Prophylaxis against venous thromboembolic disease: costs and controversy.

To The Editor: The Instructional Course Lecture "Prophylaxis Against Venous Thromboembolic Disease in Patients Having a Total Hip or Knee Arthroplasty" (2002;84: 466-77), by Sculco et al., provides an accurate summary of current practices in the United States. The authors devoted a considerable amount of space to a review of the literature on chemical prophylaxis with warfarin and low-molecular-weight heparins. A shorter section was devoted to the use of mechanical devices and an even shorter one, to the use of aspirin. The authors clearly stated the controversy about the most effective method of reducing the complications of fatal pulmonary embolism, nonfatal pulmonary embolism, and deep venous thrombosis, and they provided multiple examples. However, they addressed the issue in the legendary manner of blind men describing the elephant on the basis of touching only individual parts. In doing so, it seems that they lost objectivity and were unable to draw conclusions based on a synthesis of the results reported by a number of investigators. The review of the literature pertaining to prophylaxis with warfarin and low-molecular-weight heparin was more thorough than that pertaining to aspirin despite the fact that aspirin has been found to be effective by some investigators. In the section "Clinical Studies," the authors stated that "clinical trials involving a combination of compression devices and postoperative aspirin prophylaxis have demonstrated rates of proximal and distal venous thrombosis that are similar to those associated with the use of low-molecular-weight heparin, but with fewer major bleeding complications. The combination of pneumatic compression devices and aspirin might therefore be at least as cost-effective as low-molecular-weight heparin." The latter comment seems disingenuous. Do the authors really believe that the cost of prophylaxis with low-molecular-weight heparin is "at least as cost-effective as" that with aspirin? In our hospital, the charge for the heparin product …