As carotid endarterectomy is a prophylactic procedure, it would seem particularly important to analyze complications with an aim to avoiding them. All carotid endarterectomies in Sweden are registered, and all serious complications (death and permanent neurological deficit) are analyzed in detail, classified and discussed within the profession. During the period 1994-1996 the frequency was 4.3 percent (technical causes in 17 percent, contraindications in 8 percent and dubious indications in 21 percent, but correct indication and surgery in 54 percent). Thus, even when conditions are optimal there is a certain price to pay for the prevention of ischemic stroke.
The relative costs were analysed of (1) no prophylaxis against deep vein thrombosis (DVT), (2) selective treatment of DVT after confirmation of diagnosis, (3) general prophylaxis with standard low-dose unfractionated heparin and (4) general prophylaxis with low molecular weight heparin (LMWH) in patients undergoing elective general abdominal surgery or elective hip surgery. The mean calculated costs per patient undergoing general abdominal surgery were: Swedish crowns (SEK) 1950 for no prophylaxis, SEK 5710 for selective treatment of DVT, SEK 735 for prophylaxis with unfractionated heparin and SEK 665 for prophylaxis with LMWH. The corresponding costs for hip surgery were SEK 3930, SEK 10790, SEK 1730 and SEK 1390 respectively. Thus, the least expensive management strategy in patients undergoing elective general abdominal or hip surgery would appear to be general prophylaxis with either unfractionated heparin or LMWH. Furthermore, general prophylaxis with LMWH would appear to be more cost-effective than general prophylaxis with unfractionated heparin.
Several studies have shown thromboprophylaxis of any kind to be more cost-effective than no prophylaxis or general diagnostic surveillance and selective treatment. Little has been written on low molecular weight heparins from the cost-effectiveness point of view. This preliminary study shows low molecular weight heparin to be more cost-effective than standard low-dose heparin in most situations of prophylaxis.
Several studies have demonstrated that prolongation of thromboprophylaxis after elective hip replacement significantly reduces the frequency of venographically demonstrated deep vein thrombosis. This paper reports an economic evaluation of prolonged prophylaxis with low-molecular-weight heparin (LMWH), based on outcome data from one of these trials. Analysis showed a net saving per patient of 3,400 Swedish kronor. Consequently, if the costs of administering the LMWH -- which includes the cost of teaching the patient to self-administer whilst in hospital and the cost of a follow-up visit by a district nurse to ensure compliance -- are below this amount, the intervention will prove to be cost saving.
The need for thromboembolism (TE) prophylaxis during laparoscopic surgery is not well established. The aim of this study was to investigate current TE prophylaxis in patients undergoing laparoscopic cholecystectomy (LC) in Sweden.
Mail questionnaire to all Surgical Departments in Sweden about the current use of thromboembolism prophylaxis in patients undergoing laparoscopic cholecystectomy.
The response rate was 78 of 80 departments of surgery (98%). Seventy reported performing LC. Thirty-six percent used thromboembolism prophylaxis in all patients, 17% in most, 9% in half their patients and 39% only rarely. The current use of thromboembolism prophylaxis ranged from low-molecular-weight heparin for 7 days + stockings in all patients to no prophylaxis at all in the majority of patients.
The use of thromboembolism prophylaxis in LC patients is highly variable, even in the small and homogenous country of Sweden. Further studies concerning the risk of TE complications after laparoscopic surgery are warranted.
Deep vein thrombosis is a serious complication of orthopaedic surgery and can lead to pulmonary embolism and long term post-thrombotic syndrome. A simulation model based on both epidemiological data and data from clinical trials was used to compare the long term cost effectiveness of standard prophylaxis with subcutaneous unfractionated heparin with that of desirudin (recombinant hirudin), in patients undergoing elective hip replacement. The analysis, which was performed before the price of desirudin was set, showed that prophylactic treatment with desirudin saved 4.5 life-years per 100 patients treated, compared with unfractionated heparin. Desirudin prophylaxis was dominant up to a total drug cost of 4400 Swedish kronor (SEK) per treatment. The results were robust against changes in the parameters used in several sensitivity analyses. This study showed that prophylactic therapy with desirudin compared with unfractionated heparin was more cost effective and potentially cost saving under a wide range of assumptions concerning the future price of desirudin in preventing deep vein thrombosis following elective hip surgery.
OBJECTIVE: To evaluate the possible benefit of inserting a caval filter for the prevention of pulmonary embolism (PE) in an unselected group of patients admitted to hospital. DESIGN: Analysis of clinical data collected prospectively. SETTING: University hospital, Sweden. SUBJECTS: 1391 patients who presented during 1987 435 with deep vein thrombosis (DVT), thrombus in the right atrium or the right ventricle or PE at necropsy; 366 patients shown to have DVT on phlebography; 44 shown to have PE on pulmonary scintigraphy; and 546 patients operated on for hip fractures. OUTCOME MEASURES: Clinical description of patients and groups of patients who died of PE who could possibly have benefitted from insertion of a filter. RESULTS: Of the 435 patients with DVT or PE or both, 141 had DVT in the femoral or iliac veins or in the inferior vena cava together with PE which contributed to the cause of death. Only 11 of these had been suspected clinically of having DVT in or below the inferior vena cava and only 1 of these was less than 80 years old and did not have malignant disease with distant metastases. Of the 366 patients with phlebographically confirmed DVT 8 died with PE that had contributed to the cause of death; 6 had incurable cancer and the remaining two were over 85 years. Of the 44 patients with scintigraphically confirmed PE 2 patients (aged 78 and 89) died of PE that had already been diagnosed clinically and none would have benefited from insertion of a filter after diagnosis. There were 9 PE deaths related to PE among 546 patients operated on for hip fractures, and all but one had potentially lethal coexisting disease or were over 80 years old. CONCLUSION: In this epidemiological survey only a few patients would have benefited from insertion of a caval filter. The results call for a restricted use of caval filters until benefit has been confirmed by prospective studies.
Few studies have shown the effect of thromboprophylactic regimen with low molecular weight heparin (LMWH) on the incidence of clinical venous thromboembolism (VTE) in common practice. The aim was to study the three-year incidence of clinically overt VTE events at a university based orthopaedic department with some 3300 operations performed and 15 000 patients treated annually.
Since all Swedish citizens have an individual identification number it was possible tp follow up all patients operated during a 3 year period (2000-2002) for a period of four months.
The incidence of VTE in the classical high-risk groups of hip fracture surgery, total hip arthroplasty (THA) and total knee arthroplasty (TKA) was low - about 0.6 %, while the Pulmonary embolism (PE) incidence in the hip fracture group was 0.27%, with two cases of fatal PE occurring 72 and 109 days after surgery. Patients with ankle fractures had more VTE. The majority of clinical VTE occurred after discharge from hospital.
When using routine thrombopropylaxis with LMWH in orthopaedic surgery the rate of symptomatic VTE is low.