Journal Article Epublish 8 citations
PubMed: 38389721 DOI: 10.1136/bmjmed-2022-000408
Effectiveness and cost effectiveness of pharmacological thromboprophylaxis for medical inpatients: decision analysis modelling study.
BMJ Med 3(1):e000408
Authors: Sarah Davis, Steve Goodacre, Daniel Horner, Abdullah Pandor, Mark Holland, Kerstin de Wit, Beverley J Hunt, Xavier Luke Griffin
Affiliations
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK.
- Department of Emergency and Intensive Care Medicine, Northern Care Alliance Foundation Trust, Salford, UK.
- Division of Immunology, Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, UK.
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.
- Department of Thrombosis & Haemostasis, Kings Healthcare Partners, London, UK.
- Barts Bone and Joint Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
Abstract
Objective
To determine the balance of costs, risks, and benefits for different thromboprophylaxis strategies for medical patients during hospital admission.
Design
Decision analysis modelling study.
Setting
NHS hospitals in England.
Population
Eligible adult medical inpatients, excluding patients in critical care and pregnant women.
Interventions
Pharmacological thromboprophylaxis (low molecular weight heparin) for all medical inpatients, thromboprophylaxis for none, and thromboprophylaxis given to higher risk inpatients according to risk assessment models (Padua, Caprini, IMPROVE, Intermountain, Kucher, Geneva, and Rothberg) previously validated in medical cohorts.
Main outcome measures
Lifetime costs and quality adjusted life years (QALYs). Costs were assessed from the perspective of the NHS and Personal Social Services in England. Other outcomes assessed were incidence and treatment of venous thromboembolism, major bleeds including intracranial haemorrhage, chronic thromboembolic complications, and overall survival.
Results
Offering thromboprophylaxis to all medical inpatients had a high probability (>99%) of being the most cost effective strategy (at a threshold of £20 000 (€23 440; 25 270) per QALY) in the probabilistic sensitivity analysis, when applying performance data from the Padua risk assessment model, which was typical of that observed across several risk assessment models in a medical inpatient cohort. Thromboprophylaxis for all medical inpatients was estimated to result in 0.0552 additional QALYs (95% credible interval 0.0209 to 0.1111) while generating cost savings of £28.44 (-£47 to £105) compared with thromboprophylaxis for none. No other risk assessment model was more cost effective than thromboprophylaxis for all medical inpatients when assessed in deterministic analysis. Risk based thromboprophylaxis was found to have a high (76.6%) probability of being the most cost effective strategy only when assuming a risk assessment model with very high sensitivity is available (sensitivity 99.9% and specificity 23.7% base case sensitivity 49.3% and specificity 73.0%).
Conclusions
Offering pharmacological thromboprophylaxis to all eligible medical inpatients appears to be the most cost effective strategy. To be cost effective, any risk assessment model would need to have a very high sensitivity resulting in widespread thromboprophylaxis in all patients except those at the very lowest risk, who could potentially avoid prophylactic anticoagulation during their hospital stay.
MeSH
Risk Assessment, Probability, Quality-Adjusted Life Years