TY - JOUR
T1 - Cost-effectiveness of pharmacomechanical catheter-directed thrombolysis versus standard anticoagulation in patients with proximal deep vein thrombosis
T2 - Results from the ATTRACT trial
AU - Magnuson, Elizabeth A.
AU - Chinnakondepalli, Khaja
AU - Vilain, Katherine
AU - Kearon, Clive
AU - Julian, Jim A.
AU - Kahn, Susan R.
AU - Goldhaber, Samuel Z.
AU - Jaff, Michael R.
AU - Kindzelski, Andrei L.
AU - Herman, Kevin
AU - Brady, Paul S.
AU - Sharma, Karun
AU - Black, Carl M.
AU - Vedantham, Suresh
AU - Cohen, David J.
N1 - Funding Information:
E.A. Magnuson reports grant support from Abbott Vascular and Cardiovascular Systems, Inc. Dr. Kahn reports advisory board fees from BMS Pfizer, Sanofi, and Aspen. Dr Goldhaber reports grant support from BiO2 Medical and grant support and consulting fees from Boehringer Ingelheim, BMS, Daiichi Sankyo, Janssen, Portola, Bayer, BTG/Ekos. M.R. Jaff holds equity in Embolitech and Venarum; is an uncompensated advisor to Boston Scientific, Cordis Corporation, and Medtronic; and is a consultant for Volcano/Phillips. Dr Herman is a consultant for Cardiovascular Systems, Inc. Dr Black reports research support from Cook Medical. Dr Vedantham reports research support from Cook Medical. Dr Cohen reports grant support from Abbott Vascular and Boston Scientific, consulting fees from Cardinal Health, and grant support and consulting fees from Medtronic. The other authors report no conflicts.
Funding Information:
The ATTRACT Trial (Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis) was supported by grants from the National Heart, Lung, and Blood Institute (NHLBI) for the clinical coordinating center (U01-HL088476 to Dr Vedantham, Washington University in St. Louis) and data coordinating center (U01-HL088118 to C. Kearon, McMaster University, Hamilton, ON); the Washington University Center for Translational Therapies in Thrombosis, which is supported by a grant from the NHLBI (U54-HL112303); the Washington University Institute of Clinical and Translational Sciences, which is supported by a grant from the National Center for the Advancement of Translational Sciences (UL1-TR00044810); Boston Scientific; Covidien (now Medtronic); Genentech; the Society of Interventional Radiology Foundation; the Canada Research Chairs Program (Tier 1 support to Dr Kahn); the CanVECTOR Network (funded by Canadian Institutes of Health Research [funding reference CDT-142654] to Dr Kahn); the Heart and Stroke Foundation of Canada (Investigator Award to C. Kearon); and a Jack Hirsh Professorship in Thrombosis (to C. Kearon). BSN Medical donated the compression stockings. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the NHLBI.
Publisher Copyright:
© 2019 Lippincott Williams and Wilkins. All rights reserved.
PY - 2019/10/1
Y1 - 2019/10/1
N2 - Background: In patients with acute deep vein thrombosis (DVT), pharmacomechanical catheter-directed thrombolysis (PCDT) in conjunction with anticoagulation therapy is increasingly used with the goal of preventing postthrombotic syndrome. Long-term costs and cost-effectiveness of these 2 treatment strategies from the perspective of the US healthcare system have not been compared. Methods and Results: Between 2009 and 2014, the ATTRACT trial (Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis) randomized 692 patients with acute proximal DVT to PCDT plus anticoagulation (n=337) or standard treatment with anticoagulation alone (n=355). Costs (2017 US dollars) were assessed over a 24-month follow-up period using a combination of resource-based costing, hospital bills, Medicare reimbursement rates, and the Drug Topics Red Book. Health state utilities were obtained from the Short Form-36. In-trial results and US life tables were used to develop a Markov cohort model to evaluate lifetime cost-effectiveness. For the PCDT group, mean costs of the initial procedure were $13 600; per-patient costs associated with the index hospitalization were $21 509 for PCDT and $3877 for standard care (difference=$17 632; 95% CI, $16 117-$19 243). The 24-month difference in costs was $20 045 (95% CI, $16 093-$24 120). Utility scores increased significantly between baseline and 6 months for both groups, with no significant differences between groups at any follow-up time point. Projected differences in lifetime costs of $16 740 and quality-adjusted life years (QALYs) of 0.08, yield an incremental cost-effectiveness ratio for PCDT of $222 041/QALY gained. In probabilistic sensitivity analysis, the probability that PCDT would achieve a lifetime incremental cost-effectiveness ratio <$50 000/QALY or <$150 000/QALY was 1% and 25%, respectively. For iliofemoral DVT, QALY gains with PCDT were greater, yielding an incremental cost-effectiveness ratio of $137 526/QALY; for femoral-popliteal DVT, standard therapy was an economically dominant strategy. Conclusions: With an incremental cost-effectiveness ratio >$200 000/QALY gained, PCDT is not an economically attractive treatment for proximal DVT. PCDT may be of intermediate value in patients with iliofemoral DVT. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00790335.
AB - Background: In patients with acute deep vein thrombosis (DVT), pharmacomechanical catheter-directed thrombolysis (PCDT) in conjunction with anticoagulation therapy is increasingly used with the goal of preventing postthrombotic syndrome. Long-term costs and cost-effectiveness of these 2 treatment strategies from the perspective of the US healthcare system have not been compared. Methods and Results: Between 2009 and 2014, the ATTRACT trial (Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis) randomized 692 patients with acute proximal DVT to PCDT plus anticoagulation (n=337) or standard treatment with anticoagulation alone (n=355). Costs (2017 US dollars) were assessed over a 24-month follow-up period using a combination of resource-based costing, hospital bills, Medicare reimbursement rates, and the Drug Topics Red Book. Health state utilities were obtained from the Short Form-36. In-trial results and US life tables were used to develop a Markov cohort model to evaluate lifetime cost-effectiveness. For the PCDT group, mean costs of the initial procedure were $13 600; per-patient costs associated with the index hospitalization were $21 509 for PCDT and $3877 for standard care (difference=$17 632; 95% CI, $16 117-$19 243). The 24-month difference in costs was $20 045 (95% CI, $16 093-$24 120). Utility scores increased significantly between baseline and 6 months for both groups, with no significant differences between groups at any follow-up time point. Projected differences in lifetime costs of $16 740 and quality-adjusted life years (QALYs) of 0.08, yield an incremental cost-effectiveness ratio for PCDT of $222 041/QALY gained. In probabilistic sensitivity analysis, the probability that PCDT would achieve a lifetime incremental cost-effectiveness ratio <$50 000/QALY or <$150 000/QALY was 1% and 25%, respectively. For iliofemoral DVT, QALY gains with PCDT were greater, yielding an incremental cost-effectiveness ratio of $137 526/QALY; for femoral-popliteal DVT, standard therapy was an economically dominant strategy. Conclusions: With an incremental cost-effectiveness ratio >$200 000/QALY gained, PCDT is not an economically attractive treatment for proximal DVT. PCDT may be of intermediate value in patients with iliofemoral DVT. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00790335.
KW - Medicare
KW - hospitalization
KW - postthrombotic
KW - quality-adjusted life years
KW - syndrome
KW - thrombosis
UR - http://www.scopus.com/inward/record.url?scp=85072972190&partnerID=8YFLogxK
U2 - 10.1161/CIRCOUTCOMES.119.005659
DO - 10.1161/CIRCOUTCOMES.119.005659
M3 - Article
C2 - 31592728
AN - SCOPUS:85072972190
SN - 1941-7713
VL - 12
JO - Circulation: Cardiovascular Quality and Outcomes
JF - Circulation: Cardiovascular Quality and Outcomes
IS - 10
M1 - e005659
ER -