Cost-Effectiveness of Dalteparin versus Heparin for VTE

The results of a prospective economic evaluation study conducted concurrently with the PROTECT [Prophylaxis for Thromboembolism in Critical Care Randomized Trial] study found that the use of the low-molecular-weight heparin (LMWH) dalteparin was more effective and had similar or lower costs than unfractionated heparin (UFH) for the prevention of venous thromboembolism (VTE) among critically ill patients [JAMA. 2014; DOI:10.1001/jama.2014.15101].
__________________________________________________________________________________________________________________________
Related Content:
Dabigatran to Treat Patients with Acute Venous Thromboembolism
Bleeding Events in Patients with VTE in a Real-World Setting
__________________________________________________________________________________________________________________________

“These findings were driven by lower rates of pulmonary embolus and heparin-induced thrombocytopenia and corresponding lower overall use of resources with dalteparin,” said the study’s lead author, Robert A. Fowler, MD, MDCM, MSc, senior scientist, Sunnybrook Health Sciences Centre, University of Toronto, Canada.

Conducted by investigators from the Canadian Critical Care Trials Group and Australia and New Zealand Intensive Care Society Trials Group, the study was a prespecified part of the economic evaluation of the PROTECT study to assess the comparative cost-effectiveness of LMWH versus UFH for VTE prophylaxis in critically ill patients enrolled in the PROTECT trial.
PROTECT, a multicenter, randomized trial, found no difference in leg deep-vein thrombosis among critically ill medical-surgical patients treated with prophylaxis UFH or dalteparin but did find that patients treated with dalteparin had a reduced rate of pulmonary embolus and heparin-induced thrombocytopenia.

Most of the patients (76%) enrolled in PROTECT were admitted to the intensive care unit (ICU) for a medical critical illness and 90% required mechanical ventilation. The mean age of patients was 61 years, and 57% were male.

Among the 3746 patients enrolled in PROTECT, patient costs for the current study were collected for 2344 patients (1169 received dalteparin and 1175 received UFH) enrolled in a subset of 23 hospitals in 5 participating countries.

Using this subset of patients, the researchers measured costs, effects, incremental cost-effectiveness of dalteparin versus UFH during the hospitalization period, and sensitivity analyses across cost ranges.

The study found no difference in hospital costs per patient between the dalteparin and UFH treatment groups. Hospital costs per patient were $39,508 (interquartile [IQR], $24,676-$71,431) and $40,805 (IQR, $24,393-$76,139) for patients treated with dalteparin and UFH, respectively.

Using a sensitivity analysis, the researchers found that dalteparin was most effective and the least costly 78% of the time. This was true especially for length of stay in the ICU and hospital, with indirect costs and attendant personnel being the most influential factors on cost.

A sensitivity analysis also showed that using dalteparin remained the least costly unless the cost of acquiring the drug increased by more than 20-fold.

To put these findings into perspective and show that the use of dalteparin appeared to be less expensive and more effective for most patients in the ICU, Dr. Fowler provided an example. “If an ICU with 1000 medical-surgical admissions per year uses UFH instead of dalteparin for VTE prevention, the annual incremental cost may be between [$1 million and $1.5 million] with similar or worse clinical outcomes, despite the individual drug cost of UFH being $4 to $5 less per day,” he said. However, Dr. Fowler emphasized that these findings cannot be generalized to all LMWHs with any certainty.

Among the limitations of the study is that the results are dependent on the cost estimates used at the time of the trial, with the potential for costs to change substantially over time. Another limitation is that the analysis is based on measures of efficacy from a clinical trial rather than real-world conditions.

The prospective design of the study and collection of prespecified costs in study centers concurrent with PROTECT was listed by the investigators as a strength of the study.—Mary Beth Nierengarten