Anderson D R, O'Brien B J
Division of Hematology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
Pharmacoeconomics. 1997 Jul;12(1):17-29. doi: 10.2165/00019053-199712010-00003.
The purpose of this article is to review and critically appraise the cost-effectiveness analyses that have compared various modalities for the prevention and treatment of deep vein thrombosis (DVT) and pulmonary embolism. Studies were identified by MEDLINE search and review of bibliographies of retrieved articles. Original economic analyses for the prevention or treatment of venous thromboembolism published in the English language literature were included in the analysis. In addition to collecting clinical and economic data, the methodological quality of the studies was evaluated using predefined criteria. Separate analyses were performed for studies of the prevention, and of the treatment, of venous thromboembolism following general surgery and following total hip arthroplasty. Fourteen cost-effectiveness analyses involving thromboembolic prophylaxis following total hip arthroplasty and 7 following general surgery met the eligibility criteria for this analysis. Each of the total hip arthroplasty studies containing a 'no intervention arm' determined that effective forms of prophylaxis not only reduced the rates of venous thromboembolic complications, but were less costly than a strategy of not providing venous thromboembolic prophylaxis. Six of 7 studies found low-molecular-weight (LMW) heparin to be more effective, and 4 of 7 found it to be less costly, than either unfractionated heparin or warfarin for the prevention of venous thrombosis following total hip arthroplasty. Following general surgical procedures, 6 of 7 studies found prophylaxis to be both more effective and less costly than no prophylaxis. Two studies also concluded that LMW heparin was more effective and less costly than unfractionated heparin for the prevention of DVT after general surgery. In general, the studies included in this overview were of high methodological quality with 11 of 15 studies fulfilling 4 or more of the 6 criteria for sound cost-effectiveness analyses. Effective venous thromboembolic prophylaxis results in fewer complications and is less costly than no prophylaxis following general surgery and total hip arthroplasty. LMW heparin was reported to be more efficacious and cost effective than unfractionated heparin following general surgery, and unfractionated heparin and warfarin following total hip arthroplasty. However, these findings must be regarded with caution in view of recent clinical trials and a meta-analysis reporting that the efficacy of LMW heparin and unfractionated heparin are similar following general surgery, and the efficacy of LMW heparin and warfarin are similar following total hip arthroplasty. Conclusions about the most cost-effective treatment for DVT await the publication of cost analyses from clinical trials comparing outpatient subcutaneous LMW heparin with inpatient therapy with intravenous unfractionated heparin.
本文旨在回顾并批判性地评估比较预防和治疗深静脉血栓形成（DVT）及肺栓塞的各种方式的成本效益分析。通过MEDLINE检索及对检索文章的参考文献进行回顾来确定研究。纳入分析的是英文文献中发表的关于预防或治疗静脉血栓栓塞的原始经济分析。除收集临床和经济数据外，还使用预定义标准评估研究的方法学质量。分别对普通外科手术后和全髋关节置换术后静脉血栓栓塞的预防和治疗研究进行分析。14项关于全髋关节置换术后血栓栓塞预防的成本效益分析和7项关于普通外科手术后血栓栓塞预防的成本效益分析符合本分析的纳入标准。每项包含“无干预组”的全髋关节置换术研究均确定，有效的预防形式不仅降低了静脉血栓栓塞并发症的发生率，而且比不进行静脉血栓栓塞预防的策略成本更低。7项研究中有6项发现低分子量（LMW）肝素在预防全髋关节置换术后静脉血栓形成方面比普通肝素或华法林更有效，7项研究中有4项发现其成本更低。在普通外科手术后，7项研究中有6项发现预防措施比不预防更有效且成本更低。两项研究还得出结论，在预防普通外科手术后的DVT方面，LMW肝素比普通肝素更有效且成本更低。总体而言，本综述纳入的研究方法学质量较高，15项研究中有11项满足6项合理成本效益分析标准中的4项或更多项。有效的静脉血栓栓塞预防措施可减少并发症，且比普通外科手术和全髋关节置换术后不进行预防的成本更低。据报道，在普通外科手术后，LMW肝素比普通肝素更有效且更具成本效益；在全髋关节置换术后，LMW肝素比普通肝素和华法林更有效且更具成本效益。然而，鉴于最近的临床试验和一项荟萃分析报告称，普通外科手术后LMW肝素和普通肝素的疗效相似，全髋关节置换术后LMW肝素和华法林的疗效相似，因此必须谨慎看待这些发现。关于DVT最具成本效益的治疗方法的结论有待比较门诊皮下注射LMW肝素与住院静脉注射普通肝素治疗的临床试验成本分析的发表。
