RSS Feeds
Cost-Effectiveness of Low-Molecular-Weight Heparins for Deep Venous Thrombosis
- Michael K. Gould, MD, MSc; and
- Alan M. Garber, MD, PhD
- Veterans Affairs Palo Alto Health Care System; Stanford University School of Medicine; Stanford, CA 94305 (Gould) Veterans Affairs Palo Alto Health Care System; Stanford University School of Medicine; Stanford, CA 94305 (Garber)
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
IN RESPONSE:
Reilly and Evans correctly note that the mortality reduction for LMWHs was a critical variable in our cost-effectiveness analysis. That is why we used meta-analysis to derive estimates of treatment effectiveness based on the best available evidence. The weight of evidence from clinical trials does not support their conclusion that LMWHs and unfractionated heparin have the same effects on mortality rates in the treatment of deep venous thrombosis.
Deleting studies one at a time is a standard procedure used in meta-analysis to determine whether one or more studies exerted a disproportionate influence on the treatment effect. Deletion of the study by Hull and colleagues (1) resulted in loss of statistical significance but little change in the estimated treatment effect size. It is not logical for Reilly and Evans to suggest that this study should have been singled out for exclusion because it did not use a weight-based nomogram for the dosing of unfractionated heparin when none of the other studies used such a dosing regimen. Although we agree that evidence supports the use of the weight-based nomogram, our findings are likely to apply directly in community settings, where the weight-based nomogram may not be widely used.
Reily and Evans correctly point out that time costs associated with unfractionated heparin administration might be important if one adopts a cost-minimization approach to decision making. In a post hoc analysis, LMWH treatment became cost-saving when we assumed that unfractionated heparin administration required more than 1.4 hours of additional nursing or pharmacy time per hospital day. We suspect that less time is required in most instances of deep venous thrombosis treatment with unfractionated heparin. We agree with Reilly and Evans that this issue should be addressed in future studies. In the meantime, we stand by our conclusion that LMWHs are highly cost-effective, if not cost-saving, for the inpatient treatment of deep venous thrombosis.
Michael K. Gould, MD, MSc
Veterans Affairs Palo Alto Health Care System; Stanford University School of Medicine; Stanford, CA 94305
Alan M. Garber, MD, PhD
Veterans Affairs Palo Alto Health Care System; Stanford University School of Medicine; Stanford, CA 94305
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
