Cost-Effectiveness of Primary and Secondary Prevention of Fatal Pulmonary Embolism in High-Risk Surgical Patients

Abstract

Because death due to pulmonary embolism is relatively rare following general surgery, many question the need for prophylaxis. In addition, there has been reluctance to apply new interventions whose costeffectiveness has not been adequately evaluated. A cost-effectiveness analysis based on over 1000 highrisk patients undergoing abdominothoracic surgery, with effectiveness measured in terms of numbers of deaths from pulmonary embolism averted, has shown subcutaneous administration of heparin in low doses starting 2 hours before the operation to be the most cost-effective of several active approaches to prophylaxis. It averted seven of the eight deaths expected without active prophylaxis per 1000 such patients and cost half as much as the traditional approach of intervening only when venous thromboembolism becomes clinically apparent. Intravenous administration of dextran, although effective, was expensive, and leg scanning with iodine-1 25-labelled fibrinogen was extremely expensive. Intermittent pneumatic compression of the legs was inexpensive, but, as with leg scanning, its effectiveness has not been determined in randomized trials.

Use of venous thromboprophylaxis and adherence to guideline recommendations: a cross-sectional study

“…It has been argued that official guidelines are hardly ever evidence-based because the input of expert groups is above minimum and the long delay between arising new data and guideline completion or updating. Nevertheless, the guidelines were based on the best possible evidence, and the main recommendations of guidelines, for instance appropriate prophylaxis use in moderate and high-risk patients, have clearly showed themselves to be effective [1-10] and efficient [29-32]. …”

Risk of and prophylaxis for venous thromboembolism in hospital patients. Thromboembolic Risk Factors (THRIFT) Consensus Group.

“…2 Acute myocardial infarction-We recommend low dose subcutaneous heparin as prophylaxis for venous thromboembolism7' in patients who are not already BMJ VOLUME 305 5 SEPTEMBER 1992 receiving higher doses of heparin (25 000 units/day intravenously or subcutaneously) for maintaining patency after thrombolytic therapy or for prophylaxis for mural thrombosis and reinfarction, or both. 19 31 Acute stroke-In patients with acute stroke causing lower limb weakness we recommend low dose subcutaneous heparin as prophylaxis for venous thromboembolism,2872 provided that intracranial haemorrhage and intracranial neoplasia have been excluded by computed tomographic brain scanning.73 Though low dose heparin and some low molecular weight heparins or heparinoids are effective in preventing deep vein thrombosis after stroke,727475 their effects on intracranial bleeding, functional outcome, and mortality remain to be established by larger studies.72 In patients in whom computed tomography is not performed, or who have intracranial haemorrhage or neoplasia or other contraindications to heparin, we recommend graduated compression stockings with or without intermittent pneumatic compression, extrapolating from controlled trials in neurosurgical patients.95 6 Other groups at moderate or high risk -In other groups (for example, those immobilised with chest infection, heart failure, respiratory failure, malignancy, inflammatory bowel disease and other conditions in table I) we recommend prophylaxis with low dose subcutaneous heparin'927; warfarin (in high risk patients-for example, those with previous thromboembolism); or in patients with contraindications to heparin and warfarin graduated compression stockings with or without intermittent pneumatic compression (extrapolating from trials in surgical patients '8-20 56).…”

Cost/ Benefit Aspects on Thromboprophylaxis

“…There are several studies where the costeffectiveness of thromboprophylaxis has been analyzed, all showing that general prophylaxis is a more cost-effective alternative than no prophylaxis [6,[9][10][11][12][14][15][16][17][18][19], General pro phylaxis in most of these studies has meant prophylaxis to all patients above a certain critical age, usually 40-45 years. Thus, it has been shown repeatedly that with prophylaxis there are monetary savings to be made.…”