Costs and complications of hospital admissions for inferior vena cava filter malfunction.

OBJECTIVE: Inferior vena cava filter (IVCF) malfunction can result from penetration, fracture, or migration of the device necessitating retrieval. Endovascular and open retrieval of IVCF have been described in institutional series without comparison. This study examines national hospital admissions for IVCF malfunction and compares the outcomes of open and endovascular retrieval. METHODS: The National Inpatient Sample database (2016-2017) was reviewed for admissions with International Classification of Diseases, Tenth Revision (ICD-10) codes specific for IVCF malfunction. All ICD-10 procedural codes were reviewed, and patients were divided based on open or endovascular IVCF retrieval. Patient characteristics, outcomes, and costs of hospitalization were compared between the two groups. RESULTS: There were 665 patients admitted with a diagnosis of IVCF malfunction. Open IVCF retrieval was performed in 100 patients and endovascular removal in 90 patients. Of those undergoing open surgery, 45 patients (45%) required median sternotomy and 55 (55%) required abdominal surgeries. Most patients were white females with a mean age of 54.4 years (range, 49.3-59.6 years) with a history of deep venous thrombosis (55.3%) or pulmonary embolism (31.6%). Most patients with IVCF malfunction were treated in large (81.6%) or urban teaching (94.7%) hospitals situated most commonly in the South (42.1%) and Northeast (29.0%) with no difference in characteristics of the patients or the centers between the two groups. Patients undergoing open IVCF retrieval were more likely to undergo surgery on an elective basis compared with endovascular IVCF retrieval (75.0% vs 11.1%; P < .001). Open IVCF retrieval was associated with a higher likelihood of thromboembolic complication compared with endovascular retrieval (20% vs 0%; P = .04). There was a trend toward higher infectious complications and overall complications with endovascular removal, but this difference did not reach statistical significance. Open retrieval was associated with a mortality of 5.0% compared with no inpatient mortality with endovascular retrieval (P = .33). The mean hospital length of stay was no difference between the two groups. Open retrieval was associated with significantly higher hospital costs than endovascular retrieval ($34,276 vs $19,758; P = .05). CONCLUSIONS: Filter removal for patients with IVCF malfunction is associated with significant morbidity and cost, regardless of modality of retrieval. The introduction of specific ICD-10 codes for IVCF malfunction allows researchers to study these events. The development of effective tools for outpatient retrieval of malfunctioning IVCF could decrease related hospitalization and have potential savings for the healthcare system.

Permanent inferior vena cava filters offer greater expected patient utility at lower predicted cost.

OBJECTIVE: Retrievable inferior vena cava (IVC) filters were first approved for use in the United States in 2003 to address the long-term complications of migration, thrombosis, fracture, and perforation observed with permanent IVC filter implantation. Although Food and Drug Administration approval of retrievable IVC filters includes permanent implantation, the incidence of complications from long-term implantation appears to be greater than that reported with existing permanent IVC filters. Also, only a small fraction of such retrievable IVC filters are ever retrieved. The purpose of the present study was to determine the threshold retrieval rate at which the use of retrievable IVC filters could be justified. METHODS: A Markov decision tree was constructed comparing retrievable and permanent IVC filters regarding their effectiveness and cost. A review of the reported data provided outcome probabilities, and the Tufts Medical Center Cost-Effectiveness Analysis Registry was the source of the utility values for the various potential outcomes. Medicare reimbursement rates served as a proxy for costs. A sensitivity analysis was performed for various parameters, primarily to determine the retrieval rate threshold at which the use of retrievable IVC filters would outperform the use of permanent IVC filters. RESULTS: Base case analysis demonstrated a greater predicted effectiveness for permanent compared with retrievable IVC filter implantation (5.41 quality-adjusted life-years [QALY] vs 5.33 QALY) at a lower cost ($2070 vs $4650). Monte Carlo simulation at 10,000 iterations confirmed the expected utility (5.4 ± 3.0 QALY vs 5.3 ± 3.0 QALY; P = .0002) and cost ($1900 ± $7400 vs $4800 ± 9900; P < .0001) to be statistically superior for permanent IVC filters. A sensitivity analysis for the filter retrieval rate demonstrated that the strategy of using a retrievable IVC filter was never preferable for utility or cost. The superiority of permanent IVC filter placement for effectiveness and cost persisted, regardless of anticipated patient-predicted annual mortality. A two-way sensitivity analysis for both IVC filter removal rate and annual patient mortality confirmed the superiority of permanent IVC filter placement at all levels. CONCLUSIONS: The predicted effectiveness of permanent IVC filters was greater and the predicted cost lower than those for retrievable IVC filters, regardless of the IVC filter retrieval rate. This interpretation of existing reported data using Markov decision analysis modeling supports the argument that unless the long-term complication rate of retrievable IVC filters can be significantly improved, their use should be abandoned in favor of currently available permanent IVC filters.

Practice Variation in Vena Cava Filter Use Among Trauma Centers in the National Trauma Database.

BACKGROUND: Agreement regarding indications for vena cava filter (VCF) utilization in trauma patients has been in flux since the filter's introduction. As VCF technology and practice guidelines have evolved, the use of VCF in trauma patients has changed. This study examines variation in VCF placement among trauma centers. MATERIALS AND METHODS: A retrospective study was performed using data from the National Trauma Data Bank (2005-2014). Trauma centers were grouped according to whether they placed VCFs during the study period (VCF+/VCF-). A multivariable probit regression model was fit to predict the number of VCFs used among the VCF+ centers (the expected [E] number of VCF per center). The ratio of observed VCF placement (O) to expected VCFs (O:E) was computed and rank ordered to compare interfacility practice variation. RESULTS: In total, 65,482 VCFs were placed by 448 centers. Twenty centers (4.3%) placed no VCFs. The greatest predictors of VCF placement were deep vein thrombosis, spinal cord paralysis, and major procedure. The strongest negative predictor of VCF placement was admission during the year 2014. Among the VCF+ centers, O:E varied by nearly 500%. One hundred fifty centers had an O:E greater than one. One hundred sixty-nine centers had an O:E less than one. CONCLUSIONS: Substantial variation in practice is present in VCF placement. This variation cannot be explained only by the characteristics of the patients treated at these centers but could be also due to conflicting guidelines, changing evidence, decreasing reimbursement rates, or the culture of trauma centers.

Costs and complications of endovascular inferior vena cava filter retrieval.

OBJECTIVE: Advanced endovascular techniques are frequently used for challenging inferior vena cava (IVC) filter retrieval. However, the costs of IVC filter retrieval have not been studied. This study compares IVC filter retrieval techniques and estimates procedural costs. METHODS: Consecutive IVC filter retrievals performed at a tertiary center between 2009 and 2014 were retrospectively reviewed. Procedures were classified as standard retrieval (SR) if they required only a vascular sheath and a snare device and as advanced endovascular retrieval (AER) if additional endovascular techniques were used for retrieval. Cost data were based on hospital bills for the procedures. Patients' characteristics, filter dwell time, retrieval procedure details, complications, and costs were compared between the groups. All statistical comparisons were performed using SAS 9.3 software. RESULTS: There were 191 IVC filter retrievals (SR, 157; AER, 34) in 183 patients (mean age, 55 years; 51% male). Fifteen filters (7.9%) were placed at an outside hospital. The indications for placement were mostly therapeutic (76% vs 24% for prophylaxis). All IVC filters were retrievable, with Bard Eclipse (Bard Peripheral Vascular, Tempe, Ariz; 34%) and Cook Günther Tulip (Cook Medical, Bloomington, Ind; 24%) the most common. Venous ultrasound examination of the lower extremities of 133 patients (70%) was performed before retrieval, whereas only 5 patients (2.6%) received a computed tomography scan of the abdomen. There was no difference in the mean filter dwell time in the two groups (SR, 147.9 ± 146.1 days; AER, 161.4 ± 91.3 days; P = .49). AERs were more likely to have had prior attempts at retrieval (23.5%) compared with SRs (1.9%; P < .001). The most common AER techniques used were the wire loop and snare sling (47.1%) and the stiff wire displacement (44.1%). Bronchoscopy forceps was used in four cases (11.8%); this was the only off-label device used. AERs were more likely to require more than one venous access site for the retrieval procedure (23.5% vs 0%; P < .001). AERs were significantly more likely to have longer fluoroscopy time (34.4 ± 18.3 vs 8.1 ± 7.9 minutes; P < .001) and longer total procedural time (102.8 ± 59.9 vs 41.1 ± 25.0 minutes; P < .001) compared with SRs. The complication rate was higher with AER (20.6%) than with SR (5.2%; P = .006). Most complications were abnormal radiologic findings that did not require additional intervention. The procedural cost of AER was significantly higher (AER, $14,565 ± $6354; SR, $7644 ± $2810; P < .001) than that of SR. This translated to an average increase in cost of $6921 ± $3544 per retrieval procedure for AER. CONCLUSIONS: Advanced endovascular techniques provide a feasible alternative when standard IVC filter retrieval techniques do not succeed. However, these procedures come with a higher cost and higher rate of complications.

Prophylactic Inferior Vena Cava Filters Prior to Bariatric Surgery: Insights From the National Inpatient Sample.

OBJECTIVES: The aim of this study was to determine in-hospital mortality, post-surgical thromboembolic events, and health care costs associated with the placement of prophylactic inferior vena cava filters (IVCFs) prior to bariatric surgery. BACKGROUND: The role of prophylactic IVCFs prior to bariatric surgery is controversial, and the nationwide clinical outcomes associated with this practice are unknown. METHODS: This observational study used the National Inpatient Sample database to identify obese patients who underwent bariatric surgery from January 2005 to September 2015. Using propensity score matching, outcomes associated with patients receiving prophylactic IVCFs prior to their bariatric surgery were compared with those among patients who did not receive IVCFs. RESULTS: A total of 258,480 patients underwent bariatric surgery, of whom 1,047 (0.41%) had prophylactic IVCFs implanted. Patients with prophylactic IVCFs compared with those without IVCFs had a significantly higher rate of the combined endpoint of in-hospital mortality or pulmonary embolism (1.4% vs. 0.4%; odds ratio: 3.75; 95% confidence interval [CI]: 1.25 to 11.30; p = 0.019). Additionally, prophylactic IVCFs were associated with higher rates of lower extremity or caval deep vein thrombosis (1.8% vs. 0.3%; odds ratio: 6.33; 95% CI: 1.87 to 21.4; p < 0.01), length of stay (median 3 days vs. 2 days; p < 0.01), and hospital charges (median $63,000 vs. $37,000; p < 0.01). CONCLUSIONS: In this nationwide observational study, prophylactic IVCF implantation prior to bariatric surgery was associated with worse clinical outcomes and increased health care resource utilization.

Inferior Vena Cava Filter Malpractice Litigation: Damned if You Do, Damned if You Don't.

BACKGROUND: The aim of this study was to analyze malpractice litigation trends and to better understand the causes and outcomes of suits involving inferior vena cava filters (IVCF) to prevent future litigation and improve physician education. METHODS: Jury verdict reviews from the Westlaw database from January 1, 2000, to December 31, 2015, were reviewed. The search term "inferior vena cava filter" was used to compile data on the demographics of the defendant, plaintiff, allegation, complication, and verdict. RESULTS: A total of 156 cases were identified. Duplicates and cases in which the IVCF was incidentally included were excluded from the analysis. Forty-nine cases involving either failure to place or a complication of IVCF placement were identified. Throughout the last 15 years, there has been increased number of jury verdicts toward IVCF. The most frequent defendants were internal medicine physicians (38%), vascular surgeons (19%), and cardiothoracic surgeons (12%). The most frequent claims were denied treatment or delay in treatment (in 35% of cases), negligent surgery (in 24% of cases), and failure to diagnose and treat complications (in 24% of cases). Of these, the most frequent specific claims were failure to place IVC filter (41%), implantation failure such as misplacement and/or misaligned implant (24%), erosion of IVC/retroperitoneal bleed (6%), and discontinuation of anticoagulation prematurely (6%). Seventeen cases (35%) were found for the plaintiff, with median awards worth of $1,092,500. In the 21 cases where pulmonary embolism (PE) was involved (43% of cases), 19 were fatal (90%). Of the fatal PE cases, 8 cases ended with verdicts in favor of the plaintiff (42%). Both nonfatal PE cases were won by the defense. CONCLUSIONS: IVCF placement with subsequent PE and death results in verdicts that favor the plaintiffs. This study emphasizes that adequate and transparent communication regarding preoperative planning, decision for IVCF placement, and informed consent may reduce the frequency of litigation. Public awareness of complications related to the placement of IVCF is increasing largely and spurned by aggressive advertising and marketing by plaintiff attorneys. Conditions for which IVCF placement is contemplated carry significant risk of malpractice litigation.

Outcomes and Direct Costs of Inferior Vena Cava Filter Placement and Retrieval within the IR and Surgical Settings.

PURPOSE: To compare the outcomes and costs of inferior vena cava (IVC) filter placement and retrieval in the interventional radiology (IR) and surgical departments at a tertiary-care center. MATERIALS AND METHODS: Retrospective review was performed of 142 sequential outpatient IVC filter placements and 244 retrievals performed in the IR suite and operating room (OR) from 2013 to 2016. Patient demographic data, procedural characteristics, outcomes, and direct costs were compared between cohorts. RESULTS: Technical success rates of 100% were achieved for both IR and OR filter placements, and 98% of filters were successfully retrieved by IR means, compared with 83% in the OR (P < .01). Fluoroscopy time was similar for IR and OR filter insertions, but IR retrievals required half the fluoroscopy time, with an average of 9 minutes vs 18 minutes in the OR (P = .02). There was no significant difference between cohorts in the incidences of complications for filter retrievals, but more postprocedural complications were observed for OR placements (8%) vs IR placements (1%; P = .05). The most severe complication occurred during an OR filter retrieval, resulting in entanglement of the snare device and conversion to an emergent open filter removal by vascular surgery. Direct costs were approximately 20% higher for OR vs IR IVC filter placements ($2,246 vs $2,671; P = .01). CONCLUSIONS: Filter placements are equally successfully performed in IR and OR settings, but OR patients experienced significantly higher postprocedural complication rates and incurred higher costs. In contrast, higher technical success rates and shorter fluoroscopy times were observed for IR filter retrievals compared with those performed in the OR.

Money well spent? A cost and utilization analysis of prophylactic inferior vena cava filter placement in high-risk trauma patients.

BACKGROUND: Inferior vena cava filters (IVCF) for venous thromboembolic prophylaxis in high-risk trauma patients is a controversial practice. Utilization of IVCF prophylaxis was evaluated at a level 1 trauma center. Daily cost of IVCF prophylaxis, time to IVCF, duration between IVCF and chemoprophylaxis, and number of patients needed to treat (NNT) to prevent pulmonary embolism (PE) was calculated. METHODS: A retrospective review of prophylactic IVCF over a 5-year period (2010-2014). Demographic, physiologic, injury, procedural, and outcome data were abstracted from the administrative trauma database. Medicare fees and days without chemoprophylaxis were used to determine daily IVCF cost. NNT was calculated using PE events in a cohort without IVCF. RESULTS: Over the 5-year period, 146 patients with mean age 56.3 y (SD ± 24.2), 67.8% male, underwent prophylactic IVCF. Predominant mechanisms of injuries were falls (45.9%) and motor vehicle accidents (20.5%) with median Injury Severity Score of 25 (intraquartile range [IQR] 16-29) and head Abbreviated Injury Score of 3 (IQR 3-5). Most common operative interventions required in 24.7% were orthopedic (25.3%) and neurosurgical (21.9%). Median time to IVCF was 78 h (IQR 48-144). Most common IVCF indications were closed head injury (48.6%) and spinal injuries (30.8%). Median time to administration of chemoprophylaxis was 96 h after IVCF (IQR 24-192) in 57.5%. Median IVCF cost was $759/d (IQR $361-$1897) compared with $4.32 for chemoprophylaxis. PE occurred in 0.26% without IVCF. PE did not occur with prophylactic IVCF. Estimated NNT was 379 (95% CI 265, 661). CONCLUSIONS: Prophylactic IVCF placement is a costly practice with relatively low benefit. Anticipated time without chemoprophylaxis and patient criteria should be considered before routine IVCF placement.

Cost-benefit analysis of establishing an inferior vena cava filter clinic.

PURPOSE: Adverse events associated with retrievable inferior vena cava filters (IVCFs) have generated an increased interest in improving IVCF retrieval rates to improve patient safety and quality care. This study aims to demonstrate the cost-benefit of implementing an IVCF clinic to improve patient care in an institution in the United States. METHODS: An IVCF clinic was established at a single institution in September 2012 and for ten months referring physicians were contacted to facilitate retrieval when appropriate. Additionally, a retrospective review was conducted on filter placements over the eight preclinic months. Cost-benefit analysis was conducted by creating a model, which incorporated the average cost and reimbursement for permanent and retrievable IVCFs. RESULTS: A total of 190 IVCFs (152 retrievable IVCFs and 38 permanent IVCFs) were implanted during the IVCF clinic period. Twenty-nine percent of the retrievable IVCFs were successfully retrieved compared to 10 of 119 retrievable IVCFs placed during the preclinic period (8.4%). Cost-benefit analysis, using the average of the institution's six most common reimbursement schedules, demonstrated an average net financial loss per permanent or retrievable IVCF not removed. However, a net financial gain was realized for each retrievable IVCF removed. The additional hospital cost to maintain the IVCF clinic was offset by removing an additional 3.1 IVCFs per year. CONCLUSION: An IVCF clinic significantly increases retrieval rates, promotes patient safety, and is economically feasible. Given the adverse event profile of retrievable IVCFs, strategic efforts such as these ultimately can improve quality care for patients with in-dwelling IVCFs.

Bundling of Reimbursement for Inferior Vena Cava Filter Placement Resulted in Significantly Decreased Utilization between 2012 and 2014.

BACKGROUND: On January 1, 2012, reimbursement for inferior vena cava filters (IVCFs) became bundled by the Centers for Medicare and Medicaid Services. This resulted in ICVF placement (CPT code 37191) now yielding 4.71 relative value units (RVUs), a decrease from 15.6 RVUs for placement and associated procedures (CPT codes 37620, 36010, 75825-26, 75940-26). Our hypothesis was that IVCF utilization would decrease in response to this change as other procedures had done once they had become bundled. METHODS: Including data from 2010 to 2011 (before bundling) and 2012 to 2014 (after bundling), we utilized 5% inpatient, outpatient, and carrier files of Medicare limited data sets and analyzed IVCF utilization before and after bundling across specialty types, controlling for total diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE) (ICD-9 codes 453.xx and 415.xx, respectively) and placement location. RESULTS: In 2010 and 2011, the rates/10,000 DVT/PE diagnoses were 918 and 1,052, respectively (average 985). In 2012, 2013, and 2014, rates were 987, 877, and 605, respectively (average 823). Comparing each year individually, there is a significant difference (P < 0.0001) with 2012, 2013, and 2014 having lower rates of ICVF utilization. Comparing averages in the 2010-2011 and 2012-2014 groups, there is also a significant decrease in utilization after bundling (P < 0.0001). CONCLUSIONS: Following the bundling of reimbursement for IVCF placement, procedural utilization decreased significantly. More data from subsequent years will be needed to show if this decrease utilization continues to persist.

Impact of consensus statements and reimbursement on vena cava filter utilization.

OBJECTIVE: Pulmonary embolism is the third most common cause of death in hospitalized patients. Vena cava filters (VCFs) are indicated in patients with venous thromboembolism with a contraindication to anticoagulation. Prophylactic indications are still controversial. However, the utilization of VCFs during the past 15 years may have been affected by societal recommendations and reimbursement rates. The aim of this study was to evaluate the impact of societal guidelines and reimbursement on national trends in VCF placement from 1998 to 2012. METHODS: The National Inpatient Sample was used to identify patients who underwent VCF placement between 1998 and 2012. VCF placement yearly rates were evaluated. Societal guidelines and consensus statements were identified using a PubMed search. Reimbursement rates for VCF were determined on the basis of published Medicare reports. Statistical analysis was completed using descriptive statistics, Fisher exact test, and trend analysis using the Mann-Kendall test and considered significant for P < .05. RESULTS: The use of VCFs increased 350% between January 1998 and January 2008. Consensus statements in favor of VCFs published by the Eastern Association for the Surgery of Trauma (July 2002) and the Society of Interventional Radiology (March 2006) were temporally associated with a significant 138% and 122% increase in the use of VCFs, respectively (P = .014 and P = .023, respectively). The American College of Chest Physicians guidelines (February 2008 and 2012) discouraging the use of VCFs were preceded by an initial stabilization in the use of VCFs between 2008 and 2012, followed by a 16% decrease in use starting in March 2012 (P = .38). Changes in Medicare reimbursement were not followed by a change in VCF implantation rates. CONCLUSIONS: There is a temporal association between the societal guidelines' recommendations regarding VCF placement and the actual rates of insertion. More uniform consensus statements from multiple societies along with the use of level I evidence may be required to lead to a definitive change in practice.

Inferior vena cava filter retrieval provides no advantage in the average patient.

BACKGROUND: Inferior vena cava (IVC) filter placement is performed to mitigate the risk of pulmonary embolism (PE) when anticoagulation is contraindicated or ineffective. Technical advances now allow catheter-based filter retrieval. Many believe the benefits of retrieval are self-evident, yet retrieval carries an inherent complication risk and cost. The purpose of this study was to quantitatively weigh the risks and benefits of IVC filter retrieval using formal decision analysis. METHODS: A Markov state-transition model was used to simulate two clinical scenarios: to leave a previously placed IVC filter or to retrieve it. Analysis was performed during the lifetime of the individual, and outcomes were expressed in quality-adjusted life-years (QALYs). The base case is a 60-year-old man with a filter placed within 3 months who no longer requires mechanical thromboprophylaxis. Potential events included PE, filter complications, and death from all other causes during each cycle. Tolls were used to incorporate the disutility of short-term treatment for PE and filter complications. For the base case and sensitivity analyses, we used utilities and probabilities derived from the literature. RESULTS: In the base case scenario, leaving the filter in place was preferred to filter retrieval, yielding 22.3 vs 21.9 QALYs. One-way sensitivity analysis demonstrated that filter retrieval may be preferable if the utility of living with a filter is <0.98. For all probabilities of retrieval and PE mortality, leaving the filter in place is preferred. CONCLUSIONS: Leaving a previously placed IVC filter provides a 0.4 QALY benefit over retrieving the filter for the average patient. This decision is sensitive to the utility of living with the IVC filter.

Technical and financial feasibility of an inferior vena cava filter retrieval program at a level one trauma center.

BACKGROUND: Considering new guidelines for retrievable inferior vena cava filters (IVCFs), we examine our initial experience after establishing a comprehensive filter removal program in our level 1 trauma center. We evaluated the technical and financial feasibility of this program and barriers to IVCF retrieval, including insurance status and costs, in trauma patients. METHODS: Trauma patients receiving IVCFs from May 2011 to 2013 were consented and prospectively enrolled in the study program. Retrieval rates were assessed for the years before study initiation. Primary outcome was IVCF retrieval. Hospital financial data for retrieval were examined and univariate analysis performed. Hospital cost-to-charge and payment-to-charge ratios were assessed. RESULTS: Before study initiation from April 2009 to 2011, 66 IVCFs were placed in trauma patients with only 2 retrievals in 2 years. During the study period, 247 trauma patients had IVCF placement of which 111 (45%) were enrolled. The main reason for nonenrollment was lack of referral by the implanting team. Retrieval was attempted in 100 outpatients with success in 85 (85%). Patients enrolled in the program were more likely to have their filters removed (73% vs. 18%; odds ratio, 12.6; 95% confidence interval, 6.6-24.3; P < 0.001). Mean time from placement to attempt was 6.2 ± 4.0 months (range, 0.5-31.8). Of the total attempts, 29% were nonresource patients, 11% had Medicaid, and 60% had commercial insurance including Medicare patients. Chances of successful retrieval were higher if performed later during the study (P = 0.03). Successful retrieval was not related to insurance status (P = not significant). The mean total hospital charges related to retrieval were $4,493 (range, $2,510-$9,106). Successful retrieval contributed to lower total charges (P < 0.01). Factors contributing to higher total charges were retrieval attempt later in study period (P = 0.01) and commercial insurance status (P = 0.04). CONCLUSIONS: The rate of IVCF placement in trauma patients increased 4-fold over 4 years. The rate of IVCF retrieval increased more than 14-fold during the same period after establishment of the retrieval program. Elective outpatient retrieval of IVCFs in all eligible trauma patients is financially feasible without loss to the health care system even in regions with high rates of uninsured. A major barrier to successful filter retrieval was lack of patient referral into the program by implanting physicians. Hospital administration and physician outreach are important determinants of successful IVCF retrieval in trauma patients.

Cost-effectiveness of guidelines for insertion of inferior vena cava filters in high-risk trauma patients.

BACKGROUND: Inferior vena cava filters (IVCFs) can prevent pulmonary embolism (PE); however, indications for use vary. The Eastern Association for the Surgery of Trauma (EAST) 2002 guidelines suggest prophylactic IVCF use in high-risk patients, but the American College of Chest Physicians (ACCP) 2008 guidelines do not. This analysis compares cost-effectiveness of prophylactic vs therapeutic retrievable IVCF placement in high-risk trauma patients. METHODS: Markov modeling was used to determine incremental cost-effectiveness of these guidelines in dollars per quality-adjusted life-years (QALYs) during hospitalization and long-term follow-up. Our population was 46-year-old trauma patients at high risk for venous thromboembolism (VTE) by EAST criteria to whom either the EAST (prophylactic IVCF) or ACCP (no prophylactic IVCF) guidelines were applied. The analysis assumed the societal perspective over a lifetime. For base case and sensitivity analyses, probabilities and utilities were obtained from published literature and costs calculated from Centers for Medicare & Medicaid Services fee schedules, the Healthcare Cost & Utilization Project database, and Red Book wholesale drug prices for 2007. For data unavailable from the literature, similarities to other populations were used to make assumptions. RESULTS: In base case analysis, prophylactic IVCFs were more costly ($37,700 vs $37,300) and less effective (by 0.139 QALYs) than therapeutic IVCFs. In sensitivity analysis, the EAST strategy of prophylactic filter placement would become the preferred strategy in individuals never having a filter, with either an annual probability of VTE of ≥ 9.6% (base case, 5.9%), or a very high annual probability of anticoagulation complications of ≥ 24.3% (base case, 2.5%). The EAST strategy would also be favored if the annual probability of venous insufficiency was <7.69% (base case, 13.9%) after filter removal or <1.90% with a retained filter (base case, 14.1%). In initial hospitalization only, EAST guidelines were more costly by $2988 and slightly more effective by .0008 QALY, resulting in an incremental cost-effectiveness ratio of $383,638/QALY. CONCLUSIONS: Analysis suggests prophylactic IVC filters are not cost-effective in high-risk trauma patients. The magnitude of this result is primarily dependent on probabilities of long-term sequelae (venous thromboembolism, bleeding complications). Even in the initial hospitalization, however, prophylactic IVCF costs for the additional quality-adjusted life years gained did not justify use.

An economic evaluation of venous thromboembolism prophylaxis strategies in critically ill trauma patients at risk of bleeding.

BACKGROUND: Critically ill trauma patients with severe injuries are at high risk for venous thromboembolism (VTE) and bleeding simultaneously. Currently, the optimal VTE prophylaxis strategy is unknown for trauma patients with a contraindication to pharmacological prophylaxis because of a risk of bleeding. METHODS AND FINDINGS: Using decision analysis, we estimated the cost effectiveness of three VTE prophylaxis strategies-pneumatic compression devices (PCDs) and expectant management alone, serial Doppler ultrasound (SDU) screening, and prophylactic insertion of a vena cava filter (VCF) -- in trauma patients admitted to an intensive care unit (ICU) with severe injuries who were believed to have a contraindication to pharmacological prophylaxis for up to two weeks because of a risk of major bleeding. Data on the probability of deep vein thrombosis (DVT) and pulmonary embolism (PE), and on the effectiveness of the prophylactic strategies, were taken from observational and randomized controlled studies. The probabilities of in-hospital death, ICU and hospital discharge rates, and resource use were taken from a population-based cohort of trauma patients with severe injuries (injury severity scores >12) admitted to the ICU of a regional trauma centre. The incidence of DVT at 12 weeks was similar for the PCD (14.9%) and SDU (15.0%) strategies, but higher for the VCF (25.7%) strategy. Conversely, the incidence of PE at 12 weeks was highest in the PCD strategy (2.9%), followed by the SDU (1.5%) and VCF (0.3%) strategies. Expected mortality and quality-adjusted life years were nearly identical for all three management strategies. Expected health care costs at 12 weeks were Can$55,831 for the PCD strategy, Can$55,334 for the SDU screening strategy, and Can$57,377 for the VCF strategy, with similar trends noted over a lifetime analysis. CONCLUSIONS: The attributable mortality due to PE in trauma patients with severe injuries is low relative to other causes of mortality. Prophylactic placement of VCF in patients at high risk of VTE who cannot receive pharmacological prophylaxis is expensive and associated with an increased risk of DVT. Compared to the other strategies, SDU screening was associated with better clinical outcomes and lower costs.

Retrievable versus permanent caval filter procedures: when are they cost-effective for interventional radiology?

PURPOSE: Because many retrievable inferior vena cava (IVC) filters are placed without ever being removed, placement of a retrievable device that is not removed incurs greater technical cost for the institution than a cheaper permanent filter (PF), with no clinical benefit for the patient and no additional professional or technical revenue for the interventional radiologist and institution. The purposes of this study are to identify patient characteristics associated with lack of removal of a retrievable filter (RF) and to develop a cost-effective strategy for placement of a retrievable IVC filter. MATERIALS AND METHODS: A retrospective evaluation of 160 consecutive patients who underwent IVC filter placement with or without removal in our interventional radiology (IR) unit over a period of 31 months was performed. Patient characteristics were identified that were associated with lack of removal of retrievable IVC filters, and the cost savings were calculated in the event that a PF had been substituted for an RF in these patients. RESULTS: A total of 160 consecutive IVC filters were placed during the study period. Of these, 42 (26%) were PFs and 118 (74%) were RFs. During the study period, only 27 of the 118 RFs (23%) were subsequently removed. Factors associated with lack of removal of an RF included patient age (P = .003), presence of ongoing malignancy (P = .04), and indication for filter placement (P = .01). Retrospectively, the use of retrievable devices only in the presence of two of the three selection criteria (ie, age <65 years, no ongoing malignancy, prophylactic indication) would have resulted in a net incremental benefit of $59,562 for the IR service. CONCLUSIONS: The preferential use of retrievable versus permanent devices for filter placement is financially advantageous for an IR unit only if at least 41% of them are eventually removed. The use of clinical criteria to select device type allows significant cost savings.

Clinical outcomes and cost comparison of carotid artery angioplasty with stenting versus carotid endarterectomy.

BACKGROUND: Recently, carotid angioplasty with stenting (CAS) has evolved as an alternative to carotid endarterectomy (CEA) for the treatment of carotid occlusive disease. Some concerns have arisen regarding the high cost of stents and neuroprotection devices, which may inflate the overall procedural costs relative to CEA. We report here a review and analysis contrasting the clinical outcomes and associated hospital costs incurred for patients treated with either CAS or CEA. METHODS: Ninety-four consecutive patients with surgically amenable carotid stenosis were offered CAS or CEA. Forty-six patients elected CAS, and 48 patients underwent CEA. CAS was performed with the Smart Precise or Acculink stents, and all procedures included neuroprotection (Filter Wire or Accunet). CEA was performed with patients under general anesthesia with routine shunting and with Dacron or bovine pericardium patches. Clinical outcomes such as perioperative mortality, major adverse events (myocardial infarction, stroke, and death), length of stay, and the incidence of hemodynamic instability were analyzed. Total costs, indirect costs, and direct procedural costs associated with hospitalization were also reviewed. RESULTS: CAS was associated with a shorter length of stay compared with CEA (1.2 vs 2.1 days; P = .02). Differences in perioperative mortality (0% vs 2%; P = NS), major adverse events (2% vs 10%; P = .36), strokes (2% vs 4%; P = NS), myocardial infarctions (0% vs 4%; P = .49), and hypotension necessitating pressor support (21% vs 18%; P = NS) were not statistically significant. By using cost to charge ratio methodology according to the Medicare report, CAS was associated with higher total procedural costs (US dollars 17,402 vs US dollars 12,112; P = .029) and direct costs (US dollars 10,522 vs US dollars 7227; P = .017). The differences in indirect costs were not significant (US dollars 6879 vs US dollars 4885; P = .063). CONCLUSIONS: CAS with neuroprotection was associated with clinical outcomes equivalent to those with CEA but had higher total hospital costs. These higher costs reflect the addition of expensive devices that have improved the technical success and the clinical outcomes associated with CAS.