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. 2018 Nov 27:9:1370.
doi: 10.3389/fphar.2018.01370. eCollection 2018.

Cost-Utility Analysis of Venous Thromboembolism Prophylaxis Strategies for People Undergoing Elective Total Hip and Total Knee Replacement Surgeries in the English National Health Service

Dalia M Dawoud  1   2 , David Wonderling  3 , Jessica Glen  3 , Sedina Lewis  3 , Xavier L Griffin  4 , Beverley J Hunt  5 , Gerard Stansby  6 , Michael Reed  7 , Nigel Rossiter  8 , Jagjot Kaur Chahal  9 , Carlos Sharpin  3 , Peter Barry  10
Affiliations

Cost-Utility Analysis of Venous Thromboembolism Prophylaxis Strategies for People Undergoing Elective Total Hip and Total Knee Replacement Surgeries in the English National Health Service

Dalia M Dawoud et al. Front Pharmacol. .

Abstract

Background: Major orthopedic surgery, such as elective total hip replacement (eTHR) and elective total knee replacement (eTKR), are associated with a higher risk of venous thromboembolism (VTE) than other surgical procedures. Little is known, however, about the cost-effectiveness of VTE prophylaxis strategies in people undergoing these procedures. Aim: The aim of this work was to assess the cost-effectiveness of these strategies from the English National Health Service perspective to inform NICE guideline (NG89) recommendations. Materials and Methods: Cost-utility analysis, using decision modeling, was undertaken to compare 15 VTE prophylaxis strategies for eTHR and 12 for eTKR, in addition to "no prophylaxis" strategy. The analysis complied with the NICE Reference Case. Structure and assumptions were agreed with the guideline committee. Incremental net monetary benefit (INMB) was calculated, vs. the model comparator (LMWH+ antiembolism stockings), at a threshold of £20,000/quality-adjusted life-year (QALY) gained. The model was run probabilistically. Deterministic sensitivity analyses (SAs) were undertaken to assess the robustness of the results. Results: The most cost-effective strategies were LMWH for 10 days followed by aspirin for 28 days (INMB = £530 [95% CI: -£784 to £1,103], probability of being most cost-effective = 72%) for eTHR, and foot pump (INMB = £353 [95% CI: -£101 to £665]; probability of being most cost-effective = 18%) for eTKR. There was considerable uncertainty regarding the cost-effectiveness ranking in the eTKR analysis. The results were robust to change in all SAs. Conclusions: For eTHR, LMWH (standard dose) for 10 days followed by aspirin for 28 days is the most cost-effective VTE prophylaxis strategy. For eTKR, the results are highly uncertain but foot pump appeared to be the most cost-effective strategy, followed closely by aspirin (low dose). Future research should focus on assessing cost-effectiveness of VTE prophylaxis in the eTKR population.

Keywords: NICE guideline; cost utility analysis (CUA); direct-acting oral anticoagulants; pharmacoeconomics; total hip replacement (THR); total knee replacement (TKR); venous thromboembolism (VTE) prophylaxis.

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Figures

Figure 1
Figure 1
(A) Model structure up to 90 days post-operatively (Decision tree part). (B) Model structure after 90 days post-operatively (Markov model part).
Figure 2
Figure 2
Scatter plots showing the probabilistic analysis results for (A) elective total hip replacement (eTHR) and (B) elective total knee replacement (eTKR) populations.
Figure 3
Figure 3
Cost effectiveness plane showing the mean incremental costs and QALYs compared to LMWH (standard dose, standard duration) + AES for (A) elective total hip replacement (eTHR) and (B) elective total knee replacement (eTKR) populations.
See this image and copyright information in PMC

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