Economic Evaluations of New Oral Anticoagulants for the Prevention of Venous Thromboembolism After Total Hip or Knee Replacement: A Systematic Review

Brockbank, James; Wolowacz, Sorrel

doi:10.1007/s40273-017-0486-4

Cited by 18 publications

(20 citation statements)

References 35 publications

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“…To our knowledge, this is the first cost‐effectiveness analysis to compare multiple anticoagulants at several durations post‐TKA. Previous studies of anticoagulation therapy in TKA or THA recipients have focused on comparative analyses of 2 strategies or a single agent prescribed at different doses or durations . A cost‐effectiveness analysis by Schousboe and Brown showed that, when compared to LMWH, aspirin was the preferred strategy in THA patients but the cost‐effectiveness in TKA patients was dependent on age and DVT risk, with aspirin assuming a higher likelihood of cost‐effectiveness in older patients without high DVT risk.…”

Section: Discussionmentioning

confidence: 99%

“…Some research has suggested that longer anticoagulation regimens can substantially reduce the risk of DVT and PE ; however, in the absence of definitive recommendations, physicians are left weighing the risks of DVT and PE against those of anticoagulation therapy, including hemorrhage of gastrointestinal (GI) and central nervous system (CNS) sites, as well as a higher likelihood of prosthetic joint infection (PJI) . Prior cost‐effectiveness analyses evaluating anticoagulation therapy after joint arthroplasty have compared only 2 agents and few studies have considered the duration of therapy . One analysis evaluating prolonged (42‐day) versus standard (12‐day) treatment with enoxaparin in total hip arthroplasty (THA) or TKA patients suggested that prolonged therapy was cost‐effective in THA patients .…”

Section: Introductionmentioning

confidence: 99%

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Cost‐Effectiveness of Alternative Anticoagulation Strategies for Postoperative Management of Total Knee Arthroplasty Patients

Smith

Katz

Losina

2019

Arthritis Care & Research

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Objective. To evaluate the cost-effectiveness of prolonged (35-day) and standard-duration (14-day) anticoagulation therapy following total knee arthroplasty (TKA).Methods. Using Markov modeling, we assessed clinical and economic outcomes of 14-day and 35-day anticoagulation therapy following TKA with rivaroxaban, low molecular weight heparin (LMWH), fondaparinux, warfarin, and aspirin. Incidence of complications of TKA and anticoagulation therapy (deep vein thrombosis [DVT], pulmonary embolism [PE], prosthetic joint infection [PJI], and bleeding) were derived from published literature. Daily costs ranged from $1 (aspirin) to $43 (fondaparinux). Primary outcomes included quality-adjusted life years (QALYs), direct medical costs, and incremental cost-effectiveness ratios (ICERs) at 1 year post-TKA. The preferred regimen was the regimen with highest QALYs maintaining an ICER below the willingness-to-pay threshold ($100,000/QALY). We conducted probabilistic sensitivity analyses, varying complication incidence and anticoagulation efficacy, to evaluate the impact of parameter uncertainty on model results.Results. Aspirin resulted in the highest cumulative incidence of DVT and PE, while prolonged fondaparinux led to the largest reduction in DVT incidence (15% reduction compared to no prophylaxis). Despite differential bleeding rates (ranging from 3% to 6%), all strategies had similar incidence of PJI (1% to 2%). Prolonged rivaroxaban was the least costly strategy ($3,300 at 1 year post-TKA) and the preferred regimen in the base case. In sensitivity analyses, prolonged rivaroxaban and warfarin had similar likelihoods of being cost-effective.Conclusion. Extending postoperative anticoagulation therapy to 35 days increases QALYs compared to standard 14-day prophylaxis. Prolonged rivaroxaban and prolonged warfarin are most likely to be cost-effective post-TKA; the costs of fondaparinux and LMWH precluded their being preferred strategies.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Cost‐Effectiveness of Alternative Anticoagulation Strategies for Postoperative Management of Total Knee Arthroplasty Patients

Smith

Katz

Losina

2019

Arthritis Care & Research

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“…Findings reflect those from previous studies that have explored processes that influence implementation of ERAS for other conditions. 88,96,97 These found that multidisciplinary collaboration was essential and that this could be threatened by the need to co-ordinate working practices across different departments. 98 Likewise, components of ERAS were seen as incompatible with working practices of some members of the multidisciplinary team; this meant that some staff were resistant to change.…”

Section: Overview Of Findingsmentioning

confidence: 99%

“…26,96 The importance of providing education and information to patients, and providing realistic expectations of their recovery, was discussed. 28,88 Temporality or strategies to embed ERAS over time were discussed in a small number of studies. 59 Studies have been synthesised in a recent systematic review.…”

Section: Overview Of Findingsmentioning

confidence: 99%

“…Findings highlighted the need for comprehensive preoperative education and post-discharge support. 88 However, no studies have explored factors that have an impact on the implementation of ERAS programmes for hip and knee replacements or patients' experiences of these programmes. As ERAS programmes for hip and knee replacement involve a considerable recovery period after discharge from hospital, patient experiences are likely to be different.…”

Section: Introductionmentioning

confidence: 99%

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The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study

Judge

Carr

Price

et al. 2020

Health Serv Deliv Res

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Background There is limited evidence concerning the effectiveness of enhanced recovery programmes in hip and knee replacement surgery, particularly when applied nationwide across a health-care system. Objectives To determine the effect of hospital organisation, surgical factors and the enhanced recovery after surgery pathway on patient outcomes and NHS costs of hip and knee replacement. Design (1) Statistical analysis of national linked data to explore geographical variations in patient outcomes of surgery. (2) A natural experimental study to determine clinical effectiveness of enhanced recovery after surgery. (3) A qualitative study to identify barriers to, and facilitators of, change. (4) Health economics analysis to establish NHS costs and cost-effectiveness. Setting Data from the National Joint Registry, linked to English Hospital Episode Statistics and patient-reported outcome measures in both the geographical variation and natural experiment studies, together with the economic evaluation. The ethnographic study took place in four hospitals in a region of England. Participants Qualitative study – 38 health professionals working in hip and knee replacement services in secondary care and 37 patients receiving hip or knee replacement. Interventions Natural experiment – implementation of enhanced recovery after surgery at each hospital between 2009 and 2011. Enhanced recovery after surgery is a complex intervention focusing on several areas of patients’ care pathways through surgery: preoperatively (patient is in best possible condition for surgery), perioperatively (patient has best possible management during and after operation) and postoperatively (patient experiences best rehabilitation). Main outcome measures Patient-reported pain and function (Oxford Hip Score/Oxford Knee Score); 6-month complications; length of stay; bed-day costs; and revision surgery within 5 years. Results Geographical study – there are potentially unwarranted variations in patient outcomes of hip and knee replacement surgery. This variation cannot be explained by differences in patients, case mix, surgical or hospital organisational factors. Qualitative – successful implementation depends on empowering patients to work towards their recovery, providing post-discharge support and promoting successful multidisciplinary team working. Care processes were negotiated between patients and health-care professionals. ‘Good care’ remains an aspiration, particularly in the post-discharge period. Natural experiment – length of stay has declined substantially, pain and function have improved, revision rates are in decline and complication rates remain stable. The introduction of a national enhanced recovery after surgery programme maintained improvement, but did not alter the rate of change already under way. Health economics – costs are high in the year of joint replacement and remain higher in the subsequent year after surgery. There is a strong economic incentive to identify ways of reducing revisions and complications following joint replacement. Published cost-effectiveness evidence supports enhanced recovery pathways as a whole. Limitations Short duration of follow-up data prior to enhanced recovery after surgery implementation and missing data, particularly for hospital organisation factors. Conclusion No evidence was found to show that enhanced recovery after surgery had a substantial impact on longer-term downwards trends in costs and length of stay. Trends of improving outcomes were seen across all age groups, in those with and without comorbidity, and had begun prior to the formal enhanced recovery after surgery roll-out. Reductions in length of stay have been achieved without adversely affecting patient outcomes, yet, substantial variation remains in outcomes between hospital trusts. Future work There is still work to be done to reduce and understand unwarranted variations in outcome between individual hospitals. Study registration This study is registered as PROSPERO CRD42017059473. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.

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Economic Evaluation of Rivaroxaban Versus Enoxaparin for Prevention of Venous Thromboembolism After Total Knee Replacement and Total Hip Replacement: A Systematic Review

2020

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Economic Evaluations of New Oral Anticoagulants for the Prevention of Venous Thromboembolism After Total Hip or Knee Replacement: A Systematic Review

Cited by 18 publications

References 35 publications

Cost‐Effectiveness of Alternative Anticoagulation Strategies for Postoperative Management of Total Knee Arthroplasty Patients

Cost‐Effectiveness of Alternative Anticoagulation Strategies for Postoperative Management of Total Knee Arthroplasty Patients

The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study

Economic Evaluation of Rivaroxaban Versus Enoxaparin for Prevention of Venous Thromboembolism After Total Knee Replacement and Total Hip Replacement: A Systematic Review

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