Heparin and the In-Hospital Management of Deep Venous Thrombosis: Cost Considerations

Numerous protocols for the treatment of deep venous thrombosis (DVT) with heparin have been recommended. In the past, physicians rarely considered costs in their decision to use a particular protocol; however, the recent introduction of the diagnosis-related groups (DRGs) and other cost-reduction measures has imposed financial limitations on the practice of medicine and surgery. To determine how the cost of treatment for DVT at the Mayo Clinic might be affected by the use of alternative heparin protocols, we conducted a two-stage study. In the first part, charts of 40 patients with uncomplicated DVT were analyzed retrospectively to determine an “average” Mayo Clinic heparin protocol for DVT. In the second part, this “average” protocol was compared with four other currently advocated protocols, and the cost of using each protocol at the Mayo Clinic was estimated. These protocols differed from the Mayo Clinic protocol with respect to method and route of heparin administration, frequency of monitoring anticoagulation, and duration of heparin treatment. This analysis revealed that the average charges resulting from treatment of DVT at the Mayo Clinic exceeded the corresponding DRG payment and that the cost of treatment varied substantially with the protocol used (a difference of more than $2,000 between two of the protocols analyzed). A review of the literature provided little evidence to suggest that the alternative protocols were not equally effective. Therefore, we concluded that measures such as shortening the duration of heparin therapy, administration of heparin by the subcutaneous route, and minimal monitoring of anticoagulation (in patients with a low risk of bleeding) can substantially reduce the cost of treating DVT and may be no less effective than other protocols for heparinization. As much as $600 million could be saved annually in the United States by using the least expensive protocols as opposed to the most expensive ones.