiento farmacológicoAsunto(s)
Anticoagulantes/uso terapéutico , Fibrinolíticos/uso terapéutico , Heparina de Bajo-Peso-Molecular/uso terapéutico , Complicaciones Posoperatorias/prevención & control , Embolia Pulmonar/prevención & control , Tromboflebitis/prevención & control , Anticoagulantes/efectos adversos , Anticoagulantes/economía , Análisis Costo-Beneficio , Fibrinolíticos/efectos adversos , Fibrinolíticos/economía , Heparina de Bajo-Peso-Molecular/efectos adversos , Heparina de Bajo-Peso-Molecular/economía , Humanos , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/fisiopatología , Embolia Pulmonar/economía , Embolia Pulmonar/fisiopatología , Factores de Riesgo , Tromboflebitis/economía , Tromboflebitis/fisiopatologíaRESUMEN
Guidelines for prophylaxis of deep vein thrombosis secondary to orthopedic surgery have been developed. In selecting a specific drug for formulary inclusion, it is ideal for an individual institution to determine the cost of therapy, as well as the frequency of adverse events and the cost of treating them for each agent undergoing consideration. Cost-effectiveness analysis using incremental cost-effectiveness ratios and sensitivity analyses are useful for determining which drug may be most cost effective.
Asunto(s)
Artroplastia/economía , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/prevención & control , Tromboflebitis/economía , Tromboflebitis/prevención & control , Anticoagulantes/economía , Anticoagulantes/uso terapéutico , Artroplastia de Reemplazo de Cadera/economía , Análisis Costo-Beneficio , Costos y Análisis de Costo , Guías como Asunto , HumanosRESUMEN
The objective of this study was to compare the costs, from the perspective of the payer, of using nadroparin calcium, a low-molecular-weight heparin, instead of unfractionated heparin in the prophylaxis of venous thromboembolism in patients undergoing orthopaedic surgery or major general surgery in Italy. The methods used were based on a published meta-analysis and a survey of clinical practice. We constructed a model of the prophylaxis and management of venous thromboembolism in Italy. Resource use associated with individual events was estimated on the basis of the clinical survey. Unit costs, not available from published sources, were taken from charges made by hospitals and from direct observation. A sensitivity analysis was conducted to examine whether the results were robust to changes in key variables. In the base case, compared with unfractionated heparin, prophylaxis with nadroparin calcium reduced the expected costs of managing thromboembolism by 267,226 Italian lire (L, 1994 values; $US1 = L1600 approx.) per patient undergoing orthopaedic surgery, and by L45,588 per patient undergoing major general surgery. Therefore, switching from unfractionated heparin to nadroparin calcium in these patients offers the possibility of significant cost savings to the Italian healthcare system.