Cost-effectiveness of diagnostic strategies for venous thromboembolism: A systematic review

Guideline developers consider cost-effectiveness evidence in decisionmaking to determine value formoney. This consideration in the guideline development process can be informed either by formal and dedicated economic evaluations or by systematic reviews of existing studies. To inform the American Society ofHematology guideline on the diagnosis of venous thromboembolism (VTE),we conducted a systematic reviewfocused on the cost-effectiveness of diagnostic strategies for VTEwithin the guideline scope.We systematically searchedMedline (Ovid), Embase (Ovid),NationalHealth Service Economic EvaluationDatabase, and the Costeffectiveness Analysis Registry; summarized; and critically appraised the economic evidence on diagnostic strategies for VTE.We identified 49 studies thatmet our inclusion criteria,with 26 on pulmonary embolism(PE) and 24 on deep vein thrombosis (DVT). For the diagnosis of PE, strategies including D-dimer to exclude PEwere cost-effective comparedwith strategieswithout Ddimer testing. The cost-effectiveness of computed tomography pulmonary angiogram(CTPA) in relation to ventilation-perfusion (V/Q) scanwas inconclusive. CTPA or V/Qscan following ultrasound or D-dimer results could be cost-effective or even cost saving. ForDVT, studies supporting strategieswith D-dimer and/or ultrasound were cost-effective, supporting the recommendation that for patients at low(unlikely) VTE risk, using D-dimer as the initial test reduces the need for diagnostic imaging.Our systematic reviewinformed theAmerican Society ofHematology guideline recommendations about D-dimer, V/Qscan and CTPA for PE diagnosis, and D-dimer and ultrasound forDVT diagnosis.