Pricier heparin proves better for patients

Key Points

Hospital pharmacists fighting budget battles between unfractionated heparin (UFH) and low molecular weight heparin (LMWH) have a new ally. University of California Irvine Medical School researchers found that the total cost of care for patients at risk for venous thromboembolism (VTE) is lower using LMWH than UFH. LMWH is significantly more expensive than UHF.

"The issue that comes up is cost versus quality and doing the right thing for patients," said Alpesh Amin, MD, MBA, professor and interim chair of medicine, and executive director of the UCI Hospitalist Program. "In this study with a large database, the overall economic costs were lower with low molecular weight heparin than with unfractionated heparin."

Length of stay was similar for the two forms of heparin, but room and board, operating room, and medical supply costs were lower with LMWH. Total pharmacy costs were lower with UFH.

Amin and fellow researchers searched the MarketScan Hospital Drug Base for patients at risk for VTE who were discharged between January 2004 and March 2007. The retrospective analysis used the 7th American College of Chest Physicians (ACCP) guidelines for VTE prophylaxis.

Results were presented at the American Society of Hematology 2008 Annual Meeting.

Companion studies using data from the nationwide Premier hospital system found that full compliance with VTE prophylaxis guidelines provides better medical outcomes than does use of partial prophylaxis. Complete prophylaxis also costs less than partial prophylaxis. All three studies were supported by Sanofi-Aventis, which markets LMWH. (Amin has served on the speakers' bureau for Sanofi-Aventis.)

The difference in cost of care could be significant in even a single institution, Amin said. VTE is responsible for about 300,000 deaths in the United States annually, he said, which amounts to between 5 and 10 percent of total in-hospital mortality.

"We have the technology and the pharmacologic agents that can prevent VTE," he told Drug Topics. "Pharmacologic treatment works better than mechanical devices."

The basic problem is that appropriate VTE prophylaxis has not become part of the standard of care in many hospitals. Amin presented data at the ACCP annual meeting in 2006 showing that only about a third of US inpatients at risk for VTE receive appropriate prophylaxis.

About 62 percent of at-risk patients received some sort of VTE prophylaxis, Amin found. But only 34 percent of patients received prophylaxis meeting ACCP guidelines. Hospitals did best with ischemic stroke patients, providing appropriate prophylaxis to 49 percent.

The record was worse for other conditions: 43 percent for myocardial infarction patients, 40 percent for heart failure, 31 percent for lung disease, and 27 percent for cancer.

Amin's current studies paint an even grimmer picture. Among cancer discharges recorded in the Premier Perspective database between January 2002 and December 2006, only 16 percent of 84,000 cancer patients at risk for VTE received appropriate prophylaxis.

Cancer patients who did receive appropriate VTE prophylaxis had lower in-hospital mortality rates: 2.6 percent compared to 4.2 percent for patients who received partial prophylaxis. That translates into a 48 percent increase in the risk of in-hospital death for at-risk patients who do not receive appropriate VTE prophylaxis.

The total mean hospital cost for partial prophylaxis was $17,128, compared to $15,284 for appropriate prophylaxis. Less drug use costs hospitals more in total-care costs.

Results were similar for a larger group of medical-surgical patients hospitalized for cancer, chronic heart failure, orthopedic surgery, lung disease, and severe infectious disease. Among the 703,000 patients at risk for VTE, 22.3 percent received appropriate prophylaxis.

The median length of stay was seven days for patients with appropriate prophylaxis compared to eight days for patients who received only partial prophylaxis. The unadjusted costs were higher for partial prophylaxis ($17,712) than for complete prophylaxis ($15,458).

Even after multivariate analysis to adjust for differences between the two treatment groups, total hospital costs were $2,050 lower for patients who received appropriate VTE prophylaxis.

"Appropriate prophylaxis for [VTE] makes sense not only from an efficacy or quality-of-care perspective, but also from the economic perspective," Amin said.

He added that these results support clinicians who argue that healthcare systems should look at the total costs of care rather than at individual department budgets. Some hospitals have already abandoned budget silos in favor of system-wide costs and outcomes.

"These data help drive care toward outcomes rather than costs," Amin said. "Making that change comes down to getting the data in front of key decision makers."