Table 44LMWH versus UFH – Economic summary of findings

StudyIncremental cost per patient (£)Incremental effects (QALYs) per patientICER (£/QALY)Uncertainty
Aujesky 200511Saves 138 (a)0.184 (b)LMWH dominantScenario analysis where different proportions of patients receiving LMWH were discharged early or treated as outpatients. LMWH was cost saving when at least 8% of patients were discharged early or if at least 5% of patients were treated entirely as outpatients.

One-way SA: ICER was always <£2,000/QALY when the following variables were varied: daily cost of LMWH, cost of supplies of UFH, cost of non cerebral MB, annual cost of care after stroke, risk of MB with UFH and LMWH, risk of recurrent PE with LMWH and UFH, early mortality risk with LMWH and UFH, early DVT risk with LMWH and UFH, annual late risk of recurrent PE and DVT, frequency of haemorrhagic stroke.

PSA: the median ICER of 1,000 iterations was £751/QALY. At a willingness to pay of $50,000/QALY (about £30,000), LMWH was cost-effective in 99% of the iterations.
Caro 200231Saves 406 (c)0.53 (d)LMWH dominantScenario analysis: if LMWH as outpatient treatment or inpatient treatment with early discharge would be even more cost-saving.

One-way SA: results were not sensitive to these parameters: cost of LMWH (when increased by $20), DVT management costs, event rates with LMWH, discount rate.
Gomez-outes 200682Saves 658 (e)1.72 (f)LMWH dominantLMWH was still dominant if the initial treatment was followed by long-term bemiparin 3500 IU.
One-way SA: LMWH was always cost-saving.
Gould 19998699 (g)0.02 (h)4,950Scenario analysis: assuming 30% of patients in LMWH are treated as outpatients and 25% are discharged early after 3 days, LMWH is dominant.

Threshold analysis: LMWH is dominant if at least 8% patients are treated as outpatients or at least 13% are discharged after 3 days.

One-way SA: results were sensitive to the assumption that late complications are equal in the two interventions: when late complications are assumed to occur 25% less frequently with UFH, LMWH is not cost- effective. Results were not sensitive to other variables: risk reduction for early complications, death, PE, recurrent DVT, major and minor bleeding, thrombocytopenia, pharmacy costs, cost of complications, utilities for late complications, discount rate.

Three-way SA: when pharmacy cost of LMWH, treatment cost of early complications, and effectiveness of LMWH in preventing early complications are varied, LMWH is still cost-effective.
Valette 1995247Saves 52 (i)NA (j)NAAdjusted model: when it was assumed that bleeding events taking place after the end of the therapy are not treatment-related and deaths from causes other than PE or haemorrhage are excluded from the analysis, LMWH saves £64 compared to UFH.

LMWH is still cost-saving when the following assumptions were changed: efficacy in prevention of further VTE, frequency of bleeding complications, frequency of APTT tests with UFH, use of clotting factors concentrates instead of fresh frozen plasma.
a

Cost of drugs, supplies, PE treatment, clinical visits, complications (HIT, minor bleeding, noncerebral major bleeding, acute haemorrhagic stroke, long-term care of stroke, DVT). 2002 USD converted into GBP using the purchasing power parities.

b

Calculated using days lost because of hospitalisation or disease as proxies of utilities and age-adjusted mean utility values for patients without complications. No difference in utilities between patients treated at home or in hospital.

c

Cost of initial treatment (including inpatient and outpatient care), major and minor bleeding, recurrent DVT, PE, thrombocytopenia, minor and severe postphlebitic syndrome, recurrent VTE. 1999 USD converted into GBP using the purchasing power parities.

d

Long term utilities calculated using age-related utilities for general population and utility adjustments for mild and severe postphlebitic syndrome.

e

Cost of hospital stay, physician, pharmacy costs and costs derived from diagnostic and treatment of complications (minor and major bleeding, thrombocytopenia). 2002 Euro converted into GBP using the purchasing power parities.

f

Calculated using only age-and gender-adjusted mean utility values for general population; no utilities were attached to events.

g

Cost of hospital care, physician services, 6 days of treatment, supplies and ancillary resources (needles and daily phlebotomy) for LMWH, complications (1 hospital day+1physician visit for minor bleeding or for thrombocytopenia, 2.5 hospital days+2.5 physician visit for major bleeding; average Medicare reimbursements for others). 1997 USD converted into GBP using the purchasing power parities.

h

Calculated using age-and gender-adjusted time trade-off utilities for general population in case of no complications. Utilities for postphlebitic syndrome from standard gamble of healthy individuals. Days of hospitalisation were used as a proxy of disutilities for early complications and recurrent DVT and PE.

i

Cost of initial treatment, repeated treatment in case or recurrence, minor and major bleeding.

j

Outcomes reported in the trial were recurrence of DVT, PE events, minor bleeding short term and long term, major bleeding short term and long term, death. They were all in favour of LMWH except for minor bleeding short-term and major bleeding long term.

Cost of drugs, supplies, PE treatment, clinical visits, complications (HIT, minor bleeding, noncerebral major bleeding, acute haemorrhagic stroke, long-term care of stroke, DVT). 2002 USD converted into GBP using the purchasing power parities.

Calculated using days lost because of hospitalisation or disease as proxies of utilities and age-adjusted mean utility values for patients without complications. No difference in utilities between patients treated at home or in hospital.

Cost of initial treatment (including inpatient and outpatient care), major and minor bleeding, recurrent DVT, PE, thrombocytopenia, minor and severe postphlebitic syndrome, recurrent VTE. 1999 USD converted into GBP using the purchasing power parities.

Long term utilities calculated using age-related utilities for general population and utility adjustments for mild and severe postphlebitic syndrome.

Cost of hospital stay, physician, pharmacy costs and costs derived from diagnostic and treatment of complications (minor and major bleeding, thrombocytopenia). 2002 Euro converted into GBP using the purchasing power parities.

Calculated using only age-and gender-adjusted mean utility values for general population; no utilities were attached to events.

Cost of hospital care, physician services, 6 days of treatment, supplies and ancillary resources (needles and daily phlebotomy) for LMWH, complications (1 hospital day+1physician visit for minor bleeding or for thrombocytopenia, 2.5 hospital days+2.5 physician visit for major bleeding; average Medicare reimbursements for others). 1997 USD converted into GBP using the purchasing power parities.

Calculated using age-and gender-adjusted time trade-off utilities for general population in case of no complications. Utilities for postphlebitic syndrome from standard gamble of healthy individuals. Days of hospitalisation were used as a proxy of disutilities for early complications and recurrent DVT and PE.

Cost of initial treatment, repeated treatment in case or recurrence, minor and major bleeding.

Outcomes reported in the trial were recurrence of DVT, PE events, minor bleeding short term and long term, major bleeding short term and long term, death. They were all in favour of LMWH except for minor bleeding short-term and major bleeding long term.

From: 7, Pharmacological interventions

Cover of Venous Thromboembolic Diseases
Venous Thromboembolic Diseases: The Management of Venous Thromboembolic Diseases and the Role of Thrombophilia Testing [Internet].
NICE Clinical Guidelines, No. 144.
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