Cost-effectiveness of ruling out deep venous thrombosis in primary care versus care as usual.
BACKGROUND
Referral for ultrasound testing in all patients suspected of DVT is inefficient, because 80-90% have no DVT.


OBJECTIVE
To assess the incremental cost-effectiveness of a diagnostic strategy to select patients at first presentation in primary care based on a point of care D-dimer test combined with a clinical decision rule (AMUSE strategy), compared with hospital-based strategies.


METHODS
A Markov-type cost-effectiveness model with a societal perspective and a 5-year time horizon was used to compare the AMUSE strategy with hospital-based strategies. Data were derived from the AMUSE study (2005-2007), the literature, and a direct survey of costs (2005-2007).


RESULTS
Adherence to the AMUSE strategy on average results in savings of euro138 ($185) per patient at the expense of a very small health loss (0.002 QALYs) compared with the best hospital strategy. The iCER is euro55 753($74 848). The cost-effectiveness acceptability curves show that the AMUSE strategy has the highest probability of being cost-effective.


RESULTS
Results are sensitive to decreases in sensitivity of the diagnostic strategy, but are not sensitive to increase in age (range 30-80), the costs for health states, and events.


CONCLUSIONS
A diagnostic management strategy based on a clinical decision rule and a point of care D-dimer assay to exclude DVT in primary care is not only safe, but also cost-effective as compared with hospital-based strategies.
Department of Clinical Epidemiology, Maastricht University Medical Center, Maastricht, The Netherlands.
A J
AJ
Ten Cate-Hoek
D B
DB
Toll
H R
HR
Büller
A W
AW
Hoes
K G M
KG
Moons
R
R
Oudega
H E J H
HE
Stoffers
E F
EF
van der Velde
H C P M
HC
van Weert
M H
MH
Prins
M A
MA
Joore
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D003362:Cost-Benefit Analysis; D003625:Data Collection; D003661:Decision Support Techniques; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D006801:Humans; D008875:Middle Aged; D019095:Point-of-Care Systems; D011336:Probability; D014463:Ultrasonography; D020246:Venous Thrombosis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000191:economics*
D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D