Devlin J W, Petitta A, Shepard A D, Obeid F N
Department of Pharmacy Services, Detroit Receiving Hospital and University Health Center, Michigan 48201-4162, USA.
Pharmacotherapy. 1998 Nov-Dec;18(6):1335-42.
We attempted to determine health and economic outcomes from the perspective of an integrated health system of administering enoxaparin 30 mg twice/day versus heparin 5000 U twice/day for prophylaxis against venous thrombosis after major trauma. A decision-analytic model was developed from best literature evidence, institutional data, and expert opinion. We assumed that 40% of proximal deep vein thromboses (DVTs) and 5% of distal DVTs are diagnosed and confirmed with initial or repeat duplex scanning; 50% of undiagnosed proximal DVTs result in pulmonary embolism; 2% and 1% of undiagnosed proximal DVTs will lead to readmission for DVT and pulmonary embolism, respectively, and pulmonary embolism-related mortality rates range from 8-30%. Length of hospital stay data and 1996 institutional drug use and acquisition cost data were used to estimate the cost of enoxaparin and heparin therapy. Diagnosis and treatment costs for DVT and pulmonary embolism were derived from institutional charge data using cost:charge ratios. A second analysis of patients with lower extremity fractures was completed. One-way and multiway sensitivity analyses were performed. For 1000 mixed trauma patients receiving enoxaparin versus heparin, our model showed that 62.2 (95% CI -113 to -12) DVTs or pulmonary emboli would be avoided, resulting in 67.6 (8 to 130) life-years saved at a net cost increase of $104,764 (-$329,300 to $159,600). Enoxaparin versus heparin resulted in a cost of $1684 (-$3600 to $9800) for each DVT or pulmonary embolus avoided and a discounted cost/life-year saved of $2303 (-$8100 to $19,000). For 1000 patients with lower extremity fractures, enoxaparin versus heparin resulted in a cost of $751 (-$4200 to $3300) for each DVT or pulmonary embolus avoided and a discounted cost/life-year saved of $1017 (-$10,200 to $6300). Although enoxaparin increases overall health care costs, it is associated with a cost/additional life-year saved of only $2300, which is generally lower than the commonly used hurdle rate of $30,000/life-year saved. The cost-effectiveness ratio is more favorable in patients with lower extremity fractures than in the general mixed trauma population.
我们试图从综合卫生系统的角度确定，对于预防重大创伤后静脉血栓形成，每日两次给予30毫克依诺肝素与每日两次给予5000单位肝素相比，其健康和经济结果。基于最佳文献证据、机构数据和专家意见建立了一个决策分析模型。我们假设40%的近端深静脉血栓形成（DVT）和5%的远端DVT通过初次或重复双功扫描被诊断和确认；50%未被诊断的近端DVT会导致肺栓塞；未被诊断的近端DVT分别有2%和1%会导致因DVT和肺栓塞再次入院，且肺栓塞相关死亡率在8%至30%之间。利用住院时间数据以及1996年机构药物使用和购置成本数据来估算依诺肝素和肝素治疗的成本。DVT和肺栓塞的诊断和治疗成本来自机构收费数据，采用成本与收费比率。对下肢骨折患者进行了第二次分析。进行了单向和多向敏感性分析。对于1000名接受依诺肝素与肝素治疗的混合创伤患者，我们的模型显示，可避免62.2例（95%置信区间为-113至-12）DVT或肺栓塞，净成本增加104,764美元（-329,300美元至159,600美元）的情况下可挽救67.6个生命年（8至130个生命年）。依诺肝素与肝素相比，每避免一例DVT或肺栓塞的成本为1684美元（-3600美元至9800美元），每挽救一个生命年的贴现成本为2303美元（-8100美元至19,000美元）。对于1000名下肢骨折患者，依诺肝素与肝素相比，每避免一例DVT或肺栓塞的成本为751美元（-4200美元至3300美元），每挽救一个生命年的贴现成本为1017美元（-10,200美元至6300美元）。虽然依诺肝素增加了总体医疗保健成本，但它每挽救一个额外生命年的成本仅为2300美元，通常低于常用的30,000美元/生命年的门槛率。成本效益比在下肢骨折患者中比在一般混合创伤人群中更有利。
