Cost-effectiveness of prophylaxis in total hip replacement

Article Abstract:

The most frequent fatal complication of total hip replacement surgery in patients not protected against it is venous thromboembolism, a condition in which a clot forms, travels within the circulatory system, and then obstructs blood flow. There are two methods of preventing thromboembolism: prevention of the condition itself, and secondary prevention or detecting the condition before it causes symptoms. There is little information on the cost-effectiveness of prevention of venous thromboembolism. Cost-effectiveness was analyzed in terms of lives saved and in terms of dollars spent for prevention and treatment. The patients studied had total hip replacement surgery and were over 39 years of age; their cases were either found in the published literature or drawn from a group of 195 patients seen at one institution. Two methods of primary prevention were studied, no prevention or use of low-dose warfarin; secondary prevention methods studied were clinical surveillance, routine duplex sonography (an imaging method that provides detailed views of the vessel wall structure), and routine venography (X-rays of the veins). There were a total of seven different combinations of prevention methods analyzed. Theoretical analysis suggests that low-dose warfarin combined with clinical surveillance reduces deaths from 20 to 4 per 1,000 patients and also reduces costs from $550,000 to $400,000 per 1,000 patients. This strategy is strongly recommended. Although use of either venography or duplex sonography routinely reduces deaths from 4 to 0.15 per 1,000 patients, the cost is increased by $200,000 per saved life when routine venography is used, and $50,000 per saved life when routine sonography is used. In summary, low-dose warfarin plus routine sonography reduces deaths from 20 to 0.3 per 1,000 patients, a dramatic improvement, but does not cost any more than not using prophylaxis. (Consumer Summary produced by Reliance Medical Information, Inc.)

Economic aspects, Statistics, Medical care, Cost of, Health care costs

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Efficacy of a postoperative regimen of enoxaparin in deep vein thrombosis prophylaxis

Article Abstract:

Venous thromboembolism, a condition in which a clot breaks free and travels through the circulation, later lodging in a vessel and obstructing blood flow, is a common complication of orthopedic surgery. If prevention methods are not used, calf vein venous thrombosis will occur in from 40 to 60 percent of patients who undergo elective hip replacement. No single method of prophylaxis, or prevention, is ideal. Anticoagulant drugs reduce the incidence of thrombosis, but increase the risk of bleeding. In joint surgery, bleeding at the site can cause failure of the joint replacement procedure. Anticoagulant prophylaxis may be delayed until the early postoperative period. Another strategy to reduce the risk of bleeding may be the use of new low-molecular weight heparins that may produce less bleeding. A clinical trial was undertaken in 100 patients undergoing elective hip replacement to compare enoxaparin (a low-molecular-weight heparin) and a placebo. The fifty patients randomly assigned to receive prophylaxis were begun on enoxaparin postoperatively and continued on it for 14 days, while the control group took placebos. Of the entire 100 patients, venous thrombosis occurred in 12 percent of patients receiving enoxaparin and 42 percent of the placebo group. Both treatment groups had equal hemorrhage rates (5 percent). Patients in both groups had noninvasive surveillance for deep venous thrombosis. Venography was performed at some point during hospitalization for the last 76 patients, and this screening method detected venous thrombosis in four enoxaparin patients (10.8 percent) and 20 who took placebo (51.3 percent). These results indicate that enoxaparin prophylaxis is effective and safe for patients undergoing elective hip surgery. (Consumer Summary produced by Reliance Medical Information, Inc.)

Innovations, Heparin

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An outpatient anticoagulation protocol managed by a vascular nurse-clinician

Article Abstract:

Patients who are at risk for thrombosis (blood clot formation) due to conditions such as hyperviscosity of the blood, vascular graft placement, and arterial emboli (clots that circulate in the blood until they attach to the artery wall) may require life-long anticoagulation drug therapy. Hemorrhagic (bleeding) complications of anticoagulation with the drug crystalline warfarin sodium (Coumadin) have prompted physicians to reduce the level of anticoagulation therapy, either by dose reduction or by limiting the length of therapy. A report is presented of 93 patients who were maintained on a Coumadin protocol. These patients had a variety of other medical conditions including hypertension, heart disease, diabetes, regular alcohol consumption and advanced age. The protocol was administered by a nurse clinician and supervised by a physician. Coumadin was prescribed for a total of 1,891 months to 93 patients. During monitoring of prothrombin time (speed of blood clotting), it was found that 82 patients (88 percent) required dose adjustment after the initial medication dose had been established. During treatment, four patients developed thrombosis of a vascular graft. There were six major and 11 minor hemorrhagic complications. No patients died of a cause related to anticoagulation treatment. It is concluded that life-time anticoagulation is a viable treatment option for those patients at chronic risk for thrombosis, and that the risk of bleeding or thrombosis is low. (Consumer Summary produced by Reliance Medical Information, Inc.)

Product/Service Evaluation, Physiological aspects, Dosage and administration, Coumadin (Medication)

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