Cost-effectiveness of primary and secondary prevention of fatal pulmonary embolism in high-risk surgical patients.

Because death due to pulmonary embolism is relatively rare following general surgery, many question the need for prophylaxis. In addition, there has been reluctance to apply new interventions whose cost-effectiveness has not been adequately evaluated. A cost-effectiveness analysis based on over 1000 high-risk patients undergoing abdominothoracic surgery, with effectiveness measured in terms of numbers of deaths from pulmonary embolism averted, has shown subcutaneous administration of heparin in low doses starting 2 hours before the operation to be the most cost-effective of several active approaches to prophylaxis. It averted seven of the eight deaths expected without active prophylaxis per 1000 such patients and cost half as much as the traditional approach of intervening only when venous thromboembolism becomes clinically apparent. Intravenous administration of dextran, although effective, was expensive, and leg scanning with iodine-125-labelled fibrinogen was extremely expensive. Intermittent pneumatic compression of the legs was inexpensive, but, as with leg scanning, its effectiveness has not been determined in randomized trials.