Cost and outcomes associated with rivaroxaban vs enoxaparin for the prevention of postsurgical venous thromboembolism from a US payer’s perspective

Figures & data

Table 1.  Event rates in the prophylaxis and post-prophylaxis periods.

Outcome	Regimen	Event rate (per 1000 patients)
		THR (RECORD1)5	THR (RECORD2)6	TKR (RECORD3)7
Prophylaxis
VTE	Rivaroxaban	11.3	19.7	95.9
	Enoxaparin	37.2	93.7	189.1
Symptomatic VTE	Rivaroxaban	2.7	2.5	6.7
	Enoxaparin	2.7	12.4	19.7
Asymptomatic VTE	Rivaroxaban	8.5	17.2	89.2
	Enoxaparin	34.5	81.3	169.3
Fatal PE	Rivaroxaban	0.0	0.0	0.0
	Enoxaparin	0.0	0.0	0.0
Non-fatal PE	Rivaroxaban	2.5	1.2	0.0
	Enoxaparin	2.5	1.2	0.0
Symptomatic DVT	Rivaroxaban	0.2	1.3	6.7
	Enoxaparin	0.2	11.2	19.7
Major bleeding	Rivaroxaban	2.7	0.8	5.7
	Enoxaparin	2.7	0.8	5.7
Post-prophylaxis
Developing symptomatic VTE16	Both treatments	204.5	204.5	47.2
Developing symptomatic PE16,17	Both treatments	44.3	44.3	15.7

DVT, deep vein thrombosis; PE, pulmonary embolism; THR, total hip replacement; TKR, total knee replacement; VTE, venous thromboembolism.

Table 2.  Resource use and costs associated with prophylaxis.

	Resource use	Unit cost	Cost/patient
Drug costs
Rivaroxaban	10 mg (od)	$6.75/day	Duration dependent
Enoxaparin	40 mg (od)	$25.98/day25	Duration dependent
	30 mg (bid)	$38.97/day	Duration dependent
Administration and monitoring
Rivaroxaban	None required	$0.00/day	$0.00
Enoxaparin	Nurse assistance required during first administration (CPT 96372)	$23.10/day25	$23.10
Major bleeding
Major joint replacement or reattachment of lower extremity
With major bleeding complication (MS-DRG 469)		$17,988.9120
Without major bleeding complication (MS-DRG 470)		$10,977.5520
Cost of major bleeding complication*		$7011.3620	$7011.36
5 inpatient physician visits (CPT 99,232)27		$69.31/visit26	$346.55
2 outpatient physician visits (CPT 99,214)19		$102.27/visit26	$204.54
			Total $7562.45

MS—DRG, Medicare Severity Diagnosis—Related Group.

*Difference between major joint replacement and reattachment of lower extremity, with or without complication.

Table 3.  Resource use and costs associated with VTE diagnosis.

Diagnosis	Resource use19	Unit cost	Cost/patient
DVT (inpatient)	1 physician visit (CPT 99232)	$69.31/visit26	$69.31
	1 doppler ultrasound (CPT 93990)	$210.65/ultrasound26	$210.65
			Total $279.96
DVT (outpatient)	1 doppler ultrasound (CPT 93990)	$210.65/ultrasound26	$210.65
	2 outpatient physician visits (CPT 99214)	$102.27/visit26	$204.54
			Total $415.19
PE (inpatient)	1 physician visit (CPT 99232)	$69.31/visit26	$69.31
	1 lung V/Q scan (50% of patients) (CPT 78584)	$334.07/scan26	$167.04
	1 CT scan (50% of patients) (CPT 71260)	$312.24/scan26	$156.12
			Total $392.47
PE (outpatient)	2 outpatient physician visits (CPT 99214)	$102.27/visit26	$204.54
	1 lung (V/Q) scan (50% of patients) (CPT 78584)	$334.07/scan26	$167.04
	1 CT scan (50% of patients) (CPT 71260)	$312.24/scan26	$156.12
			Total $527.70

CT, computed tomography; DVT, deep vein thrombosis; PE, pulmonary embolism; V/Q, ventilation perfusion lung scan.

Table 4.  Resource use and costs associated with VTE treatment.

Treatment	Resource use19	Unit cost	Cost/patient
DVT (inpatient)	Inpatient treatment	$9,80521*	$12281.89
	5 outpatient physician visits (CPT 99214)	$102.27/visit26	$511.35
	180 days’ warfarin (5 mg daily)	$0.18/day28	$32.40
	26 prothrombin time tests (1/week for 6 months)	$5.53/test29	$143.78
	6 phlebotomy tests (1/month for 6 months)	$3.00/test29	$18.00
			Total $12987.42
DVT (outpatient)	1 ED visit (10% of patients)	$231.80/visit26*	$23.18
	1 ED physician service (10% of patients) (CPT 99284)	$115.52/visit30	$11.55
	5 outpatient physician visits (CPT 99214)	$102.27/visit26	$511.35
	180 days’ warfarin (5 mg daily for 6 months)	$0.18/day28	$32.40
	26 prothrombin time tests (1/week for 6 months)	$5.53/test29	$143.78
	6 phlebotomy tests (1/month for 6 months)	$3.00/test29	$18.00
	7 days’ enoxaparin (30 mg bid for 7 days)	$38.97/day28	$272.76
			Total $1013.02
PE (inpatient)	Inpatient treatment	$14,14621*	$17719.50
	5 outpatient physician visits (CPT 99214)	$102.27/visit26	$511.35
	180 days’ warfarin (5 mg daily)	$0.18/day28	$32.40
	26 prothrombin time test (1/week for 6 months)	$5.53/test29	$143.78
	6 phlebotomy (1/month for 6 months)	$3.00/test29	$18.00
			Total $18425.03

DVT, deep vein thrombosis; ED, emergency department; PE, pulmonary embolism.

*Inflated to 2010 costs.

Table 5.  Base-case model predicted cost savings and symptomatic VTE events reduction.

Surgery type	Trial	Rivaroxaban	Enoxaparin	Incremental benefit*	Summary
THR	RECORD15
	Total cost/patient	$346	$1041	−$695
	Symptomatic events/1000				Rivaroxaban is a cost-saving alternative
	patients	2.7	2.7	0.00
	RECORD26
	Total cost/patient	$319	$563	−$244
	Symptomatic events/1000				Rivaroxaban is a cost-saving alternative and
	patients	2.5	12.4	9.9	associated with greater health benefits
TKR	RECORD37
	Total cost/patient	$243	$654	−$411
	Symptomatic events/1000				Rivaroxaban is a cost-saving alternative and
	patients	6.7	19.7	13.1	associated with greater health benefits

THR, total hip replacement; TKR, total knee replacement.

*Rivaroxaban vs enoxaparin (larger negative values = greater savings and favor rivaroxaban more).

Figure 1.  Incremental costs. (a) RECORD1⁵, (b) RECORD2⁶, (c) RECORD3⁷. CI, confidence interval; E&S, efficacy and safety; THR, total hip replacement; TKR, total knee replacement; VTE, venous thromboembolism.

Figure 2.  Incremental symptomatic VTE events avoided. (a) RECORD1⁵, (b) RECORD2⁶. CI, confidence interval; E&S, efficacy and safety; THR, total hip replacement; TKR, total knee replacement; VTE, venous thromboembolism.

Figure 3.  Cost-effectiveness of rivaroxaban vs enoxaparin THR^5,6 and TKR⁷. CI, confidence interval; E&S, efficacy and safety; THR, total hip replacement; TKR, total knee replacement; VTE, venous thromboembolism.

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