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Economic Analysis of Low-Dose Heparin vs the Low-Molecular-Weight Heparin Enoxaparin for Prevention of Venous Thromboembolism After Colorectal Surgery
Edward Etchells, MD, MSc;
Robin S. McLeod, MD;
William Geerts, MD;
Paul Barton, BSc;
Allan S. Detsky, MD, PhD
Arch Intern Med. 1999;159:1221-1228.
Background Low-dose heparin and low-molecular-weight heparin are effective strategies for preventing venous thromboembolism in colorectal surgery. The economic attractiveness of these 2 strategies in North America is unknown. We conducted an economic analysis of low-dose heparin calcium compared with enoxaparin sodium, a low-molecular-weight heparin, for thromboembolism prophylaxis after colorectal surgery.
Methods We used decision analysis, with an economic perspective of a third-party payer. Efficacy data were obtained from the Canadian Multicentre Colorectal Deep Vein Thrombosis Prophylaxis Trial and a literature review. Canadian costs for diagnosis and treatment of deep vein thrombosis (DVT), pulmonary embolism (PE), and major bleeding were obtained from chart review and a national hospital database of colorectal surgery; American costs were obtained from published literature. The main outcomes were incremental benefits (symptomatic DVTs, symptomatic PEs, and major bleeding events avoided) and incremental costs for every 1000 patients treated.
Results In the Canadian Colorectal Trial, the relative risk of DVT and PE for enoxaparin compared with low-dose heparin was 1.0 (95% confidence interval, 0.7-1.5), and the relative risk of major bleeding was 1.8 (95% confidence interval, 0.8-3.9). With the use of these data in the baseline analysis, a strategy of enoxaparin prophylaxis was associated with equal numbers of symptomatic DVTs and PEs, and an excess of 12 major bleeding episodes for every 1000 patients treated, with an additional cost of $86,050 (Canadian data) or $145,667 (US data). In a sensitivity analysis using optimal assumptions for efficacy and safety of enoxaparin (relative risk of DVT, 0.8; relative risk of PE, 0.4; relative risk of major bleeding, 1.0), a strategy of enoxaparin prophylaxis was associated with 0.8 fewer symptomatic DVT, 3 fewer symptomatic PEs, and equal numbers of major bleeding episodes for every 1000 patients treated, with an additional cost of $15,217 (Canadian data) or $107,614 (US data).
Conclusion Although heparin and enoxaparin are equally effective, low-dose heparin is a more economically attractive choice for thromboembolism prophylaxis after colorectal surgery.
From the Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine, The Toronto Hospital (Drs Etchells and Detsky); Department of Surgery, Mount Sinai Hospital (Dr McLeod and Mr Barton); and Department of Medicine and the Clinical Epidemiology and Health Care Research Program, Sunnybrook Health Science Centre (Dr Geerts), University of Toronto, Toronto, Ontario.
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