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1.
J Manag Care Spec Pharm ; 26(5): 639-651, 2020 May.
Artículo en Inglés | MEDLINE | ID: mdl-32347184

RESUMEN

This article has been corrected. Please see J Manag Care Spec Pharm, 2020;26(5):682 BACKGROUND: Clinical trials have shown that direct oral anticoagulants (DOACs)-including dabigatran, rivaroxaban, apixaban, and edoxaban-are at least as effective and safe as warfarin for the risk of stroke/systemic embolism (SE) and major bleeding (MB) in patients with atrial fibrillation (AF). However, few studies have compared oral anticoagulants (OACs) among elderly patients. OBJECTIVE: To compare hospitalization risks (all-cause, stroke/SE-related, and MB-related) and associated health care costs among elderly nonvalvular AF (NVAF) patients in the Medicare population who initiated warfarin, dabigatran, rivaroxaban, or apixaban. METHODS: Patients (aged ≥ 65 years) initiating warfarin or DOACs (apixaban, rivaroxaban, and dabigatran) were selected from the Centers for Medicare & Medicaid Services database from January 1, 2013, to December 31, 2014. Patients initiating each OAC were matched 1:1 to apixaban patients using propensity score matching to balance demographic and clinical characteristics. Cox proportional hazards models were used to estimate the risk of hospitalization of each OAC versus apixaban. Generalized linear models and two-part models with bootstrapping were used to compare all-cause health care costs and stroke/SE- and MB-related medical costs between matched cohorts. RESULTS: Of the 264,479 eligible patients, 77,480 warfarin-apixaban, 41,580 dabigatran-apixaban, and 77,640 rivaroxaban-apixaban patients were matched. The OACs were associated with a significantly higher risk of all-cause hospitalization compared with apixaban (warfarin: HR = 1.27, 95% CI = 1.23-1.31, P < 0.001; dabigatran: HR = 1.13, 95% CI = 1.08-1.18, P < 0.001; and rivaroxaban: HR = 1.22, 95% CI = 1.18-1.26, P < 0.001) and were associated with a significantly higher risk of hospitalization due to stroke/SE (warfarin: HR = 2.18, 95% CI = 1.80-2.64, P < 0.001; dabigatran: HR = 1.45, 95% CI = 1.12-1.88, P = 0.006; and rivaroxaban: HR = 1.40, 95% CI = 1.14-1.71, P = 0.001). Also, the OACs were associated with significantly higher risk of hospitalization due to MB-related conditions compared with apixaban (warfarin: HR = 1.76, 95% CI = 1.59-1.95, P < 0.001; dabigatran: HR = 1.44, 95% CI = 1.23-1.68, P < 0.001; and rivaroxaban: HR = 1.89, 95% CI = 1.71-2.09, P < 0.001). Compared with apixaban, warfarin ($3,577 vs. $3,183, P < 0.001); dabigatran ($3,217 vs. $3,060, P < 0.001); and rivaroxaban ($3,878 vs. $3,180, P < 0.001) had significantly higher all-cause total health care costs per patient per month. Patients initiating the OACs had significantly higher MB-related medical costs compared with apixaban: warfarin ($472 vs. $269; P < 0.001); dabigatran ($364 vs. $245, P < 0.001); and rivaroxaban ($493 vs. $270, P < 0.001). Warfarin was also associated with higher stroke/SE-related medical costs compared with apixaban ($124 vs. $62, P < 0.001). CONCLUSIONS: This real-world study showed that among elderly NVAF patients in the Medicare population, apixaban was associated with significantly lower risks of all-cause, stroke/SE-related, and MB-related hospitalizations compared with warfarin, dabigatran, and rivaroxaban. Accordingly, apixaban showed significantly lower all-cause health care costs and MB-related medical costs. DISCLOSURES: This study was funded by Bristol Myers Squibb and Pfizer. Amin is an employee of the University of California, Irvine, and was a paid consultant to Bristol Myers Squibb in connection with this study and the development of this manuscript. He has served as a consultant and/or speaker for Bristol Myers Squibb, Pfizer, and Boehringer Ingelheim. Keshishian and Zhang are employees of STATinMED Research, a paid consultant to Pfizer and Bristol Myers Squibb in connection with this study and the development of this manuscript. Trocio, Dina, Mardekian, and Liu are employees of Pfizer, with ownership of stocks in Pfizer. Le, Rosenblatt, Nadkarni, and Vo are employees of Bristol Myers Squibb. Rosenblatt and Vo have ownership of stocks in Bristol Myers Squibb. Baser has no conflicts to disclose.


Asunto(s)
Anticoagulantes/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Hospitalización , Medicare/economía , Anciano , Anticoagulantes/administración & dosificación , Anticoagulantes/economía , Bases de Datos Factuales , Femenino , Costos de la Atención en Salud , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos
2.
J Emerg Med ; 57(4): 437-443, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31506197

RESUMEN

BACKGROUND: Clinical guidelines emphasize identifying atrial fibrillation (AF) as a strategy to reduce stroke risk. Cardiac implantable electronic device (CIED) interrogation at the point of care may facilitate AF detection, increasing opportunities to identify patients at high risk for stroke. OBJECTIVES: This study sought to quantify AF prevalence and assess stroke risk in patients with a CIED who presented to the emergency department (ED). METHODS: This noninterventional, retrospective observational study included adult patients who presented at a single facility ED that incorporated device interrogation as a routine standard practice for all patients with a CIED. Interrogations were conducted in 494 unique patients, and relevant demographic/clinical information was captured from electronic medical records. RESULTS: AF was detected via CIED interrogation in 54.8% (271/494) of the unique patient population that presented to the ED. Device interrogation detected the presence of AF in 110 patients without a documented past history or current diagnosis of AF, representing 22.3% (110/494) of total unique patients. Based on CHA2DS2-VASc (Congestive heart failure, Hypertension, Age > 75 years, Diabetes mellitus, prior Stroke or transient ischemic attack or thromboembolism, Vascular disease, Age 65-74 years, Sex category [female]) risk scoring methodology, over three-quarters of these newly detected AF patients (78.2%, 86/110) were classified in a high stroke risk category that reflected a > 2.2% annualized risk, and over half (57.3%, 63/110) presented to the ED for reasons unrelated to cardiac/dysrhythmia problems. CONCLUSIONS: The use of technology-assisted device interrogation of CIEDs at the point of care has promise in identifying patients with asymptomatic AF. Results suggest consideration of routine device interrogation of CIEDs in the ED, regardless of reason for admission or history of AF.


Asunto(s)
Fibrilación Atrial/diagnóstico , Desfibriladores Implantables/efectos adversos , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/epidemiología , California/epidemiología , Desfibriladores Implantables/estadística & datos numéricos , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo
3.
BMC Cardiovasc Disord ; 19(1): 142, 2019 06 13.
Artículo en Inglés | MEDLINE | ID: mdl-31195999

RESUMEN

BACKGROUND: Clinical trials have demonstrated that direct oral anticoagulants (DOACs) are at least non-inferior to warfarin in reducing the risk of stroke/systemic embolism (SE) among patients with non-valvular atrial fibrillation (NVAF), but the comparative risk of major bleeding varies between DOACs and warfarin. Using US Department of Defense (DOD) data, this study compared the risk of stroke/SE and major bleeding for DOACs relative to warfarin. METHODS: Adult patients with ≥1 pharmacy claim for apixaban, dabigatran, rivaroxaban, or warfarin from 01 Jan 2013-30 Sep 2015 were selected. Patients were required to have ≥1 medical claim for atrial fibrillation during the 12-month baseline period. Patients with a warfarin or DOAC claim during the 12-month baseline period were excluded. Each DOAC cohort was matched to the warfarin cohort using propensity score matching (PSM). Cox proportional hazards models were conducted to evaluate the risk of stroke/SE and major bleeding of each DOAC vs warfarin. RESULTS: Of 41,001 identified patients, there were 3691 dabigatran-warfarin, 8226 rivaroxaban-warfarin, and 7607 apixaban-warfarin matched patient pairs. Apixaban was the only DOAC found to be associated with a significantly lower risk of stroke/SE (hazard ratio [HR]: 0.55; 95% confidence interval [CI]: 0.39, 0.77; p < 0.001) and major bleeding (HR: 0.65; 95% CI: 0.53, 0.80; p < 0.001) compared to warfarin. Dabigatran and rivaroxaban initiation were associated with similar risk of stroke/SE (dabigatran: HR: 0.68; 95% CI: 0.43, 1.07; p = 0.096; rivaroxaban: HR: 0.83; 95% CI: 0.64, 1.09; p = 0.187) and major bleeding (dabigatran: HR: 1.05; 95% CI: 0.79, 1.40; p = 0.730; rivaroxaban: HR: 1.07; 95% CI: 0.91, 1.27; p = 0.423) compared to warfarin. CONCLUSION: Among NVAF patients in the US DOD population, apixaban was associated with significantly lower risk of stroke/SE and major bleeding compared to warfarin. Dabigatran and rivaroxaban were associated with similar risk of stroke/SE and major bleeding compared to warfarin.


Asunto(s)
Anticoagulantes/administración & dosificación , Fibrilación Atrial/tratamiento farmacológico , Dabigatrán/administración & dosificación , Pirazoles/administración & dosificación , Piridonas/administración & dosificación , Rivaroxabán/administración & dosificación , Accidente Cerebrovascular/prevención & control , United States Department of Defense , Warfarina/administración & dosificación , Administración Oral , Adolescente , Adulto , Anciano , Anticoagulantes/efectos adversos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Dabigatrán/efectos adversos , Femenino , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Pirazoles/efectos adversos , Piridonas/efectos adversos , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Rivaroxabán/efectos adversos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Resultado del Tratamiento , Estados Unidos/epidemiología , Warfarina/efectos adversos , Adulto Joven
4.
Clinicoecon Outcomes Res ; 11: 23-49, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30588051

RESUMEN

INTRODUCTION: Direct oral anticoagulants (DOACs) have emerged as viable alternatives to traditional treatments such as vitamin K antagonists (VKAs) for venous thromboembolism (VTE). The objective of this review was to summarize evidence on the use of DOACs and VKAs to treat VTE in the US for patients transitioning from inpatient to post-discharge settings. MATERIALS AND METHODS: A systematic review of the VTE literature identified studies published in English (January 1, 2011-December 31, 2016) that reported inpatient and post-discharge treatments and discharge location. Two reviewers screened abstracts, abstracted information from included studies, and assessed the quality of the study methodology and reporting. RESULTS: Forty-nine studies were included (24 clinical and 25 economic). A limited number of studies (eight clinical and three economic) examined VTE treatment patterns during transitions of care from inpatient to post-discharge settings, irrespective of anticoagulant (eg, DOAC, warfarin, heparin), and < 25% of all studies reported a post-discharge location. Three clinical studies that reported inpatient and outpatient treatment found better patient outcomes with DOAC vs warfarin. Fourteen economic studies reported that DOACs were associated with shorter hospital length of stay (LOS) and lower direct costs vs warfarin. No studies reported indirect costs. DISCUSSION: Although DOACs are associated with shorter LOS, lower costs, and better patient outcomes vs VKAs, it appears in one study that only a small percentage of patients with stable VTE who are discharged to home may be receiving DOACs. CONCLUSION: These findings identified the potential areas of opportunity to improve the management of VTE through coordination of care from the inpatient to the outpatient settings.

5.
J Manag Care Spec Pharm ; 24(11): 1116-1127, 2018 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-30212268

RESUMEN

BACKGROUND: The ARISTOTLE trial demonstrated that apixaban had significantly lower rates of stroke/systemic embolism (SE) and major bleeding than warfarin; however, no direct clinical trials between apixaban and other direct oral anticoagulants (DOACs) are available. Few real-world studies comparing the effectiveness and safety between DOACs have been conducted. OBJECTIVE: To compare effectiveness, safety, and health care costs among oral anticoagulants (OACs) for nonvalvular atrial fibrillation (NVAF) patients in the U.S. Department of Defense (DoD) population. METHODS: Adult NVAF patients initiating warfarin or DOACs (apixaban, rivaroxaban, and dabigatran) were selected from U.S. DoD data from January 1, 2013, to September 30, 2015. The first OAC claim date was designated as the index date. Patients initiating another OAC were matched 1:1 to apixaban patients using propensity score matching to balance demographics and clinical characteristics. Cox proportional hazards models were used to estimate the risk of stroke/SE and major bleeding for each OAC versus apixaban. Generalized linear and two-part models with bootstrapping were used to compare all-cause health care costs and stroke/SE-related and major bleeding-related medical costs. RESULTS: Of the 41,001 eligible patients, 7,607 warfarin-apixaban, 4,129 dabigatran-apixaban, and 11,284 rivaroxaban-apixaban pairs were matched. Warfarin (HR = 1.84; 95% CI = 1.30-2.59; P < 0.001) and rivar-oxaban (HR = 1.46; 95% CI = 1.08-1.98; P = 0.015) were associated with a significantly higher risk of stroke/SE compared with apixaban. Dabigatran (HR = 1.17; 95% CI = 0.68-2.03; P = 0.573) was associated with a numerically higher risk of stroke/SE compared with apixaban. Warfarin (HR = 1.53; 95% CI = 1.24-1.89; P < 0.001), dabigatran (HR = 1.76; 95% CI = 1.27-2.43; P < 0.001), and rivaroxaban (HR = 1.59; 95% CI = 1.34-1.89; P < 0.001) were associated with higher risks of major bleeding compared with apixaban. Compared with apixaban, patients prescribed warfarin incurred numerically higher all-cause total health care costs per patient per month (PPPM) ($2,498 vs. $2,277; P = 0.148) and significantly higher stroke/SE-related ($118 vs. $46; P = 0.012) and major bleeding-related ($166 vs. $76; P = 0.003) medical costs. Dabigatran patients incurred numerically higher all-cause total health care PPPM costs ($2,372 vs. $2,143; P = 0.150) and stroke/SE-related medical costs ($61 vs. $32; P = 0.240) but significantly higher major bleeding-related costs ($114 vs. $58; P = 0.025). Rivaroxaban patients incurred significantly higher all-cause total health care costs ($2,546 vs. $2,200; P < 0.001) and major bleeding-related medical costs PPPM ($137 vs. $69; P < 0.001) but numerically higher stroke/SE-related medical costs PPPM ($58 vs. $38; P = 0.057). CONCLUSIONS: Among NVAF patients in the U.S. DoD population, warfarin and rivaroxaban were associated with a significantly higher risk of stroke/SE and major bleeding compared with apixaban. Dabigatran use was associated with a numerically higher risk of stroke/SE and a significantly higher risk of major bleeding compared with apixaban. Warfarin and dabigatran incurred numerically higher all-cause total health care costs compared with apixaban. Rivaroxaban was associated with significantly higher all-cause total health care costs compared with apixaban. DISCLOSURES This study was funded by Bristol-Myers Squibb and Pfizer, which were involved in the study design, as well as in the writing and revision of the manuscript. Keshishian and Zhang are paid employees of STATinMED Research, which was paid by Bristol-Myers Squibb and Pfizer to conduct this study and develop the manuscript. Gupta, Rosenblatt, Hede, and Nadkarni are paid employees of Bristol-Myers Squibb. Trocio, Dina, Mardekian, Liu, and Shank are paid employees of Pfizer.


Asunto(s)
Anticoagulantes/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Atención a la Salud/economía , Costos de la Atención en Salud , United States Department of Defense/economía , Administración Oral , Adulto , Anciano , Anticoagulantes/economía , Fibrilación Atrial/complicaciones , Fibrilación Atrial/economía , Embolia/economía , Embolia/epidemiología , Embolia/etiología , Embolia/prevención & control , Femenino , Hemorragia/inducido químicamente , Hemorragia/economía , Hemorragia/epidemiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Estudios Retrospectivos , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control , Resultado del Tratamiento , Estados Unidos/epidemiología , Adulto Joven
6.
J Manag Care Spec Pharm ; 24(9): 911-920, 2018 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-30156450

RESUMEN

BACKGROUND: Clinical trials have shown that direct oral anticoagulants (DOACs)-including dabigatran, rivaroxaban, apixaban, and edoxaban-are at least as effective and safe as warfarin for the risk of stroke/systemic embolism (SE) and major bleeding (MB) in patients with atrial fibrillation (AF). However, few studies have compared oral anticoagulants (OACs) among elderly patients. OBJECTIVE: To compare hospitalization risks (all-cause, stroke/SE-related, and MB-related) and associated health care costs among elderly nonvalvular AF (NVAF) patients in the Medicare population who initiated warfarin, dabigatran, rivaroxaban, or apixaban. METHODS: Patients (aged ≥ 65 years) initiating warfarin or DOACs (apixaban, rivaroxaban, and dabigatran) were selected from the Centers for Medicare & Medicaid Services database from January 1, 2013, to December 31, 2014. Patients initiating each OAC were matched 1:1 to apixaban patients using propensity score matching to balance demographic and clinical characteristics. Cox proportional hazards models were used to estimate the risk of hospitalization of each OAC versus apixaban. Generalized linear models and two-part models with bootstrapping were used to compare all-cause health care costs and stroke/SE- and MB-related medical costs between matched cohorts. RESULTS: Of the 186,132 eligible patients, 41,606 warfarin-apixaban, 30,836 dabigatran-apixaban, and 41,608 rivaroxaban-apixaban pairs were matched. The OACs were associated with a significantly higher risk of all-cause hospitalization compared with apixaban (warfarin: HR = 1.33, 95% CI = 1.27-1.38, P < 0.001; dabigatran: HR = 1.17, 95% CI = 1.11-1.23, P < 0.001; and rivaroxaban: HR = 1.27, 95% CI = 1.22-1.32, P < 0.001) and were associated with a significantly higher risk of hospitalization due to stroke/SE (warfarin: HR = 2.51, 95% CI = 1.92-3.29, P < 0.001; dabigatran: HR = 2.24, 95% CI = 1.60-3.13, P < 0.001; and rivaroxaban: HR = 1.74, 95% CI = 1.31-2.30, P < 0.001). Also, the OACs were associated with significantly higher risk of hospitalization due to MB-related conditions compared with apixaban (warfarin: HR = 1.96, 95% CI = 1.71-2.23, P < 0.001; dabigatran: HR = 1.48; 95% CI = 1.25-1.76, P < 0.001; and rivaroxaban: HR = 2.17, 95% CI = 1.91-2.48, P < 0.001). Compared with apixaban, warfarin ($3,747 vs. $3,061, P < 0.001); dabigatran ($3,230 vs. $2,951, P < 0.001); and rivaroxaban ($3,950 vs. $3,060, P < 0.001) had significantly higher all-cause total health care costs per patient per month. Patients initiating the OACs also had significantly higher stroke/SE- and MB-related medical costs compared with apixaban: warfarin (stroke/SE = $135 vs. $60, P = 0.001; MB = $537 vs. $286, P < 0.001); dabigatran (stroke/SE = $94 vs. $62, P = 0.045; MB = $373 vs. $277, P = 0.010); and rivaroxaban (stroke/SE = $91 vs. $60, P = 0.008; MB = $524 vs. $287, P < 0.001). CONCLUSIONS: This real-world study showed that among elderly NVAF patients in the Medicare population, apixaban was associated with significantly lower risks of all-cause, stroke/SE-related, and MB-related hospitalizations compared with warfarin, dabigatran, and rivaroxaban. Accordingly, apixaban showed significantly lower all-cause health care costs and stroke/SE- and MB-related medical costs. DISCLOSURES: This study was funded by Bristol-Myers Squibb and Pfizer. Amin is an employee of the University of California, Irvine, and was a paid consultant to Bristol-Myers Squibb in connection with this study and the development of this manuscript. Keshishian and Zhang are employees of STATinMED Research, a paid consultant to Pfizer and Bristol-Myers Squibb in connection with this study and the development of this manuscript. Trocio, Dina, Mardekian, and Liu are employees of Pfizer, with ownership of stocks in Pfizer. Le, Rosenblatt, Nadkarni, and Vo are employees of Bristol-Myers Squibb. Rosenblatt and Vo have ownership of stocks in Bristol-Myers Squibb. Baser has no conflicts to disclose.


Asunto(s)
Anticoagulantes/administración & dosificación , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/economía , Costos de la Atención en Salud , Hospitalización/economía , Medicare/economía , Administración Oral , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/epidemiología , Femenino , Costos de la Atención en Salud/tendencias , Hospitalización/tendencias , Humanos , Masculino , Medicare/tendencias , Estudios Retrospectivos , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/prevención & control , Estados Unidos/epidemiología
7.
PLoS One ; 13(4): e0195088, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-29649277

RESUMEN

INTRODUCTION: As atrial fibrillation (AF) is often asymptomatic, it may remain undiagnosed until or even after development of complications, such as stroke. Consequently the observed prevalence of AF may underestimate total disease burden. METHODS: To estimate the prevalence of undiagnosed AF in the United States, we performed a retrospective cohort modeling study in working age (18-64) and elderly (≥65) people using commercial and Medicare administrative claims databases. We identified patients in years 2004-2010 with incident AF following an ischemic stroke. Using a back-calculation methodology, we estimated the prevalence of undiagnosed AF as the ratio of the number of post-stroke AF patients and the CHADS2-specific stroke probability for each patient, adjusting for age and gender composition based on United States census data. RESULTS: The estimated prevalence of AF (diagnosed and undiagnosed) was 3,873,900 (95%CI: 3,675,200-4,702,600) elderly and 1,457,100 (95%CI: 1,218,500-1,695,800) working age adults, representing 10.0% and 0.92% of the respective populations. Of these, 698,900 were undiagnosed: 535,400 (95%CI: 331,900-804,400) elderly and 163,500 (95%CI: 17,700-400,000) working age adults, representing 1.3% and 0.09% of the respective populations. Among all undiagnosed cases, 77% had a CHADS2 score ≥1, and 56% had CHADS2 score ≥2. CONCLUSIONS: Using a back-calculation approach, we estimate that the total AF prevalence in 2009 was 5.3 million of which 0.7 million (13.1% of AF cases) were undiagnosed. Over half of the modeled population with undiagnosed AF was at moderate to high risk of stroke.


Asunto(s)
Fibrilación Atrial/epidemiología , Fibrilación Atrial/terapia , Recolección de Datos , Accidente Cerebrovascular/complicaciones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Femenino , Humanos , Masculino , Medicare , Persona de Mediana Edad , Prevalencia , Probabilidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Estados Unidos , Adulto Joven
8.
Clin Appl Thromb Hemost ; 24(4): 602-611, 2018 May.
Artículo en Inglés | MEDLINE | ID: mdl-29363999

RESUMEN

In this study, all-cause, stroke/systemic embolism (SE)-related, and major bleeding (MB)-related health-care costs among elderly patients with nonvalvular atrial fibrillation (NVAF) initiating treatment with different oral anticoagulants (OACs) were compared. Patients ≥65 years of age initiating OACs, including apixaban, rivaroxaban, dabigatran, and warfarin, were identified from the Humana Research Database between January 1, 2013, and September 30, 2015. Propensity score matching was used to separately match the different OAC cohorts with the apixaban cohort. All-cause health-care costs and stroke/SE-related and MB-related medical costs per patient per month (PPPM) were compared using generalized linear or 2-part regression models. Compared to apixaban, rivaroxaban was associated with significantly higher all-cause health-care costs (US$2234 vs US$1846 PPPM, P < .001) and MB-related medical costs (US$106 vs US$47 PPPM, P < .001), dabigatran was associated with significantly higher all-cause health-care costs (US$1980 vs US$1801 PPPM, P = .007), and warfarin was associated with significantly higher all-cause health-care costs (US$2386 vs US$1929 PPPM, P < .001), stroke/SE-related medical costs (US$42 vs US$18 PPPM, P < .001), and MB-related medical costs (US$132 vs US$51 PPPM, P < .001). Among elderly patients with NVAF, other OACs were associated with higher all-cause health-care costs than apixaban.


Asunto(s)
Anticoagulantes/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Hemorragia/tratamiento farmacológico , Accidente Cerebrovascular/tratamiento farmacológico , Administración Oral , Anciano , Anticoagulantes/farmacología , Fibrilación Atrial/patología , Estudios de Cohortes , Femenino , Hemorragia/patología , Humanos , Estudios Longitudinales , Masculino , Estudios Retrospectivos , Accidente Cerebrovascular/patología
10.
Curr Med Res Opin ; 34(3): 539-546, 2018 03.
Artículo en Inglés | MEDLINE | ID: mdl-29235900

RESUMEN

OBJECTIVE: To evaluate inpatient oral anticoagulant (OAC) treatment, discharge location, and post-discharge OAC treatment for patients hospitalized with non-valvular atrial fibrillation (NVAF). RESEARCH DESIGN AND METHODS: Retrospective study using claims data linked to hospital electronic health records (EHR). Patients (n = 2,484) were hospitalized with a primary (38%) or secondary (62%) diagnosis of AF without evidence of mitral valvular heart disease or valve replacement between January 2009 and September 2013. Inpatient OAC treatment was identified from EHR data. MAIN OUTCOME MEASURES: Inpatient and post-discharge OAC treatment [direct OAC (DOAC; apixaban, rivaroxaban, dabigatran), warfarin, no OAC] and discharge location (long-term care, home health-care, home self-care). RESULTS: Mean age was 72.6 years, 61.2% were male, and 89.5% had a CHA2DS2-VASc score ≥2. Overall, 6.4% received a DOAC, 38.0% warfarin, and 55.6% no OAC during hospitalization. Compared to other treatment groups, patients receiving DOAC were younger and more likely to be male. The majority (72.2%) were discharged to home health-care, 13.2% home self-care, and 6.0% long-term care. Among patients who were treated with warfarin during hospitalization, 40.3% filled a warfarin prescription within 30 days post-discharge, whereas among patients who were treated with a DOAC, 52.4% filled a DOAC prescription within 30 days post-discharge. Some NVAF patients not treated with an OAC during hospitalization filled a prescription for warfarin (18.0%) or DOAC (1.9%) within 30 days post-discharge. Results were similar among patients with CHA2DS2-VASc score ≥2. CONCLUSIONS: Most patients hospitalized for NVAF were discharged to home support, and the majority did not have OAC treatment during hospitalization or the 30 days post-discharge. Additional investigation should be conducted on trends beyond 30 days post-hospitalization, and the reasons for not receiving anticoagulation therapy in patients at moderate-to-severe risk of stroke or systemic embolism. Helping to avoid preventable strokes is an important goal for public health.


Asunto(s)
Anticoagulantes/administración & dosificación , Fibrilación Atrial/terapia , Accidente Cerebrovascular/prevención & control , Administración Oral , Anciano , Anciano de 80 o más Años , Dabigatrán/administración & dosificación , Embolia/prevención & control , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Pacientes Internos , Masculino , Persona de Mediana Edad , Pacientes Ambulatorios , Alta del Paciente/estadística & datos numéricos , Pirazoles/administración & dosificación , Piridonas/administración & dosificación , Estudios Retrospectivos , Rivaroxabán/administración & dosificación , Warfarina/administración & dosificación
11.
J Med Econ ; 21(3): 244-253, 2018 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-29047304

RESUMEN

AIMS: To compare the risk of all-cause hospitalization and hospitalizations due to stroke/systemic embolism (SE) and major bleeding, as well as associated healthcare costs for non-valvular atrial fibrillation (NVAF) patients initiating apixaban, dabigatran, rivaroxaban, or warfarin. MATERIALS AND METHODS: NVAF patients initiating apixaban, dabigatran, rivaroxaban, or warfarin were selected from the OptumInsight Research Database from January 1, 2013-September 30, 2015. Propensity score matching (PSM) was performed between apixaban and each oral anticoagulant. Cox models were used to estimate the risk of stroke/SE and major bleeding. Generalized linear and 2-part models were used to compare healthcare costs. RESULTS: Of the 47,634 eligible patients, 8,328 warfarin-apixaban pairs, 3,557 dabigatran-apixaban pairs, and 8,440 rivaroxaban-apixaban pairs were matched. Compared to apixaban, warfarin patients were associated with a significantly higher risk of all-cause (hazard ratio [HR] = 1.30; 95% confidence interval [CI] = 1.21-1.40) as well as stroke/SE-related (HR = 1.60; 95% CI = 1.23-2.07) and major bleeding-related (HR = 1.95; 95% CI = 1.60-2.39) hospitalization; rivaroxaban patients were associated with a higher risk of all-cause (HR = 1.15; 95% CI = 1.07-1.24) and major bleeding-related hospitalization (HR = 1.71; 95% CI = 1.39-2.10); and dabigatran patients were associated with a higher risk of major bleeding hospitalization (HR = 1.46, 95% CI = 1.02-2.10). Warfarin patients had significantly higher major bleeding-related and total all-cause healthcare costs compared to apixaban patients. Rivaroxaban patients had significantly higher major bleeding-related costs compared to apixaban patients. No significant results were found for the remaining comparisons. LIMITATIONS: No causal relationships can be concluded, and unobserved confounders may exist in this retrospective database analysis. CONCLUSIONS: This study demonstrated a significantly higher risk of hospitalization (all-cause, stroke/SE, and major bleeding) associated with warfarin, a significantly higher risk of major bleeding hospitalization associated with dabigatran or rivaroxaban, and a significantly higher risk of all-cause hospitalization associated with rivaroxaban compared to apixaban. Lower major bleeding-related costs were observed for apixaban patients compared to warfarin and rivaroxaban patients.


Asunto(s)
Anticoagulantes/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/economía , Costos y Análisis de Costo , Hemorragia , Hospitalización , Accidente Cerebrovascular , Adolescente , Adulto , Anciano , Costos y Análisis de Costo/estadística & datos numéricos , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Estados Unidos , Adulto Joven
12.
Clin Appl Thromb Hemost ; 24(2): 364-371, 2018 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-28135822

RESUMEN

Warfarin is a recommended therapy to reduce the risk of stroke in patients with nonvalvular atrial fibrillation (NVAF). The objectives of this study were to identify potential factors associated with warfarin persistence and evaluate the impact of warfarin persistence on health-care resource utilization and costs among patients with NVAF in the United States. Patients (≥18 years) with ≥1 inpatient or ≥2 outpatient diagnoses of AF without valvular disease were identified from an electronic medical record database (January 1, 2004, to January 31, 2015). The patients with NVAF were grouped into 2 cohorts-persistent with warfarin therapy and not persistent (warfarin discontinuation in <365 days). A multivariable regression was used to identify potential predictors of warfarin persistence. Health-care costs were evaluated during a 12-month follow-up period for study cohorts. Among the study population, 52%, (n = 4086) were persistent with warfarin therapy and 48% (n = 3722) were not. Patients with NVAF with higher Charlson comorbidity index and CHADS2 scores versus those with scores of 0 were more likely to demonstrate persistence with warfarin therapy. After adjusting for patient characteristics, patients with NVAF persistent with warfarin therapy versus those who were not were 30% less likely to be hospitalized during the follow-up period ( P < .001). Additionally, total all-cause health-care costs (US $2183, P < .001) and stroke-related costs (US $788, P < .001) were significantly lower among patients persistent with warfarin therapy versus those who were not. Patients with NVAF who have greater comorbidity and stroke risk are more likely to be persistent with warfarin therapy. Patients with NVAF who are persistent with warfarin therapy versus those who are not have lower all-cause and stroke-related health-care costs.


Asunto(s)
Fibrilación Atrial/tratamiento farmacológico , Atención a la Salud/economía , Warfarina/uso terapéutico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Fibrilación Atrial/complicaciones , Fibrilación Atrial/economía , Costos y Análisis de Costo , Bases de Datos Factuales , Atención a la Salud/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis de Regresión , Accidente Cerebrovascular/economía , Estados Unidos , Warfarina/economía , Adulto Joven
13.
J Manag Care Spec Pharm ; 23(11): 1191-1201, 2017 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-29083968

RESUMEN

BACKGROUND: The clinical trial ARISTOTLE showed that apixaban was superior to warfarin in reducing the risks of stroke and bleeding among patients with nonvalvular atrial fibrillation (NVAF). Further study of the effect of apixaban versus warfarin use on health care resource utilization (HCRU) and associated costs in the real-world setting is warranted, especially among elderly patients who are at higher risk of stroke and bleeding. OBJECTIVE: To compare HCRU and costs among elderly NVAF patients treated with apixaban versus warfarin in the United States. METHODS: Elderly patients (aged ≥ 65 years) with Medicare coverage who initiated apixaban or warfarin were identified from the Humana research database during January 1, 2013-September 30, 2015. Patients were required to have 12 months of continuous insurance coverage before drug initiation (baseline period) and an atrial fibrillation diagnosis during the baseline period or on the date of drug initiation. NVAF patients were grouped into cohorts depending on the drug initiated. Propensity score matching (PSM) was conducted to control for differences in demographics and clinical characteristics of study cohorts. Patients were followed after the index date for a variable length of follow-up. All-cause and disease-specific HCRU and costs during the follow-up were evaluated before and after PSM and reported as per patient per year. RESULTS: Of the overall (unmatched) population, 8,250 patients (mean age: 78.0 years) initiated apixaban and 14,051 patients (mean age: 78.2 years) initiated warfarin. Among NVAF patients who initiated apixaban versus those who initiated warfarin, mean Charlson Comorbidity Index (CCI) scores (3.0 vs. 3.4, P < 0.001); stroke risk scores, including CHADS2 (2.7 vs. 2.9, P < 0.001) and CHA2DS2-VASc (4.6 vs. 4.7, P < 0.001); and bleeding risk scores, including HAS-BLED (3.1 vs. 3.2, P < 0.001), were lower. Additionally, total annual all-cause health care costs were lower during the baseline period for patients treated with apixaban versus warfarin ($17,077 vs. $20,236, P < 0.001). After PSM, 14,214 patients were matched, with 7,107 in each cohort. Mean age, CCI score, and stroke and bleeding risks were similar between matched cohorts, as were total all-cause health care costs during the baseline period. During the follow-up among matched cohorts, apixaban versus warfarin treatment was associated with higher annual pharmacy costs ($5,159 vs. $2,867, P < 0.001) but lower annual inpatient ($8,327 vs. $14,296, P < 0.001), outpatient ($9,655 vs. $11,469, P < 0.001), and total all-cause health care costs ($23,141 vs. $28,633, P < 0.001), which were reflective of lower inpatient, outpatient, and all-cause HCRU among apixaban-treated patients. Furthermore, bleeding-related ($2,101 vs. $3,963, P < 0.001) and stroke-related ($652 vs. $1,178, P = 0.001) annual medical costs were lower for patients treated with apixaban versus warfarin. CONCLUSIONS: After controlling for differences in patient characteristics, in the real-world setting apixaban versus warfarin use was associated with less HCRU and lower total all-cause health care costs and costs for bleeding- and stroke-related medical services, but greater pharmacy costs, among elderly NVAF patients. DISCLOSURES: This study was sponsored by Pfizer and Bristol-Myers Squibb. Deitelzweig is a consultant for Pfizer and Bristol-Myers Squibb and has served on their advisory boards and received speaker fees. Deitelzweig also serves as consultant and advisory board member to Portola and Janssen. Luo, Trocio, and Mardekian are employees of Pfizer and own stock in the company. Gupta and Curtice are employees of Bristol-Myers Squibb and own stock in the company. Lingohr-Smith, Menges, and Lin are employees of Novosys Health, which received research funds from Pfizer and Bristol-Myers Squibb to conduct this study and develop the manuscript. Study concept and design were primarily contributed by Deitelzweig, Luo, and Gupta, along with Trocio, Mardekian, Curtice, and Lin. Lin, Menges, and Lingohr-Smith took the lead in data collection, with assistance from the other authors. Data interpretation was performed by Deitelzweig, Menges, and Lin, with assistance from the other authors. The manuscript was written by Lingohr-Smith and Menges, along with the other authors, and revised by all the authors. Some aspects of this study were presented at the American Heart Association Scientific Sessions in New Orleans, Louisiana, November 12-16, 2016.


Asunto(s)
Fibrilación Atrial/economía , Costos de la Atención en Salud , Recursos en Salud/economía , Aceptación de la Atención de Salud , Pirazoles/economía , Piridonas/economía , Warfarina/economía , Anciano , Anciano de 80 o más Años , Anticoagulantes/economía , Anticoagulantes/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/epidemiología , Inhibidores del Factor Xa/economía , Inhibidores del Factor Xa/uso terapéutico , Femenino , Estudios de Seguimiento , Costos de la Atención en Salud/tendencias , Recursos en Salud/tendencias , Humanos , Masculino , Pirazoles/uso terapéutico , Piridonas/uso terapéutico , Resultado del Tratamiento , Warfarina/uso terapéutico
14.
Curr Med Res Opin ; 33(10): 1745-1754, 2017 10.
Artículo en Inglés | MEDLINE | ID: mdl-28849676

RESUMEN

OBJECTIVE: To compare the risk of stroke/systemic embolism (S/SE) and major bleeding (MB) of elderly (≥65 years of age) nonvalvular atrial fibrillation (NVAF) patients initiating apixaban vs. rivaroxaban, dabigatran, or warfarin. METHODS: NVAF patients with Medicare Advantage coverage in the US initiating oral anticoagulants (OACs, index event) were identified from the Humana database (1 January 2013-30 September 2015) and grouped into cohorts depending on OAC initiated. Propensity score matching (PSM), 1:1, was conducted among patients treated with apixaban vs. each other OAC, separately. Rates of S/SE and MB were evaluated in the follow-up. Cox regressions were used to compare the risk of S/SE and MB between apixaban and each of the other OACs during the follow-up. RESULTS: The matched pairs of apixaban vs. rivaroxaban (n = 13,620), apixaban vs. dabigatran (n = 4654), and apixaban vs. warfarin (n = 14,214) were well balanced for key patient characteristics. Adjusted risks for S/SE (hazard ratio [HR] vs. rivaroxaban: 0.72, p = .003; vs. warfarin: 0.65, p < .001) and MB (HR vs. rivaroxaban: 0.49, p < .001; vs. warfarin: 0.53, p < .001) were significantly lower during the follow-up for patients treated with apixaban vs. rivaroxaban and warfarin. Adjusted risks for S/SE (HR: 0.78, p = .27) and MB (HR: 0.82, p = .23) of NVAF patients treated with apixaban vs. dabigatran trended to be lower, but did not reach statistical significance. CONCLUSIONS: In the real-world setting after controlling for differences in patient characteristics, apixaban is associated with significantly lower risk of S/SE and MB than rivaroxaban and warfarin, and a trend towards better outcomes vs. dabigatran among elderly NVAF patients in the US.


Asunto(s)
Anticoagulantes/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Hemorragia/inducido químicamente , Pirazoles/uso terapéutico , Piridonas/uso terapéutico , Anciano , Anciano de 80 o más Años , Anticoagulantes/efectos adversos , Dabigatrán/administración & dosificación , Dabigatrán/efectos adversos , Femenino , Humanos , Masculino , Puntaje de Propensión , Pirazoles/efectos adversos , Piridonas/efectos adversos , Estudios Retrospectivos , Rivaroxabán/efectos adversos , Rivaroxabán/uso terapéutico , Accidente Cerebrovascular/prevención & control , Warfarina/efectos adversos , Warfarina/uso terapéutico
15.
J Med Econ ; 20(9): 952-961, 2017 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-28604139

RESUMEN

AIMS: This study compared the risk for major bleeding (MB) and healthcare economic outcomes of patients with non-valvular atrial fibrillation (NVAF) after initiating treatment with apixaban vs rivaroxaban, dabigatran, or warfarin. METHODS: NVAF patients who initiated apixaban, rivaroxaban, dabigatran, or warfarin were identified from the IMS Pharmetrics Plus database (January 1, 2013-September 30, 2015). Propensity score matching (PSM) was used to balance differences in patient characteristics between study cohorts: patients treated with apixaban vs rivaroxaban, apixaban vs dabigatran, and apixaban vs warfarin. Risk of hospitalization and healthcare costs (all-cause and MB-related) were compared between matched cohorts during the follow-up. RESULTS: During the follow-up, risks for all-cause (hazard ratio [HR] = 1.44, 95% confidence interval [CI] = 1.2-1.7) and MB-related (HR = 1.57, 95% CI = 1.0-2.4) hospitalizations were significantly greater for patients treated with rivaroxaban vs apixaban. Adjusted total all-cause healthcare costs were significantly lower for patients treated with apixaban vs rivaroxaban ($3,950 vs $4,333 per patient per month [PPPM], p = .002) and MB-related medical costs were not statistically significantly different ($100 vs $233 PPPM, p = .096). Risk for all-cause hospitalization (HR = 1.98, 95% CI = 1.6-2.4) was significantly greater for patients treated with dabigatran vs apixaban, although total all-cause healthcare costs were not statistically different. Risks for all-cause (HR = 2.22, 95% CI = 1.9-2.5) and MB-related (HR = 2.05, 95% CI = 1.4-3.0) hospitalizations were significantly greater for patients treated with warfarin vs apixaban. Total all-cause healthcare costs ($3,919 vs $4,177 PPPM, p = .025) and MB-related medical costs ($96 vs $212 PPPM, p = .026) were significantly lower for patients treated with apixaban vs warfarin. LIMITATIONS: This retrospective database analysis does not establish causation. CONCLUSIONS: In the real-world setting, compared with rivaroxaban and warfarin, apixaban is associated with reduced risk of hospitalization and lower healthcare costs. Compared with dabigatran, apixaban is associated with lower risk of hospitalizations.


Asunto(s)
Anticoagulantes/economía , Anticoagulantes/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Gastos en Salud/estadística & datos numéricos , Anciano , Anticoagulantes/efectos adversos , Comorbilidad , Dabigatrán/economía , Dabigatrán/uso terapéutico , Femenino , Recursos en Salud/economía , Recursos en Salud/estadística & datos numéricos , Hemorragia/inducido químicamente , Humanos , Masculino , Persona de Mediana Edad , Modelos Econométricos , Puntaje de Propensión , Pirazoles/economía , Pirazoles/uso terapéutico , Piridonas/economía , Piridonas/uso terapéutico , Estudios Retrospectivos , Rivaroxabán/uso terapéutico , Warfarina/economía , Warfarina/uso terapéutico
16.
Curr Med Res Opin ; 33(9): 1595-1604, 2017 09.
Artículo en Inglés | MEDLINE | ID: mdl-28635338

RESUMEN

OBJECTIVE: To compare the risk and cost of stroke/systemic embolism (SE) and major bleeding between each direct oral anticoagulant (DOAC) and warfarin among non-valvular atrial fibrillation (NVAF) patients. METHODS: Patients (≥65 years) initiating warfarin or DOACs (apixaban, rivaroxaban, and dabigatran) were selected from the Medicare database from 1 January 2013 to 31 December 2014. Patients initiating each DOAC were matched 1:1 to warfarin patients using propensity score matching to balance demographics and clinical characteristics. Cox proportional hazards models were used to estimate the risks of stroke/SE and major bleeding of each DOAC vs. warfarin. Two-part models were used to compare the stroke/SE- and major-bleeding-related medical costs between matched cohorts. RESULTS: Of the 186,132 eligible patients, 20,803 apixaban-warfarin pairs, 52,476 rivaroxaban-warfarin pairs, and 16,731 dabigatran-warfarin pairs were matched. Apixaban (hazard ratio [HR] = 0.40; 95% confidence interval [CI] 0.31, 0.53) and rivaroxaban (HR = 0.72; 95% CI 0.63, 0.83) were significantly associated with lower risk of stroke/SE compared to warfarin. Apixaban (HR = 0.51; 95% CI 0.44, 0.58) and dabigatran (HR = 0.79; 95% CI 0.69, 0.91) were significantly associated with lower risk of major bleeding; rivaroxaban (HR = 1.17; 95% CI 1.10, 1.26) was significantly associated with higher risk of major bleeding compared to warfarin. Compared to warfarin, apixaban ($63 vs. $131) and rivaroxaban ($93 vs. $139) had significantly lower stroke/SE-related medical costs; apixaban ($292 vs. $529) and dabigatran ($369 vs. $450) had significantly lower major bleeding-related medical costs. CONCLUSIONS: Among the DOACs in the study, only apixaban is associated with a significantly lower risk of stroke/SE and major bleeding and lower related medical costs compared to warfarin.


Asunto(s)
Fibrilación Atrial/tratamiento farmacológico , Embolia/prevención & control , Accidente Cerebrovascular/prevención & control , Warfarina/uso terapéutico , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Costos y Análisis de Costo , Dabigatrán/administración & dosificación , Femenino , Hemorragia/inducido químicamente , Humanos , Masculino , Medicare , Modelos de Riesgos Proporcionales , Pirazoles/administración & dosificación , Piridonas/administración & dosificación , Riesgo , Rivaroxabán/administración & dosificación , Accidente Cerebrovascular/epidemiología , Estados Unidos
17.
Drugs Real World Outcomes ; 3(2): 165-173, 2016 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-27398295

RESUMEN

BACKGROUND: Frequency of administration (once daily versus more than once daily) is believed to be an important consideration affecting drug choice. OBJECTIVE: The aim of this study was to describe the characteristics of patients with non-valvular atrial fibrillation (NVAF) and the extent to which they take chronic medications, other than anticoagulants, more frequently than once daily. METHODS: Using data from a large, national database of health insurance claims, patients with a diagnosis of NVAF between 1 July 2008 and 30 September 2011 were identified, along with their prescription medications, to determine the proportion of patients taking chronic medications more than once a day. Prescription medications, co-morbidities, and CHADS2 and CHA2DS2-VASc scores were evaluated. CHADS2 assesses the risk of stroke in NVAF patients with the following risk factors: Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, and history of prior Stroke or transient ischemic attack. The CHA2DS2-VASc score adds the following risk factors to the CHADS2 score: Age 65-74 years, Vascular Disease, and Sex Category (Female). RESULTS: Overall, 324,172 patients with NVAF with mean CHADS2 and CHA2DS2-VASc scores of 1.51 and 3.08, respectively, were included in the study. Of these patients, 299,716 (92.5 %) took chronic medications, with an average of 6.9 medications per patient, and 215,527 (66.5 % of all patients or 71.9 % of those taking chronic medications) took medications more than once per day. CONCLUSION: Use of chronic medications other than anticoagulants is common among patients with NVAF, and medications are typically taken multiple times per day. The average number of medications per patient and multiple therapeutic classes prescribed underscore the clinical complexity of NVAF patients. Hence, the choice of a once daily anticoagulant versus a more than once daily anticoagulant may be less relevant in a real world NVAF population in terms of a potential convenience benefit.

18.
Value Health ; 19(4): 451-9, 2016 06.
Artículo en Inglés | MEDLINE | ID: mdl-27325337

RESUMEN

OBJECTIVES: The objective of this study was to compare patient and physician preferences for different antithrombotic therapies used to treat nonvalvular atrial fibrillation (NVAF). METHODS: Patients diagnosed with NVAF and physicians treating such patients completed 12 discrete choice questions comparing NVAF therapies that varied across five attributes: stroke risk, major bleeding risk, convenience (no regular blood testing/dietary restrictions), dosing frequency, and patients' out-of-pocket cost. We used a logistic regression to estimate the willingness-to-pay (WTP) value for each attribute. RESULTS: The 200 physicians surveyed were willing to trade off $38 (95% confidence interval [CI] $22 to $54] in monthly out-of-pocket cost for a 1% (absolute) decrease in stroke risk, $14 (95% CI $8 to $21) for a 1% decrease in major bleeding risk, and $34 (95% CI $9 to $60) for more convenience. The WTP value among 201 patients surveyed was $30 (95% CI $18 to $42) for reduced stroke risk, $16 (95% CI $9 to $24) for reduced bleeding risk, and -$52 (95% CI -$96 to -6) for convenience. The WTP value for convenience among patients using warfarin was $9 (95% CI $1 to $18) for more convenience, whereas patients not currently on warfarin had a WTP value of -$90 (95% CI -$290 to -$79). Both physicians' and patients' WTP value for once-daily dosing was not significantly different from zero. On the basis of survey results, 85.0% of the physicians preferred novel oral anticoagulants (NOACs) to warfarin. NOACs (73.0%) were preferred among patients using warfarin, but warfarin (78.2%) was preferred among patients not currently using warfarin. Among NOACs, both patients and physicians preferred apixaban. CONCLUSIONS: Both physicians and patients currently using warfarin preferred NOACs to warfarin. Patients not currently using warfarin preferred warfarin over NOACs because of an apparent preference for regular blood testing/dietary restrictions.


Asunto(s)
Fibrilación Atrial/economía , Actitud del Personal de Salud , Fibrinolíticos/economía , Prioridad del Paciente/estadística & datos numéricos , Médicos/psicología , Adulto , Anciano , Anticoagulantes , Fibrilación Atrial/complicaciones , Fibrilación Atrial/tratamiento farmacológico , Actitud Frente a la Salud , Conducta de Elección , Costos y Análisis de Costo , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Prioridad del Paciente/psicología , Pacientes/psicología , Proyectos Piloto , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/prevención & control , Encuestas y Cuestionarios , Warfarina/economía , Warfarina/uso terapéutico , Adulto Joven
19.
J Med Econ ; 19(8): 769-76, 2016 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-27028360

RESUMEN

OBJECTIVE: To quantify and compare hospital length of stay (LOS) and costs between hospitalized non-valvular atrial fibrillation (NVAF) patients treated with either apixaban or warfarin via a large claims database. METHODS: Adult patients hospitalized with AF were selected from the Premier Perspective Claims Database (01JAN2013-31MARCH2014). Patients with evidence of valvular heart disease, valve replacement procedures, or pregnancy during the index hospitalization were excluded. Patients treated with apixaban or warfarin during hospitalization were identified. Propensity score matching (PSM) was performed to control for baseline imbalances between patients treated with apixaban or warfarin. Primary outcomes were hospital LOS (days), post-medication administration LOS, and index hospitalization costs, and were compared using paired t-tests in the matched sample. RESULTS: Before PSM, 2894 apixaban and 124,174 warfarin patients were identified. Patients treated with warfarin were older and sicker compared to those treated with apixaban. After applying PSM, a total of 2886 patients were included in each cohort, and baseline characteristics were balanced. The mean (standard deviation [SD] and median) hospital LOS was significantly (p = 0.002) shorter for patients treated with apixaban for 5.1 days (5.7 and 3) compared to warfarin for 5.5 days (4.8 and 4). The trend appeared consistent in the hospital LOS from point of apixaban or warfarin administration to discharge (4.5 vs 4.7 days, p = 0.051). Patients administered apixaban incurred significantly lower hospitalization costs compared to those administered warfarin ($11,262 vs $12,883; p < 0.001). CONCLUSIONS: Among NVAF patients, apixaban treatment was associated with significantly shorter hospital LOS and lower costs when compared to warfarin treatment.


Asunto(s)
Anticoagulantes/economía , Fibrilación Atrial/tratamiento farmacológico , Precios de Hospital/estadística & datos numéricos , Hospitalización/economía , Pirazoles/economía , Piridonas/economía , Warfarina/economía , Adulto , Factores de Edad , Anciano , Anticoagulantes/uso terapéutico , Comorbilidad , Femenino , Humanos , Revisión de Utilización de Seguros , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Pirazoles/uso terapéutico , Piridonas/uso terapéutico , Índice de Severidad de la Enfermedad , Factores Socioeconómicos , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/prevención & control , Warfarina/uso terapéutico , Adulto Joven
20.
Curr Med Res Opin ; 32(1): 87-94, 2016.
Artículo en Inglés | MEDLINE | ID: mdl-26451675

RESUMEN

BACKGROUND: Warfarin is efficacious for reducing stroke risk among patients with nonvalvular atrial fibrillation (NVAF). However, the efficacy and safety of warfarin are influenced by its time in therapeutic range (TTR). OBJECTIVE: To assess differences in healthcare resource utilization and costs among NVAF patients with low (<60%) and high (≥60%) warfarin TTRs in an integrated delivery network (IDN) setting. METHODS: Patients with NVAF were identified from an electronic medical record database. Patients were required to have ≥6 international normalized prothrombin time ratio (INR) tests. NVAF patients were grouped into two cohorts: those with warfarin TTR <60% (low TTR) and those with warfarin TTR ≥60% (high TTR). Healthcare resource utilization and costs were evaluated during a 12 month follow-up period. Multivariable regressions were used to assess the impact of different warfarin TTRs on healthcare costs. RESULTS: Among the study population, greater than half (54%, n = 1595) had a low TTR, and 46% (n = 1356) had a high TTR. Total all-cause healthcare resource utilization was higher among patients in the low TTR cohort vs. the high TTR cohort (number of encounters: 70.2 vs. 56.1, p < 0.001). After adjusting for patient characteristics, total all-cause healthcare costs and stroke-related healthcare costs were $2398 (p < 0.001) and $687 (p = 0.02) higher, respectively, for patients in the low TTR cohort vs. the high TTR cohort. LIMITATIONS: In this retrospective study, we were only able to evaluate the association and not the causality between healthcare resource utilization and costs with the different warfarin TTRs. CONCLUSION: Many warfarin-treated NVAF patients have a low warfarin TTR. NVAF patients with low vs. patients with high warfarin TTR used healthcare resources to a greater extent, which was reflected in higher healthcare costs.


Asunto(s)
Anticoagulantes/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Costos de la Atención en Salud , Recursos en Salud/estadística & datos numéricos , Warfarina/uso terapéutico , Adulto , Anciano , Fibrilación Atrial/sangre , Femenino , Humanos , Relación Normalizada Internacional , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo
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