Thromboprophylaxis of Patients Submitted to Total Hip and Knee Arthroplasty: A Cost-Effectiveness Assessment From the Perspective of the Brazilian National Health System

• Published in: Value in health regional issues Vol. 31; pp. 111 - 118
• Main Authors: de Brito, Artur F.S., Brito, Nayara C., Tanaka, Sandra K.T., Ferreira, Vinícius L., Ferreira Júnior, Antônio B.S., Riveros, Bruno S., Nita, Marcelo E.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.09.2022
• Subjects: apixaban; cost-effectiveness; dabigatran; enoxaparin; rivaroxaban; total hip arthroplasty; total knee arthroplasty; venous thromboembolism; cost-effectiveness; total hip arthroplasty; total knee arthroplasty; venous thromboembolism; dabigatran; enoxaparin; rivaroxaban; apixaban
• ISSN: 2212-1099; 2212-1102
• DOI: 10.1016/j.vhri.2022.04.002

Venous thromboembolism (VTE) is a serious national and international public health issue. Major orthopedic surgeries, such as a total hip (THA) and knee (TKA) arthroplasties, are associated with an increased risk of VTE, long-term complications, functional disability, and death resulting from hypercoagulability by surgical trauma. This pharmacoeconomic analysis aimed to identify the most cost-effective anticoagulant alternative in preventing VTE in patients undergoing THA and TKA. A decision tree model was developed, comparing direct oral anticoagulants (rivaroxaban, apixaban, and dabigatran) with enoxaparin, with separate THA and TKA models a 3-month time horizon from the perspective of the Brazilian National Health System. The results were presented as incremental cost-effectiveness ratio (ICER), and the outcomes analyzed were avoided complications (ACs) after thromboprophylaxis. Comparative effectiveness was obtained from a published meta-analysis. A willingness to pay value of approximately R$ 15 000.00 was used per AC, and a probabilistic sensitivity analysis with the Monte Carlo simulation was conducted. Apixaban was the anticoagulant that presented the best ICER for patients undergoing THA (R$ 207.52/AC) and TKA (R$ 133.59/AC), followed by rivaroxaban (R$ 347.21/AC), dabigatran (R$ 372.56/AC), and enoxaparin (R$ 711.44/AC) for THA and by dabigatran (R$ 194.07/AC), rivaroxaban (R$ 221.12/AC), and enoxaparin (R$ 747.25/AC) for TKA. After ICER analysis, apixaban prevails over the other technologies analyzed for both surgical procedures, confirmed after sensitivity analysis. Our model suggests that, in the Brazilian National Health System, apixaban is the most cost-effective alternative in preventing VTE after THA and TKA. •It is known that there is a high risk of venous thromboembolism in patients undergoing major orthopedic surgeries, such as total hip arthroplasty and total knee arthroplasty, and thromboprophylaxis is essential. In view of this, we have a current scenario where the Ministry of Health of Brazil does not have a published guideline for the management of these patients, hence the need to determine the available technologies with the best incremental cost-effectiveness ratio for that indication.•There is widespread use of enoxaparin for prophylaxis of patients at high risk of venous thromboembolism, but other drugs that are easier to manage and adhere to treatment already exist on the market, such as oral anticoagulants (eg, apixaban, dabigatran, and rivaroxaban). This makes it necessary to conduct studies to evaluate health technologies, for the decision making of which technology has a better cost-effectiveness profile to be made available to the population by the Brazilian National Health System.•To the best of our knowledge, this article is the first economic study, from the Brazilian National Health System perspective, that compares the use of oral anticoagulants with enoxaparin in thromboprophylaxis in patients undergoing total hip arthroplasty and total knee arthroplasty. It brings in its results apixaban as the best incremental cost-effectiveness ratio of the model, providing useful information for the need to develop a guideline, following the example of international countries, which already have a well-defined protocol for these patients.