Cost-Effectiveness of Pharmacomechanical Catheter-Directed Thrombolysis Versus Standard Anticoagulation in Patients With Proximal Deep Vein Thrombosis: Results From the ATTRACT Trial

Abstract

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.

Keywords: Medicare; hospitalization; postthrombotic; quality-adjusted life years; syndrome; thrombosis.

Conflict of interest statement

Disclosures

Elizabeth.A. Magnuson reports grant support from Abbott Vascular and Cardiovascular Systems, Inc. Susan R. Kahn reports advisory board fees from BMS Pfizer, Sanofi, and Aspen. Samuel Z. Goldhaber reports grant support from BiO2 Medical, and grant support and consulting fees from Boehringer Ingelheim, BMS, Daiichi Sankyo, Janssen, Portola, Bayer, BTG/Ekos. Michael 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.

Kevin Herman is a consultant for Cardiovascular Systems, Inc. Carl M. Black reports research support from Cook Medical. Suresh Vedantham reports research support from Cook Medical. David J. 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.

Figures

FIGURE 1.

Mean incremental follow-up costs (bars), and cumulative (index plus follow-up) costs (lines), for the PCDT and Standard Care groups. Error bars represent standard errors.

FIGURE 2.

Mean SF-36 Utility scores over time for the PCDT and Standard Care groups, after adjusting for missing data via multiple imputation. Error bars represent standard errors.

FIGURE 3.

Joint distribution of projected lifetime incremental costs and quality-adjusted life years for PCDT vs Standard Care based on probabilistic sensitivity analysis, plotted in the cost-effectiveness plane. (Red dot represents the estimated mean values (incremental cost=$16,740, incremental QALYs=0.08. Green dashed line indicates a cost-effectiveness threshold of $150,000/QALYs gained; orange dot-dashed line indicates a threshold of $50,000/QALYs gained.)

FIGURE 4.

One-way sensitivity analysis (tornado diagram) on ICER (PCDT vs. Standard Care). (The dotted vertical line represents the base-case incremental cost-effectiveness ratio for PCDT compared with standard care. Horizontal bars indicate the range of incremental cost-effectiveness ratios obtained by setting each variable to the values shown at the ends of the bar while holding all other values constant.)

FIGURE 5.

Results from two-way sensitivity analysis, varying the relative risk of worse PTS with PCDT after 6 months, and the duration of the impact of of PCDT on worsening PTS. (Chart shows the joint effect of two variables on the cost-effectiveness of PCDT at a willingness-to-pay threshold of $150,000 per QALY gained. The blue area represents values of the 2 parameters at which PCDT is favored, whereas the red area represents values of the 2 parameters at which standard care is favored. Black horizontal and vertical lines indicate basecase values of the two variables.)

FIGURE 6.

Results from two-way sensitivity analysis, varying the relative risk of worse PTS with PCDT at 6 months, and after 6 months (PCDT vs. control). (Chart shows the joint effect of two variables on the cost-effectiveness of PCDT at a willingness-to-pay threshold of $150,000 per QALY gained. The blue area represents values of the 2 parameters at which PCDT is favored, whereas the red area represents values of the 2 parameters at which standard care is favored. Black horizontal and vertical lines indicate basecase values of the two variables.)