SESSION TYPE: DVT/PE/Pulmonary Hypertension Posters I
PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM
PURPOSE: Deep vein thrombosis (DVT) remains associated with substantial morbidity. Post-thrombotic syndrome (PTS) often complicates acute DVT and may lead to major symptoms that limit quality of life (QoL). Catheter-directed thrombolysis (CDT) has recently been shown to reduce the risk for PTS. However, PTS is invasive, costly, and may result in major bleeding. Therefore, we performed a decision analysis in order to determine if CDT is cost-effective.
METHODS: We created a decision model in which patients with acute DVT were managed with or without CDT. The model examined outcomes in 1,000 hypothetical subjects and all were treated with similar anticoagulation strategies with the exception of CDT. The costs of saving one added quality-adjusted life-year (QALY) in our reference case represented the primary endpoint. Model inputs were derived from the literature and all costs were converted to 2010 US dollars. We assumed a societal perspective. We conducted univariate and multivariate sensitivity analyses to assess the robustness of our assumptions. We relied on Monte-Carlo simulation to generate 95% confidence intervals (CIs) around our point estimate of the cost-effectiveness ratio (CER).
RESULTS: In the base case scenario the CER equaled $104,394/QALY. Nearly three-quarters of all the costs in the CDT arm were due to the direct costs of CDT. CDT generated nearly 52 added QALYs compared to standard care. The marginal cost to prevent one case of PTS measured $57,309. The model was most sensitive to the estimated risk reduction (RR) for PTS with CDT. Ranging the RR for PTS with CDT around the 95% CIs for this variable yielded CERs varying from approximately $52,000/QALY to $1.7m/QALY saved. The model was mildly sensitive to the impact of PTS on QoL and the costs of CDT. In the worst case scenario with all variables simultaneously skewed against CDT, the cost for QALY came to more than $7.7m/QALY saved. The 95% CIs around the base case CER varied from $144,202 to $89,165. Few simulations fell below the $100,000/QALY threshold.
CONCLUSIONS: Although CDT may significantly reduce the risk for PTS following acute DVT, this approach is not cost-effective. The limited impact of CDT and uncertainty surrounding its efficacy elucidate why this approach proves cost-ineffective.
CLINICAL IMPLICATIONS: CDT should not be considered a routine adjunct to care for acute DVT.
DISCLOSURE: The following authors have nothing to disclose: C. Chan, M. Zilberberg, G. Lamare, A. Shorr
No Product/Research Disclosure InformationWashington Hospital Center, Washington, DC