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David Wonderling Senior Health Economist National Collaborating Centre for Acute Care

The cost-effectiveness of thromboprophylaxis. David Wonderling Senior Health Economist National Collaborating Centre for Acute Care Royal College of Surgeons of England. Content. Role of cost-effectiveness analysis Determinants of the cost-effectiveness of VTE prophylaxis

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David Wonderling Senior Health Economist National Collaborating Centre for Acute Care

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  1. The cost-effectiveness of thromboprophylaxis David Wonderling Senior Health Economist National Collaborating Centre for Acute Care Royal College of Surgeons of England

  2. Content • Role of cost-effectiveness analysis • Determinants of the cost-effectiveness of VTE prophylaxis • Some evidence: The cost-effectiveness of VTE prophylaxis in surgical patients • Discussion: remaining uncertainties

  3. Why consider cost-effectiveness? • NOT about saving the government money • cost-effectiveness =value for money =getting the most health gain from the resources available • If the NHS spends more on one thing, it has to do less of something else • The ‘opportunity cost’ is the value of the best alternative use of resources • Could we do more good by spending money in other ways?

  4. Quality-adjusted life-year (QALY) Health-related Quality of life Perfect health 1.0 Intervention A Intervention B 0.5 0 Death Years 1 2 QALYs= area under the curve

  5. Incremental cost effectivenessratio (ICER) = Expected cost with A Expected cost with B - Expected QALY with A Expected QALYwith B - How to measure cost-effectiveness • NICE’s cost-effectiveness criterion: • incremental cost-effectiveness is less than £20,000 per QALY gained • ½ QALY for every £10,000 spent 4.No prophylaxis 3.Mechanical 2.LMWH 1.Mechanical+LMWH ICER 1 ICER 2 ICER 3

  6. What health effects? • QALYs: Mortality and quality of life • Determined by • Symptomatic DVTs • Symptomatic PEs (fatal and non-fatal) • Major bleeding (fatal and non-fatal) • Post-thrombotic syndrome (PTS)

  7. What costs? • Costs • Drugs, stockings, other consumables • Prophylaxis administration: e.g. nurse time • Treatment of adverse events (major bleeds) • Cost savings • Treatment of symptomatic VTEs • Treatment of PTS

  8. Calculating cost-effectiveness.For each prophylaxis strategy • The incidence of each event • Baseline risk x Relative Risk • Health outcome • Incidence x QALYs lost • Cost outcome • Incidence x treatment cost • Sum up health and cost outcomes • Calculate incremental cost-effectiveness ratios & compare with threshold • Repeat for different populations with different baseline risks

  9. Cost-effectiveness and risk • Effectiveness & cost-effectiveness of prophylaxis is determined by baseline risk of VTE • Lowest risk • health benefits are outweighed by health harms • Higher risk • Net health benefits are outweighed by opportunity costs • Highest risk • opportunity costs are outweighed by health benefits

  10. Cost-effectiveness of surgical VTE prophylaxis: the NICE guideline • Based on the guideline systematic review • Directed by the Guideline Development Group • Public consultation • Key assumptions for base case analysis: • Observed reductions in DVTs lead to commensurate reductions in fatal & non-fatal PEs • Observed increases in Major bleeds lead to commensurate increases in fatal bleeds • Post-thrombotic syndrome is not averted by prophylaxis

  11. Results of base case analysisby baseline risk level Risk of symptomatic VTE with no prophylaxis THR Mechanical -only Prophylaxis MAS Combination Prophylaxis Risk of major bleeding with no prophylaxis

  12. Sensitivity analysis: prophylaxis is only 50% as effective for fatal events Risk of symptomatic VTE with no prophylaxis THR MAS Risk of major bleeding with no prophylaxis

  13. Sensitivity analysis: PTS is averted Risk of symptomatic VTE with no prophylaxis THR MAS Risk of major bleeding with no prophylaxis

  14. Discussion • A single type of prophylaxis is cost-effective in surgery patients • (And cost-saving in many subgroups) • Mechanical prophylaxis is preferred over LMWH unless: • baseline risk of major bleeding is negligible • long-term outcomes are assumed (PTS is averted) • there are differential effects on fatal pulmonary embolism

  15. Discussion 2 • Whether combination prophylaxis is cost-effective is highly sensitive to: • the extent that fatal events are averted • the extent that long-term events are averted • baseline risk of VTE • baseline risk of major bleeding • Extended duration LMWH prophylaxis is only cost-effective if • long-term effects (PTS) are assumed • Incidence of fatal PE is high

  16. NICE Guideline on venous thromboembolism(surgical) National Collaborating Centre for Acute Care. Venous thromboembolism. Clinical guideline no 46. National Institute of Clinical Excellence, London 2007. http://guidance.nice.org.uk/CG46 Guideline Development Group Tom Treasure (Chair), Nigel Acheson, Ricky Autar, Colin Baigent, Kim Carter, Simon Carter, David Farrell, David Goldhill, John Luckit, Robin Offord, Adam Thomas. NCC-AC staff: Enrico de Nigris, Jennifer Hill, Philippa Davies, Carlos Sharpin, Saoussen Ftouh, Peter Katz, Arash Rashidian. Funding National Institute for Health and Clinical Excellence, London, England

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