title: Cost-effectiveness of dalteparin vs unfractionated heparin for the prevention of venous thromboembolism in critically ill patients.
abstract: OBJECTIVE
  Venous thromboembolism (VTE) is a common complication of acute illness, and its prevention is a ubiquitous aspect of inpatient care. A multicenter blinded, randomized trial compared the effectiveness of the most common pharmocoprevention strategies, unfractionated heparin (UFH) and the low-molecular-weight heparin (LMWH) dalteparin, finding no difference in the primary end point of leg deep-vein thrombosis but a reduced rate of pulmonary embolus and heparin-induced thrombocytopenia among critically ill medical-surgical patients who received dalteparin.
  
  
  OBJECTIVE
  To evaluate the comparative cost-effectiveness of LMWH vs UFH for prophylaxis against VTE in critically ill patients.
  
  
  METHODS
  Prospective economic evaluation concurrent with the Prophylaxis for Thromboembolism in Critical Care Randomized Trial (May 2006 to June 2010). The economic evaluation adopted a health care payer perspective and in-hospital time horizon; derived baseline characteristics and probabilities of intensive care unit and in-hospital events; and measured costs among 2344 patients in 23 centers in 5 countries and applied these costs to measured resource use and effects of all enrolled patients.
  
  
  METHODS
  Costs, effects, incremental cost-effectiveness of LMWH vs UFH during the period of hospitalization, and sensitivity analyses across cost ranges.
  
  
  RESULTS
  Hospital costs per patient were $39,508 (interquartile range [IQR], $24,676 to $71,431) for 1862 patients who received LMWH compared with $40,805 (IQR, $24,393 to $76,139) for 1862 patients who received UFH (incremental cost, -$1297 [IQR, -$4398 to $1404]; P = .41). In 78% of simulations, a strategy using LMWH was most effective and least costly. In sensitivity analyses, a strategy using LMWH remained least costly unless the drug acquisition cost of dalteparin increased from $8 to $179 per dose and was consistent among higher- and lower-spending health care systems. There was no threshold at which lowering the acquisition cost of UFH favored prophylaxis with UFH.
  
  
  CONCLUSIONS
  From a health care payer perspective, the use of the LMWH dalteparin for VTE prophylaxis among critically ill medical-surgical patients was more effective and had similar or lower costs than the use of UFH. These findings were driven by lower rates of pulmonary embolus and heparin-induced thrombocytopenia and corresponding lower overall use of resources with LMWH.
authors.affiliation: Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Fowler
authors.affiliation: Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada3Department of Pharmacology, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Nicole
authors.initials: N
authors.lastname: Mittmann
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: William
authors.initials: W
authors.lastname: Geerts
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Diane
authors.initials: D
authors.lastname: Heels-Ansdell
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Gould
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Gordon
authors.initials: G
authors.lastname: Guyatt
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Murray
authors.initials: M
authors.lastname: Krahn
authors.affiliation: George Institute for Global Health, Royal North Shore Hospital, University of Sydney, St Leonards, Australia.
authors.forename: Simon
authors.initials: S
authors.lastname: Finfer
authors.affiliation: Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Ruxandra
authors.initials: R
authors.lastname: Pinto
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Brian
authors.initials: B
authors.lastname: Chan
authors.affiliation: Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Orges
authors.initials: O
authors.lastname: Ormanidhi
authors.affiliation: King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
authors.forename: Yaseen
authors.initials: Y
authors.lastname: Arabi
authors.affiliation: Department of Medicine, King Faisal Specialist Hospital & Research Centre-Gen. Org, Jeddah-Saudi Arabia.
authors.forename: Ismael
authors.initials: I
authors.lastname: Qushmaq
authors.affiliation: Department of Intensive Care, Hospitalar Santa Casa, Porto Alegre, Brazil.
authors.forename: Marcelo G
authors.initials: MG
authors.lastname: Rocha
authors.affiliation: Center for Health Evaluation and Outcome Sciences, Division of Critical Care Medicine, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Dodek
authors.affiliation: Ottawa Hospital Research Institute, Centre for Transfusion and Critical Care Research, Department of Medicine (Critical Care), Ottawa Hospital, Ottawa, Ontario, Canada.
authors.forename: Lauralyn
authors.initials: L
authors.lastname: McIntyre
authors.affiliation: Department of Anesthesiology, Dalhousie University, and the Capital District Health Authority, Halifax, Nova Scotia, Canada16Department of Medicine, Dalhousie University, and the Capital District Health Authority, Halifax, Nova Scotia, Canada17Department.
authors.forename: Richard
authors.initials: R
authors.lastname: Hall
authors.affiliation: Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada20Interdepartmental Division of Critical Care Medicine, Department of Physiology, University of Toronto, Toronto, Ontario, Canada2.
authors.forename: Niall D
authors.initials: ND
authors.lastname: Ferguson
authors.affiliation: Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada22Mount Sinai Hospital, Toronto, Ontario, Canada.
authors.forename: Sangeeta
authors.initials: S
authors.lastname: Mehta
authors.affiliation: Department of Surgery, University of Toronto, Toronto, Ontario, Canada24Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: John C
authors.initials: JC
authors.lastname: Marshall
authors.affiliation: Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada26Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada27Department of Medicine, University of Calgary, Calgary, Alberta, Canada28Footh.
authors.forename: Christopher James
authors.initials: CJ
authors.lastname: Doig
authors.affiliation: Department of Medicine, Queen's University, Kingston, Ontario, Canada.
authors.forename: John
authors.initials: J
authors.lastname: Muscedere
authors.affiliation: Department of Anesthesiology and Critical Care, University of Alberta Hospital, Edmonton, Alberta, Canada.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Jacka
authors.affiliation: Division of Pulmonary, Sleep, and Critical Care Medicine, Albert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island.
authors.forename: James R
authors.initials: JR
authors.lastname: Klinger
authors.affiliation: Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Vlahakis
authors.affiliation: Australian and New Zealand Intensive Care Research Centre, Intensive Care Barwon Health, Monash University School of Medicine, Deakin University, Melbourne, Victoria, Australia.
authors.forename: Neil
authors.initials: N
authors.lastname: Orford
authors.affiliation: Critical Care Medicine, Nepean Hospital, Penrith, New South Wales, Australia.
authors.forename: Ian
authors.initials: I
authors.lastname: Seppelt
authors.affiliation: Critical Care Medicine, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada.
authors.forename: Yoanna K
authors.initials: YK
authors.lastname: Skrobik
authors.affiliation: Department of Medicine, Trillium Hospital, Mississauga, Ontario, Canada.
authors.forename: Sachin
authors.initials: S
authors.lastname: Sud
authors.affiliation: Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia.
authors.forename: John F
authors.initials: JF
authors.lastname: Cade
authors.affiliation: ANZIC-RC Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
authors.forename: Jamie
authors.initials: J
authors.lastname: Cooper
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada40Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Deborah
authors.initials: D
authors.lastname: Cook
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D016638:Critical Illness / Q000191:economics*; D017985:Dalteparin / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006296:Health Services / Q000706:statistics & numerical data; D006493:Heparin / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use; D006760:Hospitalization / Q000191:economics; D006801:Humans; D007348:Insurance, Health / Q000191:economics; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000191:economics / Q000517:prevention & control; D016032:Randomized Controlled Trials as Topic; D013921:Thrombocytopenia / Q000139:chemically induced / Q000191:economics; D054556:Venous Thromboembolism / Q000191:economics / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D006493:Heparin; D017985:Dalteparin