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

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. RÉSUMÉObjectif: 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 1 er 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...

American Society of Hematology 2020 Guidelines for Management of Venous Thromboembolism: Treatment of Deep Vein Thrombosis and Pulmonary Embolism

“…All of them suggested that DOACs are costeffective relative to VKA. 100,[104][105][106][107][108][109][110][111][112][113][114][115][116] Finally, we considered DOACs to be acceptable and feasible to implement in most scenarios. However, given their cost, some patients might not be able to afford them.…”

A tutorial on dealing with time‐varying eligibility for treatment: Comparing the risk of major bleeding with direct‐acting oral anticoagulants vs warfarin

“…12 Frequent blood monitoring imposes a burden on the patient and healthcare system. 13 DOACs, which have been available in Canada since 2010, require no such routine monitoring and are given as fixed doses based on patient characteristics. Multiple studies, including phase 3 RCTs [14][15][16][17] and observational studies, 18 have thus contrasted the effectiveness (stroke and mortality prevention) and safety (risk of bleeding) of DOACs vs the mainstay warfarin for patients with atrial fibrillation.…”

“…While the safety and effectiveness of warfarin are well understood, the level of anticoagulation achieved for patients on warfarin requires close monitoring of International Normalized Ratio (INR) and frequent dose adjustments due to numerous drug interactions 12 . Frequent blood monitoring imposes a burden on the patient and healthcare system 13 . DOACs, which have been available in Canada since 2010, require no such routine monitoring and are given as fixed doses based on patient characteristics.…”

Trends in Emergency Department Anticoagulant Prescription for Patients with Venous Thromboembolism in China, 2016-2019

“…Vitamin-K antagonists remain the most widely used anticoagulation drug in the ED, although improving evidence suggests that DOACs are more viable and cost effective than conventional anticoagulation among acute VTE patients. 12,13 Several studies have been conducted to investigate the prescription of anticoagulants in VTE patients to obtain an extensive understanding of this gap between medical recommendations and clinical practice. 14,15 However, little is known concerning the trend in anticoagulant prescription for ED patients with VTE.…”