Economic burden of recurrent venous thromboembolism: analysis from a U.S. hospital perspective.

PURPOSE: An analysis of resource utilization and hospital costs associated with recurrent venous thromboembolism (VTE) is presented. METHODS: A retrospective cohort analysis was conducted using a large U.S. hospital database. Patients with VTE-related hospitalization events during the period January-December 2010 were identified; data collection extended for up to 12 months after the index event. Postdischarge hospital resource use and total costs were compared in cohorts of patients with and without recurrent VTE. Regression analysis was performed to compare hospital costs and length of stay (LOS) during initial and subsequent VTE encounters. RESULTS: Among the study population of 43,734 patients, 4% had postdischarge VTE-related events during the data collection period. The median and mean ± S.D. times to VTE recurrence were 48 days and 98 ± 106 days, respectively. Patients with recurrent VTE had more all-cause hospitalizations than those without recurrent VTE (mean ± S.D., 1.07 ± 0.96 versus 0.15 ± 0.53; p < 0.0001), more all-cause emergency room visits (mean ± S.D., 0.31 ± 0.66 versus 0.05 ± 0.31; p < 0.0001), and greater total costs (mean ± S.D., $28,353 ± $39,624 versus $17,712 ± $33,461; p < 0.0001). Relative to initial VTE admissions, admissions for recurrent VTE were, on average, associated with a 14% longer LOS (p = 0.0002) and a 22% higher total cost (p < 0.001). CONCLUSION: Patients with recurrent VTE used more hospital resources than those without recurrent VTE. Readmissions for VTE were significantly longer and more costly than index encounters.

The costs of warfarin underuse and nonadherence in patients with atrial fibrillation: a commercial insurer perspective.

BACKGROUND: Atrial fibrillation (AF) imposes a substantial clinical and economic burden on the U.S. health care system. Despite national guidelines that recommend oral anticoagulation for stroke prevention, the literature consistently reports its underuse in AF patients with moderate to high stroke risk. OBJECTIVE: To assess the economic burden of underuse and nonadherence of warfarin therapy among patients with nonvalvular AF in a commercially insured population. METHODS: Claims data between January 2003 and December 2007 from the Thomson Reuters MarketScan Research Database were used. Patients diagnosed with nonvalvular AF who were continuously enrolled for at least 12 months prior to and 2 months following their diagnosis, who had a CHADS2 score ≥ 2, and were not at high risk of bleeding (ATRIA score less than 5, HEMORR2HAGE score less than 4, and HAS-BLED score less than 3) at baseline were included. Patients were followed for up to 18 months after the AF diagnosis date to assess the level of warfarin utilization. Health care resource utilization and cost during follow-up among patients with the proportion of days covered (PDC) by warfarin greater than 0.8 (high) and ≤ 0.8 (low) versus patients with no warfarin exposure were assessed. Multivariate negative binomial regressions and generalized linear models were used to estimate differences in resource utilization and cost, respectively. RESULTS: Of the 13,289 subjects included in this analysis, 47% had no warfarin exposure; 31.5% had low PDC; and 21.5% had high PDC. The rates of ischemic stroke and transient ischemic attack (per 100 patient-years) were significantly lower for the groups that had high and low PDCs as compared with the group with no warfarin exposure (P less than 0.001). Multivariate analysis showed that patients with high PDC were 27% less likely (P less than 0.001) to incur hospitalizations, and 16% were less likely (P = 0.019) to incur emergency room visits than patients who did not receive warfarin, but the differences between low PDC patients and no warfarin exposure were not significant. Although both low and high PDC were associated with lower all-cause inpatient cost (P less than 0.001), only high PDC was associated with a lower post-index all-cause total cost (P less than 0.001) compared with no warfarin exposure. CONCLUSION: Our results confirm that underutilization and nonadherence of warfarin among nonvalvular AF patients is both prevalent and costly. Warfarin use among patients with moderate to high stroke risk and low to moderate bleed risk demonstrated a stroke benefit without a significant increase in intracranial hemorrhage. Adherence to oral anticoagulant therapy was associated with a significant reduction in inpatient service use and total health care cost. Improving adherence to oral anticoagulation is important to attaining the clinical and economic benefits of therapy.

Anticoagulation therapy for patients with non-valvular atrial fibrillation: comparison of decision analytic model recommendations and real-world warfarin prescription use.

BACKGROUND: Anticoagulation in patients with atrial fibrillation (AF) is challenging because stroke-risk reduction must be balanced against increased bleeding risk. OBJECTIVE: We developed a decision model integrating both stroke and bleeding risk schemes to guide optimal use of anticoagulation in AF, and compared model recommendations with warfarin use in a real-world database. METHODS: A Markov model based on demographics, CHADS(2) (Congestive Heart Failure, Hypertension, Age of 75 years and greater, Diabetes Mellitus and History of Stroke) stroke and ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) bleed risk scores, and anticoagulation treatment effects from clinical trials simulated health state transitions for recently diagnosed AF patients. The model recommended the treatment with greater quality-adjusted life expectancy. Model recommendations were contrasted with actual warfarin use recorded in the Thomson Reuters MarketScan database (N = 64,946). RESULTS: 74.8% (n = 48,548) of the Marketscan AF cohort had CHADS(2) ≥1, of whom 14.3% had moderate/high (≥4) ATRIA bleeding risk. While the model recommended warfarin for almost all patients with CHADS(2) ≥1 who are at low bleeding risk, it recommended warfarin for fewer patients as bleeding risk increased. Of the 44,611 patients recommended warfarin, 63.4% of patients were considered warfarin exposed (concordant with model recommendation), and of the 20,335 patients recommended aspirin (acetylsalicylic acid), 59.7% received warfarin (discordant with model recommendations). Actual warfarin use decreased modestly with higher stroke risk (p < 0.0001) and with higher bleeding risk (p < 0.0001). CONCLUSION: High discordance between actual warfarin use and model recommendations suggests that anticoagulation decisions are not based on systematic evaluation of stroke and bleeding risks. Model-based clinical decision aids may improve oral anticoagulation decisions by more systematically weighing bleed and stroke risk.