Review ArticleThe economic burden of incident venous thromboembolism in the United States: A review of estimated attributable healthcare costs☆
Introduction
Estimates of costs of disease can be used to project the benefit of prevention [1], [2]. Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is associated with more than one-half million hospitalizations in the United States (US) each year [3], and is a contributing cause in 100,000 or more deaths [4], [5]. It causes long-term morbidity, notably post-thrombotic syndrome (PTS) following DVT and chronic thromboembolic pulmonary hypertension (CTEPH) following PE. Medical costs for VTE in the US have been estimated to total $5–10 billion per year [6]. Published estimates of the total economic impact of VTE, including the value of lost economic output due to premature mortality, are as high as $69 billion per year [7], [8]. This paper reviews published estimates of the burden of VTE on the US healthcare system in terms of per-patient and aggregate incremental direct medical costs.
Estimates of the incidence of clinically validated VTE diagnoses fall in the range of 1.0–1.5 per 1000 persons per year, excluding studies of adults over 45 years. Two US studies reported all-age annual incidence of 1.18 per 1000 population in Rochester County, MN, during 1991–1997 [9] and 1.33 per 1000 population in Worcester, MA, during 2009 [10]. Applied to the US population of approximately 320 million people those incidence rates suggest 375,000–425,000 recognized incident VTE cases per year, not including cases that remain undiagnosed and untreated. Two population-based studies from Canada and France reported incident (first) VTE diagnoses in 1.22–1.36 per 1000 people [11], [12]. Two prospective Norwegian cohort studies of adults of all ages reported incidence rates of 1.43–1.48 per 1000 person-years [13], [14], which applied to 245 million US adults implies 350,000–365,000 incident cases per year in adults. Because VTE is a chronic condition, prevalence exceeds incidence; 1 million Americans may have prevalent treated VTE [15].
Section snippets
Methods
Following publication of a critique [6] of published estimates of the economic burden of VTE in the US [7], the author of that critique (SDG) conducted a non-structured literature review in late 2013. To maximize comparability, only studies based on US data published since 2002 were included for the primary search for estimates of first-year treatment costs for patients with an incident VTE. A subsequent structured search of PubMed was conducted in July 2014 to identify US studies that
Acute VTE and first-year costs
MacDougall et al. used claims data to calculate annualized costs of care for patients who had a first acute VTE event compared with similar patients, all of whom had 360 pre-index days free of claims associated with DVT or PE. The authors used regression analysis to control for age, sex, duration of follow-up, and pre-index comorbidities; 85% of VTE patients had a predisposing medical condition (Table 1) [24]. Monthly costs for individuals with less than 12 months of post-VTE claims data were
Discussion
These cost estimates are subject to caveats. First, use of administrative data could bias the average estimated cost of treatment through misclassification of who has an incident condition [16]. Although ICD-9 codes for DVT or PE have fairly high reliability in inpatient records, a fraction of inpatients with those codes do not have acute VTE [63]. Many outpatients classified as having VTE on the basis of an ICD-9 code for DVT and a prescription for an anticoagulant may not have acute DVT
Conclusion
We conclude that the best currently available estimates of the aggregate economic impact of incident or prevalent VTE cases on the US healthcare system are in the range of $7 billion to $10 billion per year, consistent with the majority of previous estimates [6]. Gross per-person treatment costs yield higher estimates, but people with VTE often have higher treatment costs for reasons unrelated to the VTE. It is essential to calculate risk-adjusted costs through use of adjustments for
Acknowledgments
We thank Patrick Lefebvre, Kurt Mahan, Nimia Reyes, and Patrick Romano for helpful comments on earlier versions of this paper.
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Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, the Department of Veterans Affairs, or the United States government. This material is the result, in part, of work supported with resources and the use of facilities of the George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah.