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The results of a study to estimate the economic costs of venous thromboembolism (VTE) in hospitalized nonsurgical patients during initial admissions and subsequent to hospital discharge are presented.Using a database linking admission records from more than 150 U.S. hospitals to health insurance claims, 49,948 patients 40 years of age or older who were hospitalized at least once during a 6-year period for diagnoses other than VTE or traumatic injury and who met other inclusion criteria were identified. Costs were tallied from the index admission to postdischarge day 180 for patients with and patients without evidence of VTE. Ordinary least-squares regression was used to estimate the independent relationship between VTE and total health care costs, controlling for differences in patient characteristics.Two hundred forty-two patients (0.5%) had VTE during the index admission, 317 (0.6%) had VTE after the index admission discharge; in total, 559 (1.1%) had VTE through postdischarge day 180. Among the 242 patients with VTE during their index admission, the adjusted mean total health care costs over 180 days were $17,848 higher than among those without VTE ($47,416 versus $29,568, p0.001); for the 317 patients with postdischarge VTE, the adjusted mean total 180-day costs were $51,863 higher than for those without postdischarge VTE ($74,136 versus $22,273, p0.001).Among medically ill patients admitted to the hospital, health care costs were significantly higher among those who developed VTE during hospitalization or after discharge compared with those who did not develop VTE.

Objective To assess cost-effectiveness of abatacept in patients with moderately to severely active RA and inadequate response to MTX. Methods We developed a simulation model to depict progression of disability [in terms of the HAQ Disability Index (HAQ-DI)] in women aged 55-64 yrs with moderately to severely active RA and inadequate response to MTX. At model entry, patients were assumed to receive either only MTX or MTX plus abatacept. Patients were then tracked from model entry until death. Future health-state utilities and medical-care costs (except study therapy) were estimated based on predicted values of the HAQ-DI. The model was estimated using data from a Phase III clinical trial of abatacept plus various secondary sources. Cost-effectiveness was expressed in terms of incremental cost (2006 US$) per quality-adjusted life-year (QALY) gained over alternatively 10 yrs and a lifetime. Costs and health effects were both discounted at 3% annually. Results Over 10 yrs, abatacept would yield 1.2 additional QALYs (undiscounted) per patient (4.6 vs 3.4 for MTX) at an incremental (discounted) cost of $51,426 ($103,601 vs $52,175, respectively); over a lifetime, corresponding figures were 2.0 QALYS (6.8 vs 4.8) and $67,757 ($147,853 vs $80,096). Cost-effectiveness was [mean (95% CI)] $47,910 ($44,641, $52,136) per QALY gained over 10 yrs and $43,041 ($39,070, $46,725) per QALY gained over a lifetime. Findings were robust in sensitivity analyses. Conclusion Abatacept is cost-effective by current standards of medical practice in patients with moderately to severely active RA and inadequate response to MTX.

The 90-day risk of venous thromboembolism (VTE) among medically ill patients admitted to a hospital was estimated and is discussed.Patients agedor =40 years who were hospitalized between January 1, 1998, and June 30, 2002, for reasons other than traumatic injury, labor and delivery, mental disorder, or VTE and who did not undergo surgery were identified in a large U.S. healthcare claims database. Patients receiving anticoagulants in the 90-day period preceding hospital admission were excluded. We estimated the percentage of study subjects who developed clinical deep-vein thrombosis (DVT) or pulmonary embolism (PE) within 90 days of hospital admission using Kaplan-Meier methods. We also estimated hazard ratios (HRs) for potential risk factors for VTE using univariate and stepwise multivariate Cox proportional hazards regression models. Among 92,162 study subjects, 1468 (1.59%) developed clinical DVT or PE within 90 days of hospital admission; 18% of these events occurred postdischarge. In multivariate analyses, significant risk factors for clinical VTE included: 1) history of cancer (HR, 1.67; 95% confidence interval [CI], 1.45-1.93); 2) history of VTE within six months of index admission (HR, 6.14; 95% CI, 4.74-7.96); 3) operating room procedure within 30 days of index admission (HR, 1.81; 95% CI, 1.47-2.24); 4) peripheral artery disease during index admission (HR, 1.68; 95% CI, 1.28-2.21); and 5) heart failure during index admission (HR, 1.72; 95% CI, 1.52-1.95).The risk of clinical VTE among medically ill patients admitted to a hospital, although less than that of patients undergoing major surgery, is not negligible. Patients with a history of recent VTE or surgery, those who are admitted to the intensive care unit, those with an admitting diagnosis of heart failure, and those with active cancer are at especially high risk of VTE and deserve increased consideration for prophylaxis.

The economic costs of clinical venous thromboembolism (VTE) in hospitalized patients after major orthopedic surgery were assessed. The discharge summaries and itemized bills from 220 U.S. acute care hospitals were examined. All patients who underwent total hip or knee replacement surgery or hip-fracture repair at these hospitals between January 1998 and June 1999 were identified and included in the study sample. Length of hospital stay, use of intensive care services, and costs of inpatient care were compared between patients with and without secondary diagnoses of deep vein thrombosis (DVT) without pulmonary embolism (PE) (DVT only) or PE with or without DVT. Mean length of hospital stay was more than twice as long for patients with VTE (11.5 and 12.4 days for DVT only and PE, respectively, versus 5.4 days for no VTE; p < 0.0001 for both comparisons). Mean time in the intensive care unit was roughly 10-fold greater (1.7 days for DVT only and 2.7 days for PE versus 0.2 day for no VTE; p < 0.0001). Mean total costs of inpatient care were almost twofold higher for patients with VTE ($17,114 for DVT only and $18,521 for PE versus $9,345 for no VTE; p < 0.0001 for both comparisons). Findings were unchanged in multivariate analyses controlling for differences in baseline characteristics between patients with and without VTE. Patients who develop in-hospital clinical VTE following major orthopedic surgery have significantly longer stays in the 'hospital and approximately twofold higher costs of inpatient care.

The epidemiology and economics of venous thromboembolism (VTE) associated with hip and knee arthroplasty and surgical repair of hip fracture are reviewed. In the 1960s and 1970s, prior to the widespread use of prophylaxis, the risk of VTE following major orthopedic surgery was substantial. The risk of fatal pulmonary embolism (PE) following hip fracture repair may have been as high as 7.5%. With improvements in surgical and anesthetic techniques and the use of anticoagulant prophylaxis, these risks have decreased significantly for most patients. Current risks after hip and knee arthroplasty appear to be about 2.5% for deep vein thrombosis, 1% for nonfatal PE, and a few tenths of 1% for fatal PE over a three-month period following surgery. Because of the traumatic nature of the injury, delays in getting to surgery, and their more advanced age and poorer overall health, hip fracture patients appear to have a greater risk of postoperative VTE, but data are lacking for a reliable estimate of current risk. The cost of VTE after major orthopedic surgery includes initial therapy (the chief component), follow-up care, and the expected costs of major hemorrhage (due to anticoagulation), recurrent VTE, and postthrombotic syndrome. The total cost per patient of such care is approximately $11,600. The risk of VTE after surgery to replace hip and knee joints and repair hip fracture is far lower today than in the 1960s and 1970s, but the cost of treating VTE remains high: an estimated $11,600 per patient, including hospitalization costs.

An overview of the techniques of cost-effectiveness analysis as they apply to clinical decision making is presented, and ways that the techniques can assist decision makers in a limited-resource environment are identified. Most applications of cost-effectiveness analysis concern a problem in which a choice must be made between different ways of accomplishing a given clinical goal, such as treating a particular illness. As such, these applications involve comparisons between competing and mutually exclusive strategies and attempt to identify those strategies that provide the greatest benefit for a given set of resource constraints. The need for these analyses continues to increase as a consequence of the growing importance of rate-based and capitated (as opposed to cost-based) methods of paying for patient care. Despite this growing need, most decision makers will not want or be able to conduct such analyses on a regular basis; they may nonetheless benefit from formal studies of clinical problems conducted and reported by others. The validity and quality of these reports, however, need to be carefully assessed before decisions can be based on such information. Properly done, cost-effectiveness analyses can be powerful tools in clinical decision making, particularly as the concern with providing quality care in a cost-constrained environment continues to grow.