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Clinical Decisionmaking

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Injectable and IV heparin have similar overall care costs and effectiveness for treating deep vein thrombosis

About 170,000 patients are hospitalized each year for deep vein thrombosis (blood clot in the vein), and an additional 90,000 patients are hospitalized for recurrent thrombosis. Intravenous heparin, an anticoagulant, has been the standard treatment for this condition for over 30 years. However, enoxaparin, a low-molecular-weight heparin that can be injected under the skin once or twice daily, is similarly effective and safe.

Even though enoxaparin is a more costly medication ($476 for once-daily and $645 for twice-daily injections versus $28 for a full course of IV heparin), the overall cost of care for patients with venous thrombosis is similar for all three treatment regimens. The higher cost of enoxaparin, which can be administered on an outpatient basis, was offset by savings associated with fewer hospital readmissions, according to a study supported by the Agency for Healthcare Research and Quality (NRSA fellowship F32 HS00124).

Roger D. Yusen, M.D., of the Washington University School of Medicine, and his colleagues did a cost minimization analysis of a 3-month trial. They randomized 339 hospitalized patients with symptomatic lower extremity deep vein thrombosis to one of the three therapies, followed by long-term oral anticoagulant therapy. Based on the cost of medical resources used by each patient, the average total cost for the 3-month episode of care was similar for all treatments: $12,166 for a once-daily dose of enoxaparin, $10,744-$12,915 for twice-daily enoxaparin, and $12,146 for IV unfractionated heparin.

However, the IV heparin group had higher readmission rates than the once- and twice-a-day enoxaparin groups (26 percent vs. 21 and 17 percent, respectively). Besides reducing readmissions, injectable heparin has the economic advantage of not needing anticoagulant monitoring (its blood thinning effects are more predictable), facilitating outpatient therapy.

More details are in "Costs for inpatient care for venous thrombosis: A trial of enoxaparin vs. standard heparin," by Gregory de Lissovoy, Ph.D., Dr. Yusen, Theodore E. Spiro, M.D., and others, in the November 13, 2000 Archives of Internal Medicine 160, pp. 3160-3165.

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