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Original Research ARTICLE Provisionally accepted The full-text will be published soon. Notify me

Front. Pharmacol. | doi: 10.3389/fphar.2018.01370

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. Dawoud1, 2*, David Wonderling3, Jessica Glen3,  Sedina Lewis3, Xavier Griffin4, Beverley J. Hunt5, Gerard Stansby6, Michael Reed7, Nigel Rossiter8, Jagjot K. Chahal9, Carlos Sharpin3* and Peter Barry10
  • 1Cairo University, Egypt
  • 2University of Hertfordshire, United Kingdom
  • 3Royal College of Physicians, United Kingdom
  • 4Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Medical Sciences Division, University of Oxford, United Kingdom
  • 5Guy's and St Thomas' NHS Foundation Trust, United Kingdom
  • 6Newcastle University, United Kingdom
  • 7Northumbria Healthcare NHS Foundation Trust, United Kingdom
  • 8Basingstoke and North Hampshire Hospital, United Kingdom
  • 9Barts Health NHS Trust, United Kingdom
  • 10University Hospitals of Leicester NHS Trust, United Kingdom

Background
Major orthopaedic surgery, such as primarily elective total hip replacement (eTHR) and elective total knee replacement (eTKR), are associated with a higher risk of venous thromboembolism (VTE) than other surgical populations. Little is known, however, about the cost-effectiveness of VTE prophylaxis strategies in these populations.
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 modelling, 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: Venous thromboembolism (VTE) prophylaxis, Pharmacoeconomics, Hospital-acquired thrombosis, Cost Utility Analysis (CUA), Total knee replacement (TKR), Total hip replacement (THR), direct-acting oral anticoagulants, NICE Guideline, Mechanical prophylaxis, Pharmacological prophylaxis

Received: 25 Jul 2018; Accepted: 07 Nov 2018.

Edited by:

Dominique J. Dubois, Free University of Brussels, Belgium

Reviewed by:

Brian Godman, Karolinska Institutet (KI), Sweden
Jean-Paul Deslypere, Besins Healthcare, Thailand  

Copyright: © 2018 Dawoud, Wonderling, Glen, Lewis, Griffin, Hunt, Stansby, Reed, Rossiter, Chahal, Sharpin and Barry. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence:
Dr. Dalia M. Dawoud, Cairo University, Giza, 12613, Giza, Egypt, ddawoud@hotmail.com
Mr. Carlos Sharpin, Royal College of Physicians, London, NW1 4LE, United Kingdom, carlos.sharpin@rcplondon.ac.uk