RESUMO
BACKGROUND: Knee surgery is a risk factor for thromboembolic disease. Prophylaxis reduces the risk of this condition. METHODS: Economic and health consequences of drugs preventing and treating thromboembolic disease in patients undergoing knee surgery from the institutional perspective (time horizon: 1 year) were estimated. The measures of effectiveness were: reduction in the number of cases (per 1,000 patients) of deep vein thrombosis, pulmonary embolism, hospital admissions and deaths. Transition probabilities were estimated by meta-analysis. The alternatives were: warfarin (reference), dalteparin, enoxaparin, nadroparin, unfractionated heparin + warfarin, and non-prophylaxis. Data on resources use and costs corresponds to the Instituto Mexicano del Seguro Social (IMSS). Acceptability curves were constructed. RESULTS: No prophylaxis implied three times higher cost ($18,835.10 versus $5,967.10) and less effectiveness in comparison with warfarin. The incremental cost-effectiveness ratios for enoxaparin were $3, $13, $17 and $3 per each additional case of deep vein thrombosis, pulmonary embolism, death and hospital admission avoided. Results of nadroparin and unfractionated heparin were inferior to warfarin (59.1% and 72.9% more costly and less effective in three measures of effectiveness, respectively). Dalteparin showed higher health outcomes and lower cost compared with warfarin (-20.6%). Dalteparin had a higher probability of being cost-effective than enoxaparin. DISCUSSION: thromboprophylaxis is a clinically and economically favorable alternative. The identification of a pharmacoeconomic profile of alternatives to perform it becomes relevant given the increasing pressure on institutional budgets. CONCLUSIONS: Dalteparin would be a cost-saving alternative in thromboprophylaxis of patients undergoing knee surgery at IMSS.
Assuntos
Anticoagulantes/economia , Artroplastia do Joelho/economia , Dalteparina/economia , Complicações Pós-Operatórias/prevenção & controle , Trombofilia/tratamento farmacológico , Academias e Institutos/economia , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Artroplastia do Joelho/estatística & dados numéricos , Redução de Custos , Análise Custo-Benefício , Dalteparina/efeitos adversos , Dalteparina/uso terapêutico , Diagnóstico por Imagem/economia , Custos de Medicamentos , Heparina/efeitos adversos , Heparina/economia , Heparina/uso terapêutico , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Cadeias de Markov , México , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Hemorragia Pós-Operatória/induzido quimicamente , Embolia Pulmonar/economia , Embolia Pulmonar/etiologia , Embolia Pulmonar/prevenção & controle , Estudos Retrospectivos , Previdência Social/economia , Trombofilia/economia , Trombofilia/etiologia , Trombofilia/prevenção & controle , Trombose Venosa/economia , Trombose Venosa/etiologia , Trombose Venosa/prevenção & controle , Varfarina/efeitos adversos , Varfarina/economia , Varfarina/uso terapêuticoAssuntos
Fibrinolíticos/uso terapêutico , Embolia Pulmonar/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Medicina Baseada em Evidências , Custos Hospitalares , Humanos , Pacientes Internados , Comunicação Interdisciplinar , Política Organizacional , Equipe de Assistência ao Paciente , Recursos Humanos em Hospital/educação , Guias de Prática Clínica como Assunto , Embolia Pulmonar/economia , Embolia Pulmonar/epidemiologia , Qualidade da Assistência à Saúde , Medição de Risco , Sociedades Médicas , Estados Unidos , Tromboembolia Venosa/economia , Tromboembolia Venosa/epidemiologiaRESUMO
BACKGROUND: The optimal diagnostic test for detecting acute pulmonary embolism (APE) is still under discussion. The ventilation /perfusion scanning has been the preferred examination for several decades, but with the development of new tests the diagnostic possibilities have increased. It is necessary to evaluate them from the cost-effectiveness perspective. The goal of this study was to evaluate several methods of imaging diagnosis so as to determine the most cost-effective for detecting APE. METHODS: Cost-effectiveness (CE) analysis using a decision tree to model various diagnostic test (V/Q lung scan, spiral CT, angiography by MDCT, MRI and conventional arteriography). Sensitivity and specificity values, and positive and negative predictive values of diagnostic tests were calculated. Expected outcome: "new APE case detected." The direct costs were evaluated in eurosos (euros), including the secondary complications of diagnostic methods. To assess the robustness of the findings, a one way sensitivity analysis was performed. RESULTS: The most cost-effective diagnostic test was angiography by MDCT. No diagnostic test were eliminated by extended dominance. The crude rate of CE for MDCT was 486 euros per case of APE detected. The marginal cost between spiral CT and V / Q lung scan was euros 103 for 8 cases of APE detected additionally, while the marginal cost between MDCT and spiral CT was 229 euros to detect an additional case of APE. CONCLUSIONS: The most cost-effective diagnostic test was the MDCT; this finding showed to be robust in relationship to sensitivity, specificity and costs changes. However, the incremental C-E analysis showed that MDCT was capable to detect only one additional case of APE than spiral CT, with an incremental cost of 229 euros. When peripheral branches are affected, high negative predictive value of the MDCT justify its conduct.