Use of Thromboprophylaxis after Autologous Breast Reconstruction: A Cost-Effective Break-Even Analysis
Charles C. Lee, Alexis Lo1, F. Jeffrey Lorenz1, Brandon J. Martinazzi1, T. Shane Johnson1
1Pennsylvania State University College of Medicine, Hershey Medical Center, Hershey, PA, USA
Background: Post-operative venous thromboembolism (VTE) is a major source of morbidity and mortality for patients. However, the use of thromboprophylaxis amongst surgeons can vary greatly and have not been well-studied in autologous breast reconstruction. The purpose of this study was to determine the rate of VTE in breast cancer patients undergoing autologous breast reconstruction and to perform a break-even analysis to compare the cost-effectiveness of heparin and enoxaparin for VTE prophylaxis.
Methods: The TriNetX National Health Research Network database was used to identify patients with breast cancer who underwent autologous breast reconstruction surgery between 2002-2022. The incidence of VTE within the first 30 days of surgery was then calculated. This value was utilized as the baseline VTE incidence in the break-even analysis.A break-even analysis was performed using a modified equation developed by Hatch et al. to determine the break-even rate of VTE at which the use of heparin and enoxaparin would be cost-effective. The absolute risk reduction (ARR) of heparin and enoxaparin was calculated by subtracting their respective break-even VTE rates found from the equation from the baseline incidence. A lower ARR indicated a smaller decrease that was needed from the baseline incidence rate, and thus a more cost-effective thromboprophylaxis agent.
Results: A cohort of 8,003 patients was analyzed in this study, with a mean age of 57.6 years. 55.1% did not receive thromboprophylaxis, while 28.9% received heparin, 12.4% enoxaparin, and 3.6% other anticoagulants. Total of 236 cases of VTE were observed (2.90%). The rate of VTE was significantly higher in those without anticoagulation (3.4%) compared to those who received anticoagulation (2.3%) (p=0.0078). Among those prophylactically anticoagulated, there was no significant difference (p=0.91) in VTE rates between heparin (2.4%) and enoxaparin (2.3%). The cost of VTE treatment was estimated to be $15,000 from existing literature. The costs of heparin and enoxaparin were determined from GoodRx to be $42.07 and $164.38, respectively. The presumed length of prophylactic treatment was 30 days. The break-even analysis for heparin and enoxaparin’s cost-effectiveness yielded ARRs of 0.28% and 1.10%, respectively.
Conclusion: The use of thromboprophylaxis significantly lowered the risk of VTE within 30 days after autologous breast reconstruction. Although both heparin and enoxaparin appear to have cost-effective potentials, heparin was more cost-effective at preventing VTE compared to enoxaparin. This model holds potential for other institution-specific variables that can be easily applied by plastic surgeons to determine the cost-effectiveness of any therapy of their choice.
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