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Screening and prevention of venous thromboembolism in critically ill patients: a decision analysis and economic evaluation.

Abstract：

RATIONALE:Venous thromboembolism is difficult to diagnose in critically ill patients and may increase morbidity and mortality. OBJECTIVES:To evaluate the cost-effectiveness of strategies to reduce morbidity from venous thromboembolism in critically ill patients. METHODS:A Markov decision analytic model to compare weekly compression ultrasound screening (screening) plus investigation for clinically suspected deep vein thrombosis (DVT) (case finding) versus case finding alone; and a hypothetical program to increase adherence to DVT prevention. Probabilities were derived from a systematic review of venous thromboembolism in medical-surgical intensive care unit patients. Costs (in 2010 $US) were obtained from hospitals in Canada, Australia, and the United States, and the medical literature. Analyses were conducted from a societal perspective over a lifetime horizon. Outcomes included costs, quality-adjusted life-years (QALY), and incremental cost-effectiveness ratios. MEASUREMENTS AND MAIN RESULTS:In the base case, the rate of proximal DVT was 85 per 1,000 patients. Screening resulted in three fewer pulmonary emboli than case-finding alone but also two additional bleeding episodes, and cost $223,801 per QALY gained. In sensitivity analyses, screening cost less than $50,000 per QALY only if the probability of proximal DVT increased from a baseline of 8.5-16%. By comparison, increasing adherence to appropriate pharmacologic thromboprophylaxis by 10% resulted in 16 fewer DVTs, one fewer pulmonary emboli, and one additional heparin-induced thrombocytopenia and bleeding event, and cost $27,953 per QALY gained. Programs achieving increased adherence to best-practice venous thromboembolism prevention were cost-effective over a wide range of program costs and were robust in probabilistic sensitivity analyses. CONCLUSIONS:Appropriate prophylaxis provides better value in terms of costs and health gains than routine screening for DVT. Resources should be targeted at optimizing thromboprophylaxis.

journal_name

Am J Respir Crit Care Med

journal_title

American journal of respiratory and critical care medicine

authors

Sud S,Mittmann N,Cook DJ,Geerts W,Chan B,Dodek P,Gould MK,Guyatt G,Arabi Y,Fowler RA,Canadian Critical Care Trials Group.,E-PROTECT Investigators.

doi

10.1164/rccm.201106-1059OC

subject

Has Abstract

pub_date

2011-12-01 00:00:00

pages

1289-98

issue

eissn

1073-449X

issn

1535-4970

pii

201106-1059OC

journal_volume

184

pub_type

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Screening and prevention of venous thromboembolism in critically ill patients: a decision analysis and economic evaluation.