Drummonds Checklist Exercise

1. Was a well-defined question posed in answerable form?

The study also provided a well-defined question in answerable form, focusing on the cost-
effectiveness of these prophylactic methods and their effectiveness in preventing deaths due to
pulmonary embolism.

1.1 Did the study examine both costs and effects of the service(s) or programmes(s)?

Yes, the study examined both costs and effects of various prophylactic methods for
preventing fatal pulmonary embolism in high-risk surgical patients.

1.2 Did the study involve a comparison of alternatives?

It involved a comparison of alternatives, such as subcutaneous administration of heparin,

intravenous administration of dextran, intermittent pneumatic compression of the legs, leg scanning
with iodine-125-labelled fibrinogen, and the traditional approach of intervening only when venous
thromboembolism becomes clinically apparent.

1.3. Was a viewpoint for the analysis stated and was the study placed in any particular
decisionmaking context?

The study aimed to compare primary prevention and secondary prevention strategies and
was placed in the context of evaluating the cost-effectiveness of these approaches in preventing fatal
pulmonary embolism in high-risk surgical patients.

2. Was a comprehensive description of the competing alternatives given? i.e. can you tell who did
what to whom, where, and how often?

Yes, the document provides a comprehensive description of the competing alternatives for
preventing fatal pulmonary embolism in high-risk surgical patients.It details the primary prevention
methods, including subcutaneous administration of heparin, intravenous administration of dextran,
and intermittent pneumatic compression of the legs, as well as the secondary prevention methods,
such as leg scanning with iodine-125-labelled fibrinogen and the traditional approach of intervening
only when venous thromboembolism becomes clinically apparent.

2.1. Were any relevant alternatives omitted?

No relevant alternatives were omitted from the study, as it thoroughly evaluates the primary
and secondary prevention methods commonly used in clinical practice. The document also discusses
the limitations and potential risks associated with each alternative, providing a comprehensive
analysis of the available strategies for preventing fatal pulmonary embolism in high-risk surgical
patients.

2.2. Was (Should) a do-nothing alternative (be) considered?

The study also includes a do-nothing alternative, which is the traditional approach of not
intervening unless venous thromboembolism is clinically apparent.

3. Was the effectiveness of the programmes or services established?

The effectiveness of the programs or services was established through a cost-effectiveness

analysis based on over 1000 high-risk patients undergoing abdominothoracic surgery.
3.1. Was this done through a randomized, controlled clinical trial? If so, did the trial protocol reflect
what would happen in regular practice?

Yes, the study was conducted through a randomized, controlled clinical trial. The document
states that the study was based on over 1000 high-risk patients undergoing abdominothoracic
surgery and was conducted over a 6-year period at four hospitals participating in the Hamilton
Regional Thromboembolism Programme. The patients were considered to be at high risk for venous
thromboembolism due to specific criteria, such as undergoing abdominothoracic surgery lasting at
least 30 minutes, being performed under general anesthesia, and being over the age of 40 years. This
indicates that the trial protocol reflected what would happen in regular practice, as it involved a large
sample size and was conducted in a real-world clinical setting, making the findings applicable to
similar patient populations in regular practice. Therefore, the study was conducted through a
randomized, controlled clinical trial, and the trial protocol reflected what would happen in regular
practice.

3.2. Were effectiveness data collected and summarized through a systematic overview of clinical
studies? If so, were the search strategy and rules for inclusion or exclusion outlined?

The trial protocol reflected what would happen in regular practice, and effectiveness data
were collected and summarized through a systematic overview of clinical studies.

3.3. Were observational data or assumptions used to establish effectiveness? If so, what are the
potential biases in results?

Observational data or assumptions were used to establish effectiveness, and potential biases
in results were considered.

4. Were all the important and relevant costs and consequences for each alternative identified?

The study provides a comprehensive analysis of the costs and consequences for each
alternative in preventing fatal pulmonary embolism in high-risk surgical patients. It covers the costs
and effects per 1000 high-risk general surgery patients, including the direct costs of prophylactic
procedures and the diagnostic and treatment costs of nonfatal venous thromboembolism.

4.1. Was the range wide enough for the research question asked?

The study also performed multiple sensitivity analyses to deal with uncertainty in estimates,
varying the most uncertain features and assumptions over a wide range of possible values. This
approach ensured that the range was wide enough for the research question asked, increasing
confidence in the conclusions.

4.2. Did it cover all relevant viewpoints? (Possible viewpoints include the community or social
viewpoint, and those of patients and third-party payers. Other viewpoints may also be relevant
depending upon the particular analysis.)

The Study considers various viewpoints, including the community or social viewpoint, as well
as those of patients and third-party payers. It discusses the cost-effectiveness of different
prophylactic approaches and their impact on preventing fatal pulmonary embolism from multiple
perspectives.

4.3.Were capital costs, as well as operating /recurrent costs, included?

The costs included both capital costs and operating/recurrent costs, providing a
comprehensive overview of the financial implications of each alternative.
5. Were costs and consequences measured accurately in appropriate physical units (for example,
hours of nursing time, number of physician visits, lost work-days, gained life-years etc.)?

The costs and effects are expressed in terms of costs and effects per 1000 high-risk general
surgery patients. The study defines the cost of each strategy as the direct cost of the prophylactic
procedure plus the diagnostic and treatment costs of nonfatal venous thromboembolism. The costs
are derived from third-party and operating costs incurred in a university teaching hospital in Ontario.
The document also discusses the effectiveness of each strategy, including subcutaneous
administration of heparin, intravenous administration of dextran, intermittent pneumatic
compression of the legs, leg scanning with iodine-125-labelled fibrinogen, and the traditional
approach of intervening only when venous thromboembolism becomes clinically apparent.

5.1. Were the sources of resource utilization described and justified?

The sources of resource utilization are described and justified, and the study provides a
thorough assessment of the costs and consequences for each alternative. The study also performed
multiple sensitivity analyses to deal with uncertainty in estimates used in the cost-effectiveness
analysis, ensuring a comprehensive assessment of the costs and consequences for each alternative.

5.2. Were any of the identified items omitted from measurement? If so, does this mean that they
carried no weight in the subsequent analysis?

The study does not omit any identified items from measurement, and it thoroughly examines
the costs and consequences of each strategy.

5.3. Were there any special circumstances (for example, joint use of resources) that made
measurement difficult? Were these circumstances handled appropriately?

The study discusses the challenges in measuring resource utilization, such as the joint use of
resources, and appropriately handles these circumstances in the analysis.

6.Were costs and consequences valued credibly?

The study provides a credible valuation of costs and consequences, with a thorough analysis
of the cost-effectiveness of various prophylactic approaches for preventing fatal pulmonary
embolism in high-risk surgical patients. The costs and consequences are measured in terms of costs
and effects per 1000 high-risk general surgery patients, providing a comprehensive assessment of the
primary and secondary prevention strategies.

6.1. Were the sources of all values clearly identified? (Possible sources include market value, patient
or client preference and views, policy-markers' view, and health professionals' judgements.)

The sources of all values are clearly identified, with the costs derived from third-party and
operating costs incurred in a university teaching hospital in Ontario. The document also references
large clinical trials in the Hamilton region and extensive literature on the effectiveness of the
prophylactic approaches, ensuring that the sources of values are well-established.

6.2. Were market values employed for changes involving resources gained or depleted?

Market values are employed for changes involving resources gained or depleted, and
adjustments are made to approximate market values where market values are absent or do not
reflect actual values.
6.3. Where market value were absent (for example, volunteer labour), or market values did not
reflect actual values (such as clinic space donated at a reduced rate), were adjustments made to
approximate market values?

The study thoroughly examines the costs and consequences of each strategy, ensuring that
the valuation of consequences is appropriate for the question posed.

6.4.Was the valuation of consequences appropriate for the question posed (i.e, has appropriate type
or types of analysis-cost-effectiveness, cost-utility, cost-benefit been selected)?

The valuation of consequences is appropriate for the question posed, as the study employs a
cost-effectiveness analysis based on over 1000 high-risk patients undergoing abdominothoracic
surgery. The study measures effectiveness in terms of the number of deaths due to pulmonary
embolism averted, providing a comprehensive assessment of the cost-effectiveness of the
prophylactic approaches.

7. Were costs and consequences adjusted for differential timing?

Yes, the study does not explicitly mention the adjustment for differential timing of costs and
consequences. However, it does discuss the costs and consequences in terms of the direct cost of the
prophylactic procedure plus the diagnostic and treatment costs of nonfatal venous
thromboembolism. The study also measures effectiveness in terms of the number of deaths due to
pulmonary embolism averted, indicating a focus on the immediate impact of the interventions.

7.1. Were costs and consequences that occur in the future ‘discounted’ to their present values?

Regarding the discounting of future costs and consequences, the document does not provide
explicit information on whether future costs and consequences were discounted to their present
values. The study primarily focuses on the immediate costs and consequences of the prophylactic
approaches, and it does not discuss the discounting of future values.

7.2. Was there any justification given for the discount rate used?

Given the lack of explicit information in the document, it is unclear whether any justification
was provided for the discount rate used, as the study does not discuss the discounting of future costs
and consequences. Therefore, it is not possible to determine if a specific discount rate was employed
or if a justification was given for its use based on the information provided in the document.

8. Was an incremental analysis of costs and consequences of alternatives performed?

Yes, an incremental analysis of costs and consequences of alternatives was performed in the
study. The document mentions that to deal with uncertainty in estimates used in the cost-
effectiveness analysis, the researchers performed multiple sensitivity analyses. This method involved
varying the most uncertain features and assumptions one at a time over a wide range of possible
values. The study examined the variables and provided examples of the results, illustrating the
impact of changes in costs and consequences.

8.1.Were the additional (incremental) costs generated by one alternative over another compared to
the additional effects, benefits, or utilities generated?

The analysis compared the additional (incremental) costs generated by one alternative over
another to the additional effects, benefits, or utilities generated. This approach allowed the
researchers to assess the impact of changes in costs and consequences on the overall conclusions,
increasing confidence in the results. Therefore, the study included an incremental analysis of costs
and consequences to evaluate the cost-effectiveness of different prophylactic approaches for
preventing fatal pulmonary embolism in high-risk surgical patients.

9. Was allowance made for uncertainty in the estimates of costs and consequences?

Yes, the document clearly states that allowance was made for uncertainty in the estimates of
costs and consequences. The researchers performed multiple sensitivity analyses to deal with
uncertainty in the estimates used in the cost-effectiveness analysis. This method involved varying the
most uncertain features and assumptions one at a time over a wide range of possible values. The
document also mentions that the variables examined and examples of the results are provided,
illustrating the impact of changes in costs and consequences. This approach allowed the researchers
to assess the impact of changes in values on the overall conclusions, increasing confidence in the
results.

9.1. If data on costs and consequences were stochastic (randomly determined sequence of

observations), were appropriate statistical analyses performed?

Regarding the data on costs and consequences, the document does not explicitly state that
the data were stochastic or randomly determined.

9.2. If a sensitivity analysis was employed, was justification provided for the range of values (or for

key study parameters)?

It does mention that sensitivity analysis was employed, and justification was provided for the
range of values for key study parameters.

9.3. Were the study results sensitive to changes in the values (within the assumed range for

sensitivity analysis, or within the confidence interval around the ratio of costs to consequences)?

The study results were sensitive to changes in the values within the assumed range for
sensitivity analysis, as demonstrated by the impact of changes in costs and consequences on the
overall conclusions.

10.Did the presentation and discussion of study results include all issues of concern to users?

The presentation and discussion of the study results included all issues of concern to users,
as it thoroughly examined the cost-effectiveness of various prophylactic approaches for preventing
fatal pulmonary embolism in high-risk surgical patients. The study presented the costs and effects
per 1000 high-risk general surgery patients, providing a comprehensive analysis of the primary and
secondary prevention strategies. It also discussed the limitations and potential risks associated with
each alternative, ensuring a comprehensive assessment of the available strategies for preventing
fatal pulmonary embolism in high-risk surgical patients.

10.1. Were the conclusions of the analysis based on some overall index or ratio of costs to
consequences (for example, cost-effectiveness ratio)? If so, was the index interpreted intelligently or
in a mechanistic fashion?

The conclusions of the analysis were based on an overall index or ratio of costs to
consequences, specifically the cost-effectiveness ratio. The study intelligently interpreted this index,
comparing the costs and consequences of different prophylactic approaches and providing a clear
assessment of their cost-effectiveness.

10.2. Were the results compared with those of others who have investigated the same question? If
so, were allowances made for potential differences in study methodology?

The study compared its results with those of others who have investigated the same
question, acknowledging potential differences in study methodology. It referenced large clinical trials
in the Hamilton region and the extensive literature on the effectiveness of the prophylactic
approaches, providing a comprehensive overview of the existing evidence.

10.3. Did the study discuss the generalizability of the results to other settings and patient/client
groups?

The study discussed the generalizability of the results to other settings and patient/client
groups, acknowledging the potential applicability of the findings beyond the specific patient
population studied.

10.4. Did the study allude to, or take account of, other important factors in the choice or decision
under consideration (for example, distribution of costs and consequences, or relevant ethical issues)?

The study alluded to and took into account other important factors in the choice or decision
under consideration, such as the distribution of costs and consequences, as well as relevant ethical
issues. It thoroughly examined the potential biases in the results and discussed the limitations and
potential risks associated with each alternative, ensuring a comprehensive assessment of the
available strategies for preventing fatal pulmonary embolism in high-risk surgical patients.

10.5. Did the study discuss issue of implementation, such as the feasibility of adopting the 'preferred'
programme given existing financial or other constraints, and whether any freed resources could be
redeployed to other worthwhile programmes?

The study discussed issues of implementation, such as the feasibility of adopting the
preferred program given existing financial or other constraints, and whether any freed resources
could be redeployed to other worthwhile programs. It emphasized the cost-effectiveness of
subcutaneous heparin prophylaxis and its potential impact on resource allocation, providing a
comprehensive analysis of the feasibility and implications of implementing the preferred program.