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

Value Health Reg Issues. 2022 Sep:31:111-118. doi: 10.1016/j.vhri.2022.04.002. Epub 2022 May 28.

Abstract

Objectives: 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.

Methods: 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.

Results: 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.

Conclusion: Our model suggests that, in the Brazilian National Health System, apixaban is the most cost-effective alternative in preventing VTE after THA and TKA.

Keywords: apixaban; cost-effectiveness; dabigatran; enoxaparin; rivaroxaban; total hip arthroplasty; total knee arthroplasty; venous thromboembolism.

Publication types

  • Meta-Analysis

MeSH terms

  • Anticoagulants / therapeutic use
  • Arthroplasty, Replacement, Hip* / adverse effects
  • Arthroplasty, Replacement, Knee* / adverse effects
  • Arthroplasty, Replacement, Knee* / methods
  • Brazil
  • Cost-Benefit Analysis
  • Dabigatran / therapeutic use
  • Enoxaparin / adverse effects
  • Humans
  • Rivaroxaban / therapeutic use
  • Venous Thromboembolism* / etiology
  • Venous Thromboembolism* / prevention & control

Substances

  • Anticoagulants
  • Enoxaparin
  • Rivaroxaban
  • Dabigatran