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Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. A cost-utility analysis.

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Abstract

Background

Among patients undergoing elective total hip or knee replacement, prolonged prophylaxis with low-molecular-weight heparin significantly reduces the risk of symptomatic venous thromboembolism. Whether implementing routine prolonged prophylaxis is cost-effective remains uncertain.

Methods

We performed an economic modeling study to compare the costs and health outcomes of standard (12 days) with prolonged (42 days) enoxaparin prophylaxis against venous thromboembolism after elective total hip and knee replacement. The primary economic perspective was that of a societal healthcare payer, taking Belgium as a case country. We used cost-utility analysis, a form of cost effectiveness analysis in which costs are reported in monetary terms (euros) and health outcomes are converted into quality-adjusted life years (QALYs) gained, thereby incorporating a measure of quality of life (utility) into the health outcomes. Costs for diagnosis and treatment of proximal and distal deep vein thrombosis, pulmonary embolism, postphlebitic syndrome, and major bleeding were obtained from a Delphi panel (orthopaedic surgeons) and the official reimbursement rates (Federal Ministry of Health). QALYs for these health outcomes were based on utility scores as reported in the literature. The main outcome measure was the incremental cost-utility ratio, reported as the incremental cost per quality-adjusted life year gained (euros/QALY). The incremental cost-utility ratio refers to the amount of money needed to produce one additional QALY. We also performed sensitivity analyses on clinical and economic parameters to identify important model uncertainties.

Results

In the base-case analysis, incremental costs of prolonged prophylaxis amounted to 58 euros and 114 euros per patient, with an additional gain in QALY of 0.0083 and 0.0018 after total hip and knee replacement, respectively. Thus, a strategy of prolonged enoxaparin prophylaxis was associated with a cost-utility ratio of 6,964 euros/QALY and 64,907 euros/QALY after total hip and knee replacement, respectively. This tenfold difference in incremental cost-utility ratios between hip and knee replacement might have important practical implications. According to recent European guidelines, an intervention costing less than 20,000 euros per QALY is said to exhibit strong evidence for adoption, whereas one costing 20,000–100,000 euros exhibits moderate evidence for adoption. By current European guidelines, the cost of 6,964 euros and 64,907 euros per QALY gained would give strong evidence for adoption of prolonged enoxaparin prophylaxis among total hip replacement patients, but moderate evidence for adoption among total knee replacement patients. Sensitivity analyses using 20% changes from the base-case analysis showed this outcome to be robust.

Conclusions

Our findings indicate that, among patients undergoing elective total hip or knee replacement, prolonged enoxaparin prophylaxis leads to increased health benefits at increased cost. Given the additional costs that healthcare decision makers in Europe are usually prepared to pay for a gain in utility, prolonged prophylaxis with enoxaparin is cost-effective after elective total hip replacement, and our data provide strong evidence for adoption of prolonged enoxaparin prophylaxis after elective total hip replacement.

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Acknowledgements

The Delphi panel members are (alphabetical listing, locations in Belgium): Dr. Georges De Brouckère, R.H.M.S., Baudour; Dr. Jean-Pierre Delcour, C.H. Bois de l’Abbaye, Seraing; Dr. Sabri El Banna, C.H.U. Vésale, Montigny-le-Tilleul; Dr. Patrick Haentjens, Academisch Ziekhuis V.U.B., Jette; Dr. Michiel Mulier, U.Z. Pellenberg, Pellenberg; Dr. Philippe Putz, C.H.U. Brugmann, Laeken; Dr. José Stuyck, U.Z. Pellenberg, Pellenberg; Dr. Vanlommel, Virga Jesse Ziekenhuis, Hasselt; Dr. Johan Vaninbroukx, Salvator Ziekenhuis, Hasselt; Dr. Jacques Van Overschelde, Algemeen Stedelijk Ziekenhuis, Aalst; Dr. René Verdonk, U.Z. Gent, Gent; Dr. Jozef Verstreken, U.Z. Antwerpen, Deurne. This study is made possible by an unrestricted research grant from Aventis Pharma NV-SA, Brussels, Belgium

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Authors and Affiliations

  1. Department of Orthopaedics and Traumatology, Academisch Ziekenhuis, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 , Brussels, Belgium

    Patrick Haentjens

  2. Health Economic Disease Management HEDM Independent Research Organization, Brusselse Straat 91, 1860 , Meise, Belgium

    Katrien De Groote

  3. Department of Public Health, Ghent University, De Pintelaan 185, 9000 , Ghent, Belgium

    Lieven Annemans

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Correspondence to Patrick Haentjens.

Technical appendix: prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. A cost-utility analysis

Technical appendix: prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. A cost-utility analysis

This technical appendix provides further details with regard to resource use and unit costs for prophylaxis, diagnosis, and treatment of venous thromboembolic events among patients receiving total hip or knee replacement in Belgium. Resources used were estimated by applying a two-round Delphi technique. The Delphi panel was composed of 12 orthopaedic surgeons selected on the basis of the following criteria: extensive experience in treating patients with elective total hip or knee replacement, prominence in research or health-policy issues relevant to venous thromboembolism, and geographic balance. The expert panel’s final estimates of resource utilization are reported as the mean with the 10th and 90th percentile (i.e., 10% of the experts answered a lower number, and 10% of the experts answered a higher number, respectively).

Costs assigned for these medical services were based on the official 2001 Belgian Health Insurance Association reimbursement rates (a third-party payer system that is regulated by law and financed by the federal government). In Belgium, the direct costs to these different services are almost completely covered by this federal health care system. Therefore, we obtained unit cost data from the Belgian Ministry of Social Affairs (“Nomenclature générale”) and the National Drug Compendium.

This technical appendix is available upon request.

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Haentjens, P., De Groote, K. & Annemans, L. Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. A cost-utility analysis.. Arch Orthop Trauma Surg 124, 507–517 (2004). https://doi.org/10.1007/s00402-004-0720-3

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