Economic Impact of Venous Thromboembolism After Hip and Knee Arthroplasty

Potential Impact of Rivaroxaban

Richard J Friedman; Nishan Sengupta; Michael Lees

Expert Rev Pharmacoeconomics Outcomes Res. 2011;11(3):299-306.

Abstract and Introduction

Abstract

The number of total hip and knee arthroplasties is increasing, with a consequent rise in the number of patients at risk of venous thromboembolism. Each such event is associated with the risk of morbidity and mortality, plus substantial healthcare costs. Consequently, the American College of Chest Physicians guidelines recommend low-molecular-weight heparins, fondaparinux or vitamin K antagonists (usually warfarin) after total hip and knee arthroplasty. However, such agents are also associated with healthcare costs for administration and monitoring. New oral anticoagulants in development may reduce post-arthroplasty symptomatic thromboembolic events and produce potential savings for the healthcare system. This brief article outlines such potential savings with rivaroxaban based on the results of the REgulation of Coagulation in ORthopaedic surgery to prevent Deep vein thrombosis and pulmonary embolism (RECORD) program.

Introduction

In 2005, approximately 285,000 total hip arthroplasties (THAs) and 523,000 total knee arthroplasties (TKAs) were performed in the USA.^[1] As the US population ages, these figures will rise, and by 2030 the demand for THA is estimated to grow to 572,000 and for TKA to 3,481,000.^[2] One of the complications after THA and TKA is venous thromboembolism (VTE), which comprises deep-vein thrombosis (DVT) and pulmonary embolism (PE). Patients undergoing THA are at a high risk of asymptomatic DVT (incidence 40–60%) and symptomatic VTE (incidence 2–5%)^[3] in the absence of prophylaxis, and the risk is even higher after TKA.^[3] DVT can result in morbidity and mortality and, if thromboprophylaxis is not used, fatal PE occurs in approximately one patient per 300 undergoing THA.^[3] Nonfatal PE can also have considerable consequences and may result in chronic pulmonary hypertension.^[4,5] VTE treatment is also associated with significant cost implications for the US healthcare system.^[6] Current guidelines recommend the routine use of established anticoagulants for the prevention of VTE after THA and TKA:^[3] either low-molecular-weight heparins (LMWHs), fondaparinux or adjusted-dose vitamin K antagonists (usually warfarin).

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Cite this: Economic Impact of Venous Thromboembolism After Hip and Knee Arthroplasty - Medscape - Jun 01, 2011.

Table 1. Selected costs related to venous thromboembolism and pulmonary embolism.
Event	Cost (US$)
Bleeding (prophylaxis related)
Major bleeding (fatal or nonfatal)	3828
Costs related to venous thromboembolism
Treating deep-vein thrombosis during hospitalization	11,676
Treating pulmonary embolism during hospitalization	16,538
Treating deep-vein thrombosis post-discharge	8180
Treating pulmonary embolism post-discharge	16,538
Treatment of recurrent venous thromboembolism	13,980

All costs in the model are corrected to 2007 US$. Costs are per event. Data from [23,59].

Table 2. Cost savings based on the 1year economic model^†.
Study	Oral rivaroxaban (10 mg once daily)	Subcutaneous enoxaparin (40 mg once daily)	Incremental
RECORD1	For 31–39 days	For 31–39 days
Cost (US$)	894.86	977.14	-82.29
Symptomatic venous thromboembolic events^‡	4.9	10.7
Symptomatic venous thromboembolic events avoided^‡			5.8
RECORD3	For 10–14 days	For 10–14 days
Cost (US$)	482.46	767.02	-284.57
Symptomatic venous thromboembolic events^‡	11.8	30.0
Symptomatic venous thromboembolic events avoided^‡			18.2
	Oral rivaroxaban (10 mg once daily)	Subcutaneous enoxaparin (30 mg twice daily)
RECORD4	For 10–14 days	For 10–14 days
Cost (US$)	501.50	792.93	-291.43
Symptomatic venous thromboembolic events^‡	11.0	12.6
Symptomatic venous thromboembolic events avoided^‡			1.6

^†It is conservatively assumed that there are no administrative or nursing monitoring costs relevant to the subcutaneous administration of enoxaparin.
^‡Events per 1000 patients undergoing total hip or knee arthroplasty. RECORD: REgulation of Coagulation in ORthopaedic surgery to prevent Deep vein thrombosis and pulmonary embolism.

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