Comparing strategies for thromboprophylaxis in major orthopedic surgery using an estimation of net risk-benefit through probabilistic simulation A clinical cost-effectiveness study

Abstract

Clinical decisions should take into account the clinical risk and benefit of a new intervention compared to the reference treatment. A method was developed to compare multiple competing interventions using a clinical cost-effectiveness approach. A meta-analysis was conducted to estimate the clinical cost (major bleeding) and benefit (averted venous thromboembolism) of thromboprophylaxis with different anticoagulants in orthopedic surgery. The increment in cost and benefit of anticoagulants compared to placebo were calculated using replications of the values obtained through Monte Carlo simulations. Net clinical benefit was calculated for each replication across a range of risk acceptance values (risk-benefit acceptability threshold). Multiple anticoagulants were compared by calculating the probability that each agent had of achieving the highest net clinical benefit. The preferred anticoagulants varied depending on risk acceptance, type of surgery, bleeding and thrombosis definitions, and timing of anticoagulant initiation. This method allowed comparing multiple interventions in the absence of randomized trials.