Abstract
BACKGROUND: Acute deep vein thrombosis has traditionally been treated with unfractionated heparin (UFH), administered intravenously, but low-molecular-weight heparins (LMWH), administered subcutaneously, have recently become available. The authors sought to determine which therapy was more cost-effective for inpatient and outpatient treatment of deep vein thrombosis. METHODS: An incremental cost-effectiveness analysis based on a decision tree was performed for 4 treatment strategies for deep vein thrombosis. Rate of major hemorrhage while receiving heparin, rate of recurrence of venous thromboembolism 3 months after treatment and mortality rate 3 months after treatment were determined by meta-analysis. Costs for the UFH therapy were prospectively collected by a case-costing accounting system for 105 patients with deep vein thrombosis treated in fiscal year 1995/96. The costs for LMWH therapy were modelled, and cost-effectiveness was determined by decision analysis. RESULTS: Meta-analysis revealed a mean difference in risk of hemorrhage of -1.1% (95% confidence interval [CI] -2.4% to 0.3%), a mean difference in risk of recurrence of venous thromboembolism of -2.6% (95% CI -4.5% to -0.7%) and a mean difference in risk of death of -1.9% (95% CI -3.6% to -0.4%), all in favour of subcutaneous unmonitored administration of LMWH. The cost to treat one inpatient was $2993 for LMWH and $3048 for UFH. Even more would be saved if LMWH was delivered on an outpatient basis (cost of $1641 per patient). The cost-effectiveness analysis showed that LMWH in any treatment setting is more cost effective than UFH. A sensitivity analysis demonstrated the robustness of this conclusion. INTERPRETATION: Treatment of deep vein thrombosis with LMWH is more cost effective than treatment with UFH in both inpatient and outpatient settings.
Full Text
The Full Text of this article is available as a PDF (204.5 KB).
Selected References
These references are in PubMed. This may not be the complete list of references from this article.
- Anderson F. A., Jr, Wheeler H. B., Goldberg R. J., Hosmer D. W., Patwardhan N. A., Jovanovic B., Forcier A., Dalen J. E. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. 1991 May;151(5):933–938. [PubMed] [Google Scholar]
- Hirsh J., Levine M. N. Low molecular weight heparin. Blood. 1992 Jan 1;79(1):1–17. [PubMed] [Google Scholar]
- Hirsh J., Siragusa S., Cosmi B., Ginsberg J. S. Low molecular weight heparins (LMWH) in the treatment of patients with acute venous thromboembolism. Thromb Haemost. 1995 Jul;74(1):360–363. [PubMed] [Google Scholar]
- Hull R. D., Raskob G. E., Pineo G. F., Green D., Trowbridge A. A., Elliott C. G., Lerner R. G., Hall J., Sparling T., Brettell H. R. Subcutaneous low-molecular-weight heparin compared with continuous intravenous heparin in the treatment of proximal-vein thrombosis. N Engl J Med. 1992 Apr 9;326(15):975–982. doi: 10.1056/NEJM199204093261502. [DOI] [PubMed] [Google Scholar]
- Hull R. D., Raskob G. E., Rosenbloom D., Pineo G. F., Lerner R. G., Gafni A., Trowbridge A. A., Elliott C. G., Green D., Feinglass J. Treatment of proximal vein thrombosis with subcutaneous low-molecular-weight heparin vs intravenous heparin. An economic perspective. Arch Intern Med. 1997 Feb 10;157(3):289–294. [PubMed] [Google Scholar]
- Koopman M. M., Prandoni P., Piovella F., Ockelford P. A., Brandjes D. P., van der Meer J., Gallus A. S., Simonneau G., Chesterman C. H., Prins M. H. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tasman Study Group. N Engl J Med. 1996 Mar 14;334(11):682–687. doi: 10.1056/NEJM199603143341102. [DOI] [PubMed] [Google Scholar]
- Leizorovicz A., Simonneau G., Decousus H., Boissel J. P. Comparison of efficacy and safety of low molecular weight heparins and unfractionated heparin in initial treatment of deep venous thrombosis: a meta-analysis. BMJ. 1994 Jul 30;309(6950):299–304. doi: 10.1136/bmj.309.6950.299. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lensing A. W., Prins M. H., Davidson B. L., Hirsh J. Treatment of deep venous thrombosis with low-molecular-weight heparins. A meta-analysis. Arch Intern Med. 1995 Mar 27;155(6):601–607. [PubMed] [Google Scholar]
- Levine M., Gent M., Hirsh J., Leclerc J., Anderson D., Weitz J., Ginsberg J., Turpie A. G., Demers C., Kovacs M. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med. 1996 Mar 14;334(11):677–681. doi: 10.1056/NEJM199603143341101. [DOI] [PubMed] [Google Scholar]
- van den Belt A. G., Bossuyt P. M., Prins M. H., Gallus A. S., Büller H. R. Replacing inpatient care by outpatient care in the treatment of deep venous thrombosis--an economic evaluation. TASMAN Study Group. Thromb Haemost. 1998 Feb;79(2):259–263. [PubMed] [Google Scholar]