Thromboprophylaxis and total hip replacement: A cost-efficacy study comparing duplex screening of asymptomatic venous thrombosis versus prolonged prophylaxis with low-molecular-weight heparins

Background: Despite use of the anti-thrombotic prophylaxis, clinical thrombo-embolic events and fatal pulmonary embolism are still observed after total hip replacement. To reduce these complications, two strategies have been adopted: to prolong the use of low-molecular-weight heparins (LMWH) to 35 days or to screen patients systematically before discharge, using duplex ultrasonography, following the short-course prophylactic treatment. Objective: To assess, based on published literature, the relative costs and benefits of these two strategies for prophylaxis following total hip arthroplasty. Method: The author identified relevant papers in this field from his own resources and from medical literature databases. Synthesis: Prolonging LMWH treatment to a total of 35 days represents a direct cost in France of approximately euro340 per patient, or for 100000 total hip replacements per year, an annual budget of EURO34 000 000. If this strategy attained maximum efficacy, it would avoid 150 fatal pulmonary embolisms. The direct cost would therefore be at least euro227 000 per life saved. A systematic single duplex ultrasound examination before discharge from hospital would cost euro76 per patient, or for 100 000 arthroplasties a total annual budget in France of EURO7 600 000. If this approach achieved maximum efficacy, preventing the 150 fatal pulmonary embolisms corresponding to 100000 total hip replacements, the minimum direct cost would be euro50 300 per life saved. Conclusion: Duplex screening may be more effective and lest costly than prolongation of prophylactic treatment using LMWH. This deduction needs to be confirmed by complex cost-benefit studies using clinical end-points.