Should female relatives of factor V Leiden carriers be screened prior to oral contraceptive use?

Kenneth J. Smith; Brenna S. Monsef; Margaret V. Ragni

doi:10.1160/TH08-03-0149

Thrombosis and Haemostasis, Inhaltsverzeichnis

Thromb Haemost 2008; 100(03): 447-452
DOI: 10.1160/TH08-03-0149

Blood Coagulation, Fibrinolysis and Cellular Haemostasis

Schattauer GmbH

Should female relatives of factor V Leiden carriers be screened prior to oral contraceptive use?

A cost-effectiveness analysis

Autoren

Kenneth J. Smith

¹Medicine/Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA

²Section of Decision Sciences and Clinical Systems Modeling, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
Brenna S. Monsef

¹Medicine/Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
Margaret V. Ragni

¹Medicine/Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA

³Hemophilia Center of Western PA, Pittsburgh, Pennsylvania, USA

Abstract

Summary

Venous thromboembolism (VTE) is three-fold higher among FV Leiden (FVL) carriers receiving oral contraceptives (OCPs) than in the general population. FVL screening, however, is not routinely performed before prescribing OCP, and the cost-effectiveness of this strategy is unknown. A decision tree model was constructed to evaluate FVL screening and prophylactic anticoagulation (AC) strategies in female relatives of FVL carriers. In the model, AC was low molecular weight heparin, given warfarin embryopathy risks. VTE morbidity, mortality, and other clinical parameters were obtained from published studies. Drug costs were based on average wholesale price, and counseling included VTE risk with OCP use and FVL status. Outcomes included medical costs, effectiveness measured as quality-adjusted-life-years (QALY), and the incremental cost-effectiveness ratio (ICER) over 30 years, with cost and effectiveness discounted at 3%/year. FVL screening and counselling without prophylactic AC cost less and was more effective than no screening in this population, but was less effective than screening, counselling,and prophylaxis during high-risk periods, which gained 0.083 QALY, for an ICER of $147/QALY gained. Screening with counselling and long-term AC cost $3,536 with minimal QALY gain and an ICER >$600,000/QALY. Screening, OCP counseling, and prophylactic AC during high-risk periods was favoured and cost <$20,000/QALY, unless: (a) high-risk prophylaxis cost >$4,231 (base $932), (b) long-term prophylaxis cost < $1199 (base $6,546), or (c)VTE relative risk reduction with prophylaxis was <21% (base 90%).In conclusion, screening, counselling and prophylactic AC during high-risk periods in female relatives of FVL carriers is an economically favourable strategy.

Keywords

Cost effectiveness analysis - health economics - deep vein thrombosis - thrombophilia - familial thrombosis - oral contraceptives

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Referenzen

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