Intermittent pneumatic compression is a cost-effective method of orthopedic postsurgical venous thromboembolism prophylaxis

Figures & data

Figure 1 Depiction of the two Markov models for (A) VTE and (B) VTE prophylaxis.

Abbreviations: DVT, deep-vein thrombosis; GI, gastrointestinal; HIT, heparin-induced thrombocytopenia; ICH, intracranial hemorrhage; PE, pulmonary embolism; PTS, postthrombotic syndrome; VTE, venous thromboembolism.

Table 1 Incidence of adverse events during VTE prophylaxis

Events	Incidence USA (per days)	Incidence Australia (per days)	RR with IPC (95% CI)	RR with IPC+LMWH (95% CI)
DVT	0.55% (3)^Citation23	4.48% (11.52)^Citation24	0.86 (0.56–1.31)^Citation22	0.32 (0.16–0.64)^Citation22
PE	0.39% (3)^Citation23	0.25% (11.52)^Citation24	0.99 (0.36–2.76)^Citation22	0.62 (0.13–3.02)^Citation22
VTE recurrence	14.3% (365.25)^Citation25	1.9% (90)^Citation26
Recurrent VTE that is PE	20.5%^Citation25	20%^Citation26
Non-major bleed	9.9% (42)^Citation7	9.9% (12)^Citation17	0.41 (0.26–0.65)^Citation22	1a
Major bleed	0.26% (9)^Citation27	1.9% (90)^Citation28	0.85 (0.74–0.97)^Citation29	1a
Major bleed that is ICH	7.5%^Citation12	4%^Citation30
Wound infection	2.6% (30)^Citation7	5.2% (30)^Citation11	1a	1a
Wound infections that are deep	34.62%^Citation7	30.77%^Citation11
Heparin-induced thrombocytopenia	0.04% (4)^Citation31	0.2% (6.55)^Citation28	0b	1a
PTS	22.8% (730.5)^Citation32	22.8% (730.5)^Citation32
Severe PTS	10%^Citation33	10%^Citation33
Mortality	From US lifetables	From Australian lifetables	0.92^Citation22	0.61^Citation22

Notes:

a No available data assumed to be equivalent;

b no heparin used. Units of measure are % of patients (per N days) for all those with parenthesis and % of events for all those without parenthesis.

Abbreviations: DVT, deep vein thrombosis; ICH, intracranial hemorrhage; IPC, intermittent pneumatic compression; LMWH, low-molecular-weight heparin; PE, pulmonary embolism; PTS, postthrombotic syndrome; RR, risk ratio; VTE, venous thromboembolism.

Table 2 Cost and quality of life associated with VTE adverse events

Events	Cost in USA (USD)	Cost in Australia (AUD)	Annual quality of life disutility
DVT	18,104^Citation23	3,643a	0.01 (0.001)^Citation12
PE	18,104^Citation23	9,441a	0.03 (0.003)^Citation12
DVT and PE	37,290.67^Citation39	16,456a	0.01 (0.001)^Citation12
Recurrent VTE	27,955.87^Citation40	7,015a	As DVT
Non-major bleed	367.22^Citation41	2325a	0
ICH	36,217.45^Citation20	26,839a	0.6 (0.06)^Citation19
Other major bleed	17,567.39^Citation20	4,719a	0.01 (0.001)^Citation13
Superficial wound infection	7,644.03^Citation40	6,997a	0.05 (0.005)^Citation42
Deep wound infection	28,075.43^Citation40	37,648a	0.04 (0.004)^Citation42
Heparin-induced thrombocytopenia	18,177.43^Citation31	1,690^Citation28	0.02 (0.002)^43,c
Severe PTS, per year	6,040.93^Citation44	9,315b	0.09 (0.01)^Citation14
Mild PTS, per year	1,327.83^Citation44	4,104b	0.09 (0.01)^Citation14

Notes:

a https://www.ihpa.gov.au/sites/g/files/net636/f/publications/final_nep16_determination.pdf;⁵²

b data provided Australia AR-DRG, http://www.aihw.gov.au/hospitals-data/ar-drg-data-cubes/;⁵³

c reference indicates that HIT is associated with an extra 12.5 days in hospital. 1 day of full QoL is 1/365.25 (0.0027378) and assume 50% reduction in QoL (0.001369), multiplied by 12.5 =0.017.

Abbreviations: AR-DRG, Australian refined diagnosis-related group; DVT, deep vein thrombosis; HIT, heparin-induced thrombocytopenia; ICH, intracranial hemorrhage; PE, pulmonary embolism; PTS, postthrombotic syndrome; QoL, quality of life; RR, risk ratio; VTE, venous thromboembolism.

Table 3 Clinical and economic outcomes estimated by the models

Outcomes	LMWH		IPC		IPC+LMWH
	USA	Australia	USA	Australia	USA	Australia
Cost (USD / AUD)	2,083	1,605	1,657	1,228	1,950	1,481
VTE (N per 2,000)	151	160	140	142	136	127
Major bleeds (N per 2,000)	6	46	5	39	6	46
Life years (mean)	16.84	14.35	16.90	14.47	16.91	14.51
QALYs (mean)	11.28	9.07	11.32	9.14	11.33	9.15
ICER vs LMWH
Cost per QALY gained	–	–	Dominant	Dominant	Dominant	Dominant
Cost per VTE avoided	–	–	Dominant	Dominant	Dominant	Dominant
ICER vs IPC
Cost per QALY gained	Dominated	Dominated	–	–	42,323	15,608
Cost per VTE avoided	Dominated	Dominated	–	–	144,675	32,908

Abbreviations: ICER, incremental cost-effectiveness ratio; IPC, intermittent pneumatic compression; LMWH, low-molecular-weight heparin; QALY, quality-adjusted life year; VTE, venous thromboembolism.

Table 4 Results from the scenario analyses

Scenario comparison	Cost per QALY gained in the US			Cost per QALY gained in Australia
	IPC vs LMWH	IPC+LMWH vs LMWH	IPC+LMWH vs IPC	IPC vs LMWH	IPC+LMWH vs LMWH	IPC+LMWH vs IPC
Time horizon
10	Dominant	Dominant	117,760	Dominant	Dominant	38,542
20	Dominant	Dominant	52,157	Dominant	Dominant	17,556
30	Dominant	Dominant	43,097	Dominant	Dominant	15,677
40	Dominant	Dominant	42,339	Dominant	Dominant	15,610
Bleeding risk
Minor 10%, major 2%	Dominant	Dominant	Dominated	Dominant	Dominant	17,041
Minor 2%, major 0.4%	Dominant	Dominant	55,514	Dominant	Dominant	2,177
Minor 1%, major 0.01%	Dominant	Dominant	23,455	Dominant	Dominant	914
Patient population
Aged 45 years	Dominant	Dominant	24,165	Dominant	Dominant	7,520
Aged 75 years	Dominant	Dominant	118,683	Dominant	Dominant	36,444
All TKA	Dominant	Dominant	37,687	Dominant	Dominant	10,420
All THA	Dominant	Dominant	Dominated	Dominant	Dominant	Dominated
Quality of life
No VTE decrement	Dominant	Dominant	50,471	Dominant	Dominant	15,689
No fear of bleeding with LMWH	Dominant	Dominant	27,402	Dominant	Dominant	11,983
No major bleed decrement	Dominant	Dominant	49,813	Dominant	Dominant	15,501
Minor bleed at 0.001	Dominant	Dominant	50,535	Dominant	Dominant	15,674
Only sig. differences plus…	Dominant	Dominant	8,425	Dominant	Dominant	3,258
… Minor 1%, major 0.01%	1.1 million SPQL	Dominant	6,605	578,403 SPQL	Dominant	Dominant
… DVT 10%	Dominant	Dominant	Dominant	Dominant	Dominant	114

Notes: Dominant, more QALYs at lower cost; dominated, fewer QALYs at higher cost.

Abbreviations: DVT, deep vein thrombosis; IPC, intermittent pneumatic compression; LMWH, low-molecular-weight heparin; sig, significant; SPQL, saving per QALY lost; QALY, quality-adjusted life year; THA, total hip arthroplasty; TKA, total knee arthroplasty; VTE, venous thromboembolism.

Figure 2 Cost-effectiveness plane for IPC and IPC+LMWH compared with LMWH alone.

Notes: The cost-effectiveness plane for IPC (open circles) and IPC+LMWH (gray stars) compared with LMWH alone in the USA (left) and Australia (right). The gray dashed line indicates the willingness-to-pay threshold, with points that are below and to the right of the line considered cost-effective.
Abbreviations: IPC, intermittent pneumatic compression; LMWH, low-molecular-weight heparin; QALY, quality-adjusted life year.

Figure 3 Likelihood of cost-effectiveness of IPC+LMWH by the number of days of combined use.

Notes: In the base case, IPC+LMWH is used while in hospital (3 days in USA and 5 days in Australia) followed by LMWH after discharge. As the number of days that IPC+LMWH is used, the likelihood of it being cost-effective increases. By 7 days, it is extremely likely to be considered cost-effective versus LMWH (A) but <50% of simulations would be considered cost-effective versus IPC alone (B). All data from 500 sensitivity analyses were performed for each length of combined IPC+LMWH prophylaxis.
Abbreviations: Aus, Australia; IPC, intermittent pneumatic compression; LMWH, low-molecular-weight heparin.

Figure 4 Uncertainty in model outcomes.

Notes: Box plots show the distribution of data from 500 sensitivity analyses, with IPC depicted in white and IPC+LMWH in gray. Data for the USA have a solid black outline, whereas Australian data have a dashed-black outline.
Abbreviations: IPC, intermittent pneumatic compression; LMWH, low-molecular-weight heparin; QALY, quality-adjusted life year.

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