of 43
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
Related Documents
  Best Practices PreventingDVT & PE Center for Outcomes Research  Page 8.1 Chapter-8 Bibliography  Where is the evidence? Literature Cited Alpert JS, Dalen JE. Epidemiology and natural history of venous thromboembo-lism.   Prog Cardiovas Dis   1994; 36:417-22.Anderson FA, Wheeler HB, Golberg RJ, Hosmer DW, Forcier A, Patwardhan NA. Changing clinical practice: Prospective study of the impact of continuingmedical education and quality assurance programs on use of prophylaxis forvenous thromboembolism   Arch Intern Med 1994; 154:669-677.Anderson FA Jr, Wheeler HB, Goldberg RJ, Hosmer DW, Forcier A, Patwardhan NA. Physician practices in the prevention of venous thromboembolism.   Ann Intern Med   1991;115:591-595.Anderson FA Jr, Wheeler HB. Strategies to improve implementation.  In: GoldhaberS, ed. Prevention of Venous Thromboembolism . New York, NY: Marcel DekkerInc.; 1992; 519-539.Bergqvist D. 1983. Post-operative Thromboembolism, Frequency, Etiology,Prophylaxis.  Berlin: Springer-Verlag.Clagett GP, Anderson FA Jr, Heit J, Levine MN, Wheeler HB. Prevention of venousthromboembolism.   Chest   1995; 108:312S-334S.Collins R, Scrimgeour A, Yusuf S, et al. Reduction in fatal pulmonary embolismand venous thrombosis by perioperative administration of subcutaneousheparin. N Engl J Med   1988; 318:1162-73.Gallus AS. Anticoagulants in the prevention of venous thromboembolism. Baillieres Clin Haematol   1990; 3(3):651-684.Hull RD, Raskob GE, Hirsh J. The diagnosis of clinically suspected pulmonaryembolism: Practical approaches.   Chest 1986; 89(5 Suppl):417S-425S.Morrell MP, Dunhill MA. The postmortem incidence of pulmonary embolism ina hospital population.   Br J Surg   1968; 55:347-352. NIH Consensus Development. Prevention of venous thrombosis and pulmonaryembolism . JAMA  1986; 256:744-749.Oster G, Tuden R, Colditz G. A cost-effectiveness analysis of prophylaxis againstdeep-vein thrombosis in major orthopedic surgery . JAMA  1987; 257:203-8. Prevention of postoperative pulmonary embolism by low doses of heparin: aninternational multicentre trial.   Lancet   1975; 2:45-51.Salzman EW, Hirsh J.: Prevention of venous thromboembolism  .  In: Colman RW,Hirsh J, Marder VJ, Salzman EW, eds. Hemostasis and Thrombosis, Basic Prin-ciples and Clinical Practice .  3rd edition, Philadelphia PA: JB Lippincott 1987;1332-45. print  Best Practices PreventingDVT & PE Center for Outcomes Research  Page 8.2 Selected Abstracts on Prevention of Deep Vein Thrombosis Cost-Effectiveness Subcutaneous low-molecular-weight heparin vs warfarin for prophylaxis of deep veinthrombosis after hip or knee implantation. An economic perspective. Hull RD, Raskob GE, Pineo GF, Feldstein W, Rosenbloom D, Gafni A, Green D, Feinglass J,Trowbridge AA, Elliott CG Arch Intern Med 1997 Feb 10;157(3):298-303 Faculty of Medi-cine, University of Calgary, Alberta.BACKGROUND: Postoperative venous thrombosis and pulmonary embolism present amajor clinical threat to patients undergoing total hip or knee arthroplasty. We performedan economic evaluation of warfarin sodium and subcutaneous low-molecular-weightheparin sodium prophylaxis comparing cost and effectiveness. METHODS: A consecutiveseries of 1436 patients who underwent hip or knee arthroplasty comparing these 2regimens in a randomized trial with objective documentation of outcomes provided theopportunity to perform economic evaluations for Canada and the United States. RESULTS:Deep vein thrombosis was documented in 231 (37.4%) of 617 patients given warfarin andin 185 (31.4%) of 590 patients given low-molecular-weight heparin (P = .03). In Canada,warfarin and low-molecular-weight heparin (tinzaparin sodium) incurred costs per 100patients of $11,598 and $9,197, respectively, providing a cost savings of $2,401 for thelow-molecular-weight heparin group. The drug cost of low-molecular-weight heparin(tinzaparin) was $6 per day and for warfarin was $0.32 per day. Sensitivity analysisshowed that low-molecular-weight heparin is more costly if drug costs are increased by1.5-fold (ie, the cost of tinzaparin is increased from $6 per day to $8.82 per day or more).In the United States, the analysis was also not definitive; low-molecular-weight heparinwas more costly than warfarin at drug costs of $15 and $2.01 per day, respectively.CONCLUSIONS: Our findings indicate that the decision to use low-molecular-weightheparin or warfarin prophylaxis in patients undergoing major joint replacement surgeryis a finely tuned trade-off. Prophylaxis with low-molecular-weight heparin is equally ormore effective than the more complex prophylaxis with warfarin. Major bleeding isuncommon but less frequent with warfarin use. The most significant parameters thatinfluence the comparative cost-effectiveness are the cost of the drug, the cost of interna-tional normalized ratio monitoring, and the costs associated with major bleeding. Theanalysis also demonstrates that the results are health care system dependent (Canada vsUS). In Canada, low-molecular-weight heparin (tinzaparin) is less costly because it avoidsthe need for international normalized ratio monitoring. In the United States, the drug costfor low-molecular-weight heparin will likely be the principal determinant of relative cost-effectiveness. Cost-effectiveness of enoxaparin vs low-dose warfarin in the prevention of deep-veinthrombosis after total hip replacement surgery. Menzin J, Colditz GA, Regan MM, Richner RE, Oster GArch Intern Med 1995 Apr 10;155(7):757-764Policy Analysis Inc., Brookline, Mass.BACKGROUND: Enoxaparin sodium, a low-molecular-weight heparin, was recentlyapproved for use in the United States to prevent deep-vein thrombosis after total hipreplacement surgery. Its cost-effectiveness relative to prophylaxis with low-dose warfarinsodium is unknown. METHODS: A decision-analytic model was developed to compare twostrategies of prophylaxis for deep-vein thrombosis with a strategy of not using prophy-laxis in a hypothetical cohort of 10,000 patients undergoing total hip replacement sur-gery. For each of these strategies, we estimated the expected number of cases of con-firmed deep-vein thrombosis or pulmonary embolism, the expected number of throm-boembolic deaths, and the expected costs of venous thromboembolic care, includingprophylaxis, diagnosis, and treatment. Data were drawn primarily from the publishedliterature. RESULTS: Compared with no prophylaxis, the use of low-dose warfarin would print  Best Practices PreventingDVT & PE Center for Outcomes Research  Page 8.3 be expected to reduce the number of cases of confirmed deep-vein thrombosis fromabout 1000 (per 10,000 patients) to 420 and the number of thromboembolic deaths fromabout 250 to 110. Expected costs of care related to deep-vein thrombosis also would bereduced from approximately $530 to $330 per patient. Prophylaxis with enoxaparinwould be expected to reduce further the number of cases of confirmed deep-vein throm-bosis and the number of thromboembolic deaths (to 250 and 70, respectively) but in-crease costs of care by approximately $50 per patient. The cost-effectiveness ofenoxaparin (relative to low-dose warfarin) is estimated to be approximately $12,000 perdeath averted. CONCLUSION: Although enoxaparin is more costly than low-dose warfarin,its cost-effectiveness in total hip replacement compares favorably with that of othergenerally accepted medical interventions. Cost-effectiveness of prophylaxis in total hip replacement. Paiement GD, Wessinger SJ, Harris WHAm J Surg 1991 Apr;161(4):519-524Division of Orthopedics, University of Montreal Medical School, Quebec, Canada.A theoretical analysis was performed regarding the cost-effectiveness in terms of livessaved (reduction of fatal pulmonary embolism [PE]) and in terms of money (dollars spentfor prevention and treatment) of seven strategies in the management of venous throm-boembolic disease in patients over 39 years of age undergoing elective total hip replace-ment (THR). Strikingly, this theoretical analysis suggests that low-dose warfarin combinedwith clinical surveillance of deep vein thrombosis would reduce the incidence of fatal PEfrom 20 per 1,000 patients to 4 per 1,000 patients and simultaneously reduce the chargesfor venous thromboembolic disease from $550,000 to about $400,000 per 1,000 patients.Based on this analysis, we strongly recommend this measure on a routine basis. Addingvenography or duplex sonography routinely to this prophylactic regimen would, in thistheoretical analysis, reduce the incidence of fatal PE from 4 per 1,000 patients to 0.15 per1,000, but adds charges of $200,000 per extra life saved in the case of routine venographyand $50,000 in the case of routine sonography. Low-dose warfarin prophylaxis combinedwith routine sonography does not generate more charges than no prophylaxis with noscreening while drastically reducing the incidence of fatal PE from 20 to 0.3 per 1,000patients. Where duplex sonography is not easily available, a 12-week postoperative courseof low-dose warfarin for every patient with no routine screening will be efficacious inreducing fatal PE and as cost-effective. Cost-effectiveness of enoxaparin versus warfarin prophylaxis against deep-vein throm-bosis after total hip replacement. O’Brien BJ, Anderson DR, Goeree RCan Med Assoc J 1994 Apr 1;150(7):1083-1090Department of Clinical Epidemiology and Biostatistics, McMaster University,Hamilton, Ont.OBJECTIVE: To compare the efficacy and cost-effectiveness of enoxaparin, a low-molecu-lar-weight heparin derivative, with that of low-dose warfarin in the prevention of deep-vein thrombosis (DVT) after total hip replacement. DATA SOURCES: English-languagearticles on enoxaparin and warfarin prophylaxis is patients undergoing total hip replace-ment published from January 1982 to December 1992. STUDY SELECTION: Four trials ofenoxaparin (involving 567 patients) and six trials of warfarin (involving 630) met thefollowing criteria: randomized controlled trial, prophylaxis started no later than 24 hoursafter surgery and continued for at least 7 days, warfarin dose monitored and adjustedappropriately, enoxaparin dosage 30 mg twice daily, and DVT confirmed by bilateralvenography. DATA EXTRACTION: Rates of DVT, cost of prophylaxis, diagnosis and treat-ment per patient, rate of pulmonary embolism (PE), number of deaths and incrementalcost-effectiveness (cost per life-year gained). DATA SYNTHESIS: The pooled rate of DVTwas 13.6% with enoxaparin (95% confidence interval [CI] 10.9% to 16.3%) and 20.6%with warfarin (95% CI 17.4% to 23.8%). At a cost of $19.55 per day for enoxaparin thetotal cost per patient, including prophylaxis and management of DVT, exceeded that per print  Best Practices PreventingDVT & PE Center for Outcomes Research  Page 8.4 patient receiving warfarin by about $121. For every 10,000 patients treated the use ofenoxaparin will prevent 47 cases of DVT, 3 cases of PE and 4 deaths. Thus, the estimatedincremental cost-effectiveness of enoxaparin is $29 120 per life-year gained. CONCLU-SION: On the basis of current Canadian cost-effectiveness guidelines the results of thisstudy would be considered moderate to strong evidence to adopt enoxaparin prophylaxisagainst DVT after total hip replacement. However, because of the limited data the esti-mates are uncertain. Future trials should compare enoxaparin and warfarin and incorpo-rate a prospective economic appraisal. Efficacy and cost of low-molecular-weight heparin compared with standard heparin forthe prevention of deep vein thrombosis after total hip arthroplasty. Anderson DR, O’Brien BJ, Levine MN, Roberts R, Wells PS, Hirsh JAnn Intern Med 1993 Dec 1;119(11):1105-1112McMaster University Medical Centre, Hamilton, Ontario, Canada.PURPOSE: To compare the efficacy, safety, and cost-effectiveness of low-molecular-weightheparin with standard heparin for the prevention of deep vein thrombosis after total hiparthroplasty. DATA IDENTIFICATION: Studies were identified by MEDLINE search andreview of bibliographies of retrieved articles. Hospital resources used in treating deep veinthrombosis and bleeding complications after total hip arthroplasty were estimated usingretrospectively collected data from 447 patients who participated in a recently completedrandomized controlled deep vein thrombosis prophylaxis trial at our center. STUDYSELECTION: Randomized controlled trials directly comparing a low-molecular-weightheparin preparation with standard heparin for the prevention of deep vein thrombosisafter total hip arthroplasty were potentially eligible for the meta-analysis. DATA EXTRAC-TION: Data from eligible studies were extracted independently by two of the authors.Multiple regression analysis of data from the patient cohort was used to estimate theeffect of deep vein thrombosis and bleeding on length of hospital stay. A hypotheticalNorth American price for low-molecular-weight heparin was determined based on theratio between low-molecular-weight heparin and standard heparin in France. Costs werebased on weighted per-diem hospital expenditures and physician fees for procedures andreported in 1992 U.S. dollars. RESULTS OF DATA SYNTHESIS: Meta-analysis of six eligibletrials determined that low-molecular-weight heparin was significantly more effective thanstandard heparin at preventing deep vein thrombosis after total hip arthroplasty (commonodds ratio, 0.72; 95% CI, 0.53 to 0.95). However, this benefit was restricted to the preven-tion of proximal deep vein thrombosis (common odds ratio, 0.40; CI, 0.28 to 0.59). Nosignificant differences were found in the rates of distal deep vein thrombosis or total,major, or minor bleeding between the two groups. Based on a 2.6 to 1 price ratio betweenlow-molecular-weight heparin and standard heparin, use of low-molecular-weightheparin would save the health care system about $50,000 per 1000 patients treated.Sensitivity analysis shows that if the low-molecular-weight heparin/standard heparinprice ratio exceeds 3.7 (the threshold value lies between 0.8 and 5.5 based on the ex-tremes of the 95% CI of the common odds ratios for deep vein thrombosis and bleedingcomplications), use of low-molecular-weight heparin is more expensive. At a price ratio of10, it would cost more than $250,000 to treat 1000 patients with low-molecular-weightheparin compared with standard heparin or about $5000 for each additional deep veinthrombosis prevented with low-molecular-weight heparin. CONCLUSIONS: Low-molecu-lar-weight heparin is more effective and is at least as safe as standard heparin for theprevention of deep vein thrombosis after total hip arthroplasty. Based on the currentFrench price ratio of low-molecular-weight heparin to standard heparin, the use of low-molecular-weight heparin in North America would result in overall savings in cost;however, the relative cost-effectiveness is critically dependent on the price ratio betweenthe two drugs. Further research is needed to compare the cost-effectiveness of low-molecular-weight heparin with other prophylactic regimens and postoperative deep veinthrombosis management strategies. print
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks