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Venous Thromboembolism After Total Hip Arthroplasty and Total Knee Arthroplasty: Current and Future
Volume 17
Issue 1 Suppl

Prevalence and Economic Burden of Venous Thromboembolism After Total Hip Arthroplasty or Total Knee Arthroplasty

Author(s):

Abstract

Venous thromboembolism (VTE) is a common complication following total hip arthroplasty or total knee arthroplasty and can lead to morbidity and mortality, as well as considerable healthcare costs. However, the incidence of VTE can be greatly minimized with effective thromboprophylaxis administered for the appropriate period of time. While guidelines exist to assist clinicians in determining what type of thromboprophylaxis should be prescribed and for how long, those guidelines are frequently not followed. Prevention of VTE would improve patient outcomes and result in substantial savings to payers and providers.

(Am J Manag Care. 2011;17:S6-S8)

Due to an aging and increasingly obese population, it has been predicted that by 2030 the number of total hip arthroplasty (THA) operations in the United States will reach over half a million, a rise of approximately 100% compared with 2005 figures, and the number of total knee arthroplasty (TKA) operations will reach 3.5 million, an increase of over 560%.1 As a consequence, the number of revision operations is expected to reach over 95,000 and 260,000 for THA and TKA, respectively, by 2030.1

After THA or TKA, patients are at increased risk of venous thromboembolism (VTE), a potentially fatal condition that comprises deep vein thrombosis (DVT) and pulmonary embolism (PE).2 Without prophylaxis after THA and TKA, patients are at high risk for asymptomatic (venographic) DVT (incidence after THA: 40%-60%; after TKA: 40%-85%).3 If routine thromboprophylaxis is used, fatal PE is uncommon, although symptomatic VTE continues to be reported in 1% to 10% of patients within 3 months after surgery.33 Non-fatal PE can also have considerable consequences and may result in chronic thromboembolic pulmonary hypertension (CTPH), a serious disease associated with progressive disability and a high risk of mortality.4,5

DVT can result in considerable morbidity and mortality-without thromboprophylaxis, fatal PE occurs in approximately 1 patient per 300 undergoing THA.

Clinical Burden of VTE

Using a large US healthcare claims database, investigators estimated the burden of VTE after major orthopedic surgery.6 In all, 2.2% of patients developed clinical VTE over a 90-day period following hospital admission (DVT: 1.7%, PE: 0.4%, DVT and PE: 0.01%). Over 60% of events occurred following hospital discharge. In a long-term follow-up study, patients with and without VTE were matched by age and procedure. Investigators found that patients who developed in-hospital VTE after major orthopedic surgery had a longer length of hospital stay compared with patients without VTE.6

Using data from discharge summaries for 105,562 patients from 220 acute care hospitals, Ollendorf et al7 examined the incidence of VTE after major orthopedic surgery. They found that during the initial hospital stay, DVT occurred in 0.7% of patients and PE (with or without DVT) in 0.4% of patients. Patients with VTE spent almost 10 times as long in the intensive care unit and more than twice as long in hospital as did those without VTE.7

Approximately one-third to one-half of all DVT patients will develop post-thrombotic syndrome (PTS).8,9 PTS is a chronic condition characterized by persistent pain, or intermittent pain, swelling, itching, tingling, or cramping in the limb, that develops in 20% to 60% of patients within 1 to 2 years of DVT.10,11 Severe PTS can lead to lipodermatosclerosis and intractable venous leg ulcers.12,13 Due to its chronic nature, PTS is a cause of substantial patient morbidity.10 Caprini et al14 used a Markov model to simulate the natural history of DVT complications after THA, using published estimates of the incidence and prognosis of PTS and recurrent VTE. They projected that the cumulative proportion of patients who survived an initial acute, post-surgery DVT and subsequently developed mild-to-moderate PTS would be 21.5%, compared with 1.3% in the control group, who did not experience DVT after THA. The estimated cumulative proportions of post-surgery DVT patients who developed severe PTS and recurrent DVT and PE were 8.1%, 24.4%, and 6.5%, respectively. Corresponding figures for the control group were estimated at 0.4%, 2.4%, and 1.0%, respectively.14

Long-Term Consequences of VTE

Most VTEs are diagnosed in the 3 months after hospitalization.15 As stated earlier, VTE is associated with a number of potentially serious complications, including recurrent VTE, PTS, and CTPH.4,16 Most cases of PTS will occur within 1 to 2 years of acute DVT, with poor-quality initial anticoagulant therapy being an important risk factor.17 A 10-year follow-up of patients who experienced an index VTE found an incidence of severe PTS of 6%, with 56.3% of patients having some sign of PTS during the follow-up period.18

CTPH is a relatively common and serious complication of PE and is associated with considerable morbidity and mortality.4,19 It is notoriously underdiagnosed and its true prevalence remains unknown.4 In a prospective, long-term follow-up study of 314 consecutive patients who presented with an initial acute PE, the cumulative incidence of symptomatic CTPH was 1% at 6 months, 3.1% at 1 year, and 3.8% at 2 years.4

Ollendorf et al7 reported a mortality rate of 1.02% among those with no VTE, rising to 2.51% in those with DVT alone, and 19.49% in those with PE. In patients who had finished a course of anticoagulant therapy for a first episode of symptomatic VTE, the risk for fatal PE was reported to be 0.19 to 0.49 events per 100 person-years.20

Economic Impact of Venous Thromboembolism

VTE has a major clinical impact on US Medicare, other payers, and patients, and significantly increases the economic burden on the US healthcare system. Despite the costs of thromboprophylaxis, it has been noted that following major orthopedic surgery, any type of prophylaxis is cost-saving compared with no prophylaxis.21

Studies of the economic consequences of VTE after major orthopedic surgery have yielded a number of contrasting estimates. Caprini et al14 reported annual projected costs (first year) of complications of $839 for mild-to-moderate PTS, $3817 for severe PTS, $3798 for recurrent DVT, and $6604 for recurrent PE. From discharge summaries, Ollendorf et al found mean costs of inpatient care were $17,114 for patients with DVT and $18,521 for patients with PE compared with $9345 for patients with no VTE.7 A study using data from a large healthcare claims database calculated much higher in-hospital mean billed charges for the index admission after THA: $36,705 in patients with no VTE, $62,558 in patients with in-hospital VTE, and $34,970 for post-discharge VTE.6 Similarly, costs after TKA were $35,601 in patients with no VTE, $44,898 in patients with in-hospital VTE, and $31,774 for post-discharge VTE.6

An older estimate of costs for treating VTE after major orthopedic surgery was $11,600.22 Yet, despite changes in healthcare following surgery, such as reduced time in hospital,23 more recent estimates remain high at $17,114 for treating DVT and $18,521 for treating PE after orthopedic surgery.24

While health economic modeling of cost-effectiveness of thromboprophylaxis has evolved over recent years,25 cost estimates will still vary from one analysis to another, reflecting the range of healthcare services included, the proportion of patients who use them, and the unit costs applied.

Conclusions

Patients undergoing major orthopedic surgery are classified as being at high risk of developing VTE. Even when prophylaxis for VTE was given, studies indicated rates of VTE of 1.1% to 3.3% in patients who underwent major orthopedic surgery. VTE imposes significant clinical and economic consequences on patients and on the healthcare systems that support them-extending hospital stays and precipitating additional hospitalizations. The incremental inpatient costs of patients with major orthopedic surgery who developed VTE were substantially higher compared with patients with no VTE (approximately $12,000-$17,000 higher). Consequently, there is a need for more cost-effective and prolonged VTE prophylaxis following THA and TKA. The development of cost-effective anticoagulants is of paramount importance in order to ensure that the most appropriate anticoagulant care can be provided for the largest number of patients at risk of VTE.26 Preventing VTE could lead to substantial savings to healthcare systems, and to significant reductions in morbidity and mortality. After all, prevention of VTE is much easier and less expensive than diagnosis and treatment.27

Author Affiliation: The University of Michigan and STATinMED Research, Ann Arbor, MI.

Funding Source: Financial support for this supplement was provided by Ortho-McNeil Janssen Scientific Affairs, LLC and Johnson & Johnson Worldwide Market Access.

Author Disclosure: Dr Baser reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Analysis and interpretation of data; drafting of the manuscript; and statistical analysis.

Address correspondence to: Onur Baser, PhD, STATinMED Research, 211 N 4th Ave, Ste 2B, Ann Arbor, MI 48104. E-mail: obaser@statinmed.com.

1. Iorio R, Robb WJ, Healy WL, et al. Orthopaedic surgeon workforce and volume assessment for total hip and knee replacement in the United States: preparing for an epidemic. J Bone Joint Surg Am. 2008;90:1598-1605.

2. Colwell CW. Evidence-based guidelines for venous thromboembolism prophylaxis in orthopedic surgery. Orthopedics. 2007;30:129-135.

3. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence- based clinical practice guidelines (8th ed). Chest. 2008;133:381S-453S.

4. Pengo V, Lensing AW, Prins MH, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med. 2004;350:2257-2264.

5. Lang I, Kerr K. Risk factors for chronic thromboembolic pulmonary hypertension. Proc Am Thorac Soc. 2006;3:568-570.

6. Oster G, Ollendorf DA, Vera-Llonch M, Hagiwara M, Berger A, Edelsberg J. Economic consequences of venous thromboembolism following major orthopedic surgery. Ann Pharmacother. 2004;38:377-382.

7. Ollendorf DA, Vera-Llonch M, Oster G. Cost of venous thromboembolism following major orthopedic surgery in hospitalized patients. Am J Health Syst Pharm. 2002;59:1750-1754.

8. Van Dongen CJ, Prandoni P, Frulla M, Marchiori A, Prins MH, Hutten BA. Relation between quality of anticoagulant treatment and the development of the postthrombotic syndrome. J Thromb Haemost. 2005;3:939-942.

9. Stain M, Schoenauer V, Minar E, et al. The post-thrombotic syndrome: risk factors and impact on the course of thrombotic disease. J Thromb Haemost. 2005;3:2671-2676.

10. Kahn SR, Ginsberg JS. Relationship between deep venous thrombosis and the postthrombotic syndrome. Arch Intern Med. 2004;164:17-26.

11. Ashrani AA, Heit JA. Incidence and cost burden of postthrombotic syndrome. J Thromb Thrombolysis. 2009;28:465-476.

12. Pirard D, Bellens B, Vereecken P. The post-thrombotic syndrome- a condition to prevent. Dermatology Online Journal. 2008;14:13.

13. Hopkins NJ, Wolfe JH. Deep venous insufficiency and occlusion. BMJ. 1992;304:107-110.

14. Caprini JA, Botteman MF, Stephens JM, et al. Economic burden of long-term complications of deep vein thrombosis after total hip replacement surgery in the United States. Value Health. 2003;6:59-74.

15. Tapson VF, Decousus H, Pini M, et al. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest. 2007;132:936-945.

16. Kearon C. Natural history of venous thromboembolism. Circulation. 2003;107:I22-I30.

17. Kahn SR. Frequency and determinants of the postthrombotic syndrome after venous thromboembolism. Curr Opin Pulm Med. 2006;12:299-303.

18. Schulman S, Lindmarker P, Holmstrom M, et al. Post-thrombotic syndrome, recurrence, and death 10 years after the first episode of venous thromboembolism treated with warfarin for 6 weeks or 6 months. J Thromb Haemost. 2006;4:734-742.

19. Peacock A, Simonneau G, Rubin L. Controversies, uncertainties and future research on the treatment of chronic thromboembolic pulmonary hypertension. Proc Am Thorac Soc. 2006;3:608-614.

20. Douketis JD, Gu CS, Schulman S, Ghirarduzzi A, Pengo V, Prandoni P. The risk for fatal pulmonary embolism after discontinuing anticoagulant therapy for venous thromboembolism. Ann Intern Med. 2007;147:766-774.

21. Sullivan SD, Kahn SR, Davidson BL, Borris L, Bossuyt P, Raskob G. Measuring the outcomes and pharmacoeconomic consequences of venous thromboembolism prophylaxis in major orthopaedic surgery. Pharmacoeconomics. 2003;21:477-496.

22. Edelsberg J, Ollendorf, D, Oster G. Venous thromboembolism following major orthopedic surgery: review of epidemiology and economics. Am J Health Syst Pharm. 2001;58(suppl 2):S4-S13.

23. Friedman RK, Gallus AS, Cushner FD, FitzGerald G, Anderson FA Jr; the Global Orthopaedic Registry Investigators. Physician compliance with guidelines for deep-vein thrombosis prevention in total hip and knee arthoplasty. Curr Med Res Opin. 2008;24:87-97.

24. Dobesh PP. Economic burden of venous thromboembolism in hospitalized patients. Pharmacotherapy. 2009;29:943-953.

25. Wolowacz SE, Hess N, Brennan VK, Monz BU, Plumb JM. Cost-effectiveness of venous thromboembolism prophylaxis in total hip and knee replacement surgery: the evolving application of health economic modelling over 20 years. Curr Med Res Opin. 2008;24:2993-3006.

26. Avorn J, Winkelmayer WC. Comparing the costs, risks, and benefits of competing strategies for the primary prevention of venous thromboembolism. Circulation. 2004;110:IV25-IV32.

27. Goldhaber SZ. Venous thromboembolism: an ounce of prevention. Mayo Clin Proc. 2005;80:725-726.

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