Skip to main content
×
Home

A pharmacoeconomic study of traditional anticoagulation versus direct oral anticoagulation for the treatment of venous thromboembolism in the emergency department

  • Stephanie Law (a1), Daljit Ghag (a1), Eric Grafstein (a2) (a3), Robert Stenstrom (a2) (a3) and Devin Harris (a3) (a4)...
Abstract
Abstract Objectives

Patients with venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [PE]) are commonly treated as outpatients. Traditionally, patients are anticoagulated with low-molecular-weight heparin (LMWH) and warfarin, resulting in return visits to the ED. The direct oral anticoagulant (DOAC) medications do not require therapeutic monitoring or repeat visits; however, they are more expensive. This study compared health costs, from the hospital and patient perspectives, between traditional versus DOAC therapy.

Methods

A chart review of VTE cases at two tertiary, urban hospitals from January 1, 2010 to December 31, 2012 was performed to capture historical practice in VTE management, using LMWH/warfarin. This historical data were compared against data derived from clinical trials, where a DOAC was used. Cost minimization analyses comparing the two modes of anticoagulation were completed from hospital and patient perspectives.

Results

Of the 207 cases in the cohort, only 130 (63.2%) were therapeutically anticoagulated (international normalized ratio 2.0–3.0) at emergency department (ED) discharge; patients returned for a mean of 7.18 (range: 1–21) visits. Twenty-one (10%) were admitted to the hospital; 4 (1.9%) were related to VTE or anticoagulation complications. From a hospital perspective, a DOAC (in this case, rivaroxaban) had a total cost avoidance of $1,488.04 per VTE event, per patient. From a patient perspective, it would cost an additional $204.10 to $349.04 over 6 months, assuming no reimbursement.

Conclusions

VTE management in the ED has opportunities for improvement. A DOAC is a viable and cost-effective strategy for VTE treatment from a hospital perspective and, depending on patient characteristics and values, may also be an appropriate and cost-effective option from a patient perspective.

RÉSUMÉ Objectif

Les patients souffrant d’une thromboembolie veineuse (TEV) (thrombose veineuse profonde [TVP] ou embolie pulmonaire [EP]) sont souvent traités en consultation externe. L’anticoagulation se réalise habituellement par l’héparine de faible masse moléculaire (HFMM) et par la warfarine, ce qui nécessite des consultations ultérieures au service des urgences (SU). Il existe aussi l’anticoagulation orale directe (AOD), qui ne nécessite pas de surveillance thérapeutique ou de consultations rapprochées, mais son coût est plus élevé que celui du traitement classique. L’étude décrite ici visait donc à comparer les coûts, liés aux soins de santé, de l’anticoagulation classique avec ceux de l’AOD, et ce, tant pour les hôpitaux que pour les patients.

Méthode

Les auteurs ont procédé à un examen des dossiers des cas de TEV traités dans deux hôpitaux urbains, de soins tertiaires, pour la période du 1er janvier 2010 au 31 décembre 2012, afin de recueillir des données sur la pratique historique du traitement de la TEV par l’HFMM et la warfarine. Il y a eu par la suite comparaison des données historiques avec celles provenant d’essais cliniques d’anticoagulants oraux directs. Enfin, des analyses de minimisation des coûts ont été effectuées afin que soient comparés les coûts des deux modalités de traitement anticoagulant, et ce, tant pour les hôpitaux que pour les patients.

Résultats

La cohorte comptait 207 cas et, dans seulement 130 (63,2 %) d’entre eux, le degré d’anticoagulation était suffisant sur le plan thérapeutique (RIN : 2,0 – 3,0) au moment du congé du SU; le suivi des patients a nécessité en moyenne 7,18 (plage : 1-21) consultations. Vingt et un (10 %) patients ont été hospitalisés, dont 4 (1,9 %) pour des complications liées à la TEV ou à l’anticoagulation. Du point de vue des hôpitaux, l’AOD (en l’occurrence, le rivaroxaban) a permis d’éviter des coûts totaux de 1488,04 $ par TEV, par patient. Du point de vue des patients, le traitement entraînerait des coûts additionnels variant de 204,10 $ à 349,04 $ sur une période de six mois, en cas de non-remboursement.

Conclusions

Il y a place à l’amélioration dans la prise en charge de la TEV au SU. L’AOD se montre une stratégie durable et rentable du traitement de la TEV pour les hôpitaux; elle peut aussi se révéler une modalité appropriée et rentable pour les patients, selon les caractéristiques et les valeurs de chacun.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      A pharmacoeconomic study of traditional anticoagulation versus direct oral anticoagulation for the treatment of venous thromboembolism in the emergency department
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about sending content to Dropbox.

      A pharmacoeconomic study of traditional anticoagulation versus direct oral anticoagulation for the treatment of venous thromboembolism in the emergency department
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about sending content to Google Drive.

      A pharmacoeconomic study of traditional anticoagulation versus direct oral anticoagulation for the treatment of venous thromboembolism in the emergency department
      Available formats
      ×
Copyright
Corresponding author
Correspondence to: Dr. Devin Harris, Department of Emergency Medicine, Kelowna General Hospital, 2268 Pandosy Avenue, Kelowna, BC V1Y 1T2; Email: devinh@shaw.ca
References
Hide All
1. Franchini M, Mannucci PM. New anticoagulants for treatment of venous thromboembolism. Eur J Intern Med 2012;23(8):692-695.
2. Guyatt GH, Akl EA, Crowther M, et al. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):7S-47S.
3. Pollack C. New oral anticoagulants in the ED setting: a review. Am J Emerg Med 2012;30(9):2046-2054.
4. Fox BD, Kahn SR, Langleben D, et al. Efficacy and safety of novel oral anticoagulants for treatment of acute venous thromboembolism: direct and adjusted indirect meta-analysis of randomised controlled trials. BMJ 2012;345:e7498.
5. Rudd KM, Phillips EL. New oral anticoagulants in the treatment of pulmonary embolism: efficacy, bleeding risk, and monitoring. Thrombosis 2013;2013:973710. doi:10.1155/2013/973710.
6. Nutescu E. Emerging options in the treatment of venous thromboembolism. Am J Health Syst Pharm 2004;61(23 Suppl 7):S12-S17.
7. Bauersachs R, Berkowitz SD, Brenner B, et al. Oral rivaroxaban for symptomatic venous thromboembolism. New Engl J Med 2010;363(26):2499-2510.
8. Büller HR, Prins MH, Lensin AW, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. New Engl J Med 2012;366(14):1287-1297.
9. Sardar P, Chatterjee S, Mukherjee D. Efficacy and safety of new oral anticoagulants for extended treatment of venous thromboembolism: systematic review and meta-analyses of randomized controlled trials. Drugs 2013;73(11):1171-1182.
10. Kaji AH, Schriger D, Green S. Looking through the retrospectoscope: reducing bias in emergency medicine chart review studies. Ann Emerg Med 2014;64(3):292-298.
11. Canadian Institute for Health Information (CIHI). Health care cost drivers; 2011. Available at: http://www.cihi.ca/CIHI-ext-portal/pptx/internet/HOSPITAL_COST_DRIVERS_EN (accessed September 15, 2014).
12. British Columbia Ministry of Health. Laboratory Services Outpatient Payment Schedule. Laboratory, Diagnostic and Blood Services Branch; 2014. Available at: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/laboratory-services/information-for-laboratory-operators/laboratory-services-outpatient-payment-schedule (accessed September 15, 2014).
13. Guidelines and Protocols Advisory Committee. Warfarin therapy management. Victoria, BC: British Columbia Ministry of Health Services; 2010: 1-10.
14. Prins MH, Lensing AW, Bauersachs R, et al. Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE randomized studies. Thromb J 2013;11(1):21.
15. Beyer-Westendorf J, Förster K, Pannach S, et al. Rates, management, and outcome of rivaroxaban bleeding in daily care: results from the Dresden NOAC registry. Blood 2014;124(6):955-962, doi:10.1182/blood-2014-03-563577.
16. Van Walraven C, Jennings A, Oake N, et al. Effect of study setting on anticoagulation control: a systematic review and metaregression. Chest 2006;129(5):1155-1166.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Canadian Journal of Emergency Medicine
  • ISSN: -
  • EISSN: 1481-8035
  • URL: /core/journals/canadian-journal-of-emergency-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Keywords:

Metrics

Full text views

Total number of HTML views: 42
Total number of PDF views: 252 *
Loading metrics...

Abstract views

Total abstract views: 680 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 24th November 2017. This data will be updated every 24 hours.