Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. A cost-effectiveness analysis.
BACKGROUND
Low-molecular-weight heparins are effective for treating venous thrombosis, but their cost-effectiveness has not been rigorously assessed.


OBJECTIVE
To evaluate the cost-effectiveness of low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis.


METHODS
Decision model.


METHODS
Probabilities for clinical outcomes were obtained from a meta-analysis of randomized trials. Cost estimates were derived from Medicare reimbursement and other sources.


METHODS
Two hypothetical cohorts of 60-year-old men with acute deep venous thrombosis.


METHODS
Patient lifetime.


CONCLUSIONS
Societal.


METHODS
Fixed-dose low-molecular-weight heparin or adjusted-dose unfractionated heparin.


METHODS
Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. An in-patient hospital setting was used for the base-case analysis. Secondary analyses examined outpatient treatment with low-molecular-weight heparin.


RESULTS
Total costs for inpatient treatment were $26,516 for low-molecular-weight heparin and $26,361 for unfractionated heparin. The cost of initial care was higher in patients who received low-molecular-weight heparin, but this was partly offset by reduced costs for early complications. Low-molecular-weight heparin treatment increased quality-adjusted life expectancy by approximately 0.02 years. The incremental cost-effectiveness of inpatient low-molecular-weight heparin treatment was $7820 per QALY gained. Treatment with low-molecular-weight heparin was cost saving when as few as 8% of patients were treated at home.


RESULTS
When late complications were assumed to occur 25% less frequently in patients who received unfractionated heparin, the incremental cost-effectiveness ratio increased to almost $75,000 per QALY gained. When late complications were assumed to occur 25% less frequently in patients who received low-molecular-weight heparin, this treatment resulted in a net cost savings. Inpatient low-molecular-weight heparin treatment became cost saving when its pharmacy cost was reduced by 31% or more, when it reduced the yearly incidence of late complications by at least 7%, when as few as 8% of patients were treated entirely as outpatients, or when at least 13% of patients were eligible for early discharge.


CONCLUSIONS
Low-molecular-weight heparins are highly cost-effective for inpatient management of venous thrombosis. This treatment reduces costs when small numbers of patients are eligible for outpatient management.
Gould
M K
MK
Pulmonary and Critical Care Section, Veterans Affairs Palo Alto Health Care System, California 94304, USA. gould@stanford.edu
Dembitzer
A D
AD
Sanders
G D
GD
Garber
A M
AM
D000925:Anticoagulants / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D006493:Heparin / Q000191:economics / Q000627:therapeutic use*; D006495:Heparin, Low-Molecular-Weight / Q000191:economics / Q000627:therapeutic use*; D017721:Hospital Costs; D006801:Humans; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011655:Pulmonary Embolism / Q000209:etiology; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012680:Sensitivity and Specificity; D020246:Venous Thrombosis / Q000150:complications / Q000188:drug therapy* / Q000191:economics*
D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D006493:Heparin