THE TREATMENT OF THROMBOSIS

The Treatment Of Thrombosis

Abstract

Background: The outpatient treatment of deep vein thrombosis (DVT) with low-molecular-weight heparin (LMWH) has been shown to be cost-effective from the perspective of a third party payer. The aim of this study is to determine if some or all of these cost savings to third party payers are shifted to patients and their families. Methods: A prospective cohort study with micro-costing of patient/family costs was conducted at the thrombosis units of The Ottawa Hospital. Costs were determined by administering a questionnaire at the end of the patients' heparin therapy. Over a period of 4 months, consecutive patients presenting at the thrombosis units were approached at the initiation of their heparin therapy; 44 patients consented to participate and completed questionnaires were obtained for 41. Results: The mean patient/family costs associated with outpatient therapy were significantly less than those associated with inpatient therapy ($219.42 versus $402.93, p=0.003); a savings of $190.91 per patient. Even when lost income to patients/families was ignored, mean patient/family costs remained significantly less for outpatient therapy ($72.00 versus $134.29, p=0.004); a savings of $62.30 per patient. Furthermore, patients preferred outpatient to inpatient therapy by almost 3:1 (30 versus 11, respectively). Interpretation: The outpatient treatment of DVT does not result in any net shifting of costs to patients and their families, and further, brings about cost savings. Given the cost savings associated with and the preference of patients for outpatient care, this study further supports the shift of DVT therapy from the inpatient unit to the outpatient clinic.

Introduction

Deep vein thrombosis (DVT) is a common and potentially fatal disorder that may affect hospital inpatients as well as otherwise healthy people. The incidence of DVT has been estimated to be 48 cases per 100,000 persons . Patients presenting with acute proximal DVT require immediate anticoagulant treatment to prevent pulmonary embolism (PE) and recurrent thrombosis. Low-molecular-weight heparin (LMWH) administration is becoming an increasingly desirable alternative to conventional unfractionated heparin (UFH) therapy. Several meta-analyses of randomised clinical trials have found LMWH to be at least as effective and safe as UFH . The once or twice daily subcutaneous unmonitored administration of LMWH has the advantage of permitting patients with acute DVT to be treated at home, rather than in the hospital.

Indeed, several separate studies have found outpatient-based LMWH therapy to be as safe and effective as inpatient UFH treatment in controlled clinical trials . Additional studies have shown outpatient LMWH therapy to be feasible, safe and effective in the clinical setting . Furthermore, we have found that outpatient LMWH DVT therapy is more cost-effective for the third party payer than inpatient UFH therapy. For those who are eligible for outpatient treatment, LMWH therapy results in savings of $912 (Can) per patient compared to inpatient UFH therapy. Other groups have published similar findings.

The importance of examining possible cost shifting to patients has been stressed by our group and by van den Belt et al. , but has otherwise been largely ignored in the ...