Potential long-term hospital-level economic impact of anticoagulation alone vs endovascular treatment in patients with deep vein thrombosis-related leg ulcers

Abstract

Objectives

Endovascular treatments for deep vein thrombosis (DVT) have shown effectiveness at rapidly restoring flow, which may help to decrease chronic venous disease (CVD) and venous leg ulcer (VLU) incidence. However, data describing such long-term outcomes are sparse. We analyze the location of thrombus at the incident acute DVT event in patients who subsequently developed VLUs. Further, we establish a model to estimate the long-term hospital level economic impact associated with endovascular DVT treatment compared with the standard of care, anticoagulation (AC).

Methods

This analysis consisted of a single-center retrospective chart review and hypothetical cost model. Patients were identified by International Classification of Diseases, 10th edition clinical modification, codes, chart, and imaging review. The economic model evaluated a hypothetical cohort of 100 patients through three distinct health care phases: initial DVT management, a period of worsening CVD symptoms, and long-term VLU wound care. Model parameters were derived from prior literature. Patients were simulated to receive endovascular treatment or AC over a period of 12 years. Cumulative costs were estimated assuming 20%, 40%, 50% (base case), 60%, and 80% effectiveness of endovascular treatment to prevent worsening CVD symptoms and VLU development.

Results

In total, 73 patients were identified and included. Incident DVTs were iliofemoral-popliteal in 4 of 73 (5.5%), isolated femoropopliteal in 43 of 73 (58.9%), femoropopliteal with below-the-knee-involvement in 11 of 73 (15.1%), and isolated below the knee in 15 of 73 (20.5%). The median initial DVT event occurred in July 2020 (interquartile range, June 2018 to January 2022) and the median time to VLU onset was 466 days (interquartile range, 51-1190 days). Per patient long-term cost estimates were $100,186 for AC and $100,100, $80,245, $70,318, $60,391, and $40,536 for endovascular treatment that is 20%, 40%, 50%, 60%, and 80% effective, respectively. The initial cost benefit compared with AC was anticipated at 11.4, 3.7, 2.8, 2.3, and 1.9 years for endovascular treatment that is 20%, 40%, 50%, 60%, and 80% effective, respectively.

Conclusions

This retrospective analysis identified a high incidence of femoral and below DVTs associated with VLU development, with little iliac involvement. Identifying at-risk patients with DVT is crucial for decreasing chronic complications; current technologies can treat femoropopliteal or more proximal disease effectively. Additionally, the hypothetical economic model suggests that endovascular DVT treatments could provide long-term savings if demonstrated to moderately decreasing VLU incidence.