Cost-effectiveness of dalteparin vs unfractionated heparin for the prevention of venous thromboembolism in critically ill patients. Academic Article uri icon

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abstract

  • IMPORTANCE: 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. DESIGN, SETTING, AND PARTICIPANTS: 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. MAIN OUTCOMES AND MEASURES: 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 AND RELEVANCE: 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

  • Fowler, Robert A
  • Mittmann, Nicole
  • Geerts, William
  • Heels-Ansdell, Diane
  • Gould, Michael K
  • Guyatt, Gordon
  • Krahn, Murray
  • Finfer, Simon
  • Pinto, Ruxandra
  • Chan, Brian
  • Ormanidhi, Orges
  • Arabi, Yaseen
  • Qushmaq, Ismael
  • Rocha, Marcelo G
  • Dodek, Peter
  • McIntyre, Lauralyn
  • Hall, Richard
  • Ferguson, Niall D
  • Mehta, Sangeeta
  • Marshall, John C
  • Doig, Christopher James
  • Muscedere, John
  • Jacka, Michael J
  • Klinger, James R
  • Vlahakis, Nicholas
  • Orford, Neil
  • Seppelt, Ian
  • Skrobik, Yoanna K
  • Sud, Sachin
  • Cade, John F
  • Cooper, Jamie
  • Cook, Deborah
  • Canadian Critical Care Trials Group
  • Australia and New Zealand Intensive Care Society Clinical Trials Group

publication date

  • November 26, 2014

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