Initiation of direct oral anticoagulants versus warfarin for venous thromboembolism: impact on time to hospital discharge.

The objective of this project was to compare the time from initiation of oral anticoagulation to hospital discharge between warfarin and direct oral anticoagulants (DOACs) for the treatment of acute venous thromboembolism (VTE). This retrospective observational study was done at a single VA medical center. A total of 107 patients were included, with 42 patients (39%) in the DOAC group, which included rivaroxaban, dabigatran, and apixaban, and 65 patients (61%) in the warfarin group. Variables collected through chart review included comorbid conditions, time from initiation of oral anticoagulation to discharge, emergency department (ED) visits and readmission within 30 or 90 days, and bleeding events. The DOAC group had a shorter time to discharge compared to the warfarin group (28 vs. 114 h, p < 0.001). There were similar 30 and 90-day hospital readmission rates and/or ED visits for DOACs (23.8 and 33.3%) compared to warfarin (18.5 and 30.8%), including those related to bleeding of any severity (11.9% for DOACs vs. 9.2% for warfarin; p = 0.75). There was one major bleeding event in the DOAC group and two in the warfarin group. The use of DOACs for the treatment of acute VTE in hospitalized patients was associated with shorter time to hospital discharge when compared to warfarin.

A Comparison Between Dabigatran and Warfarin on Time to Elective Cardioversion.

OBJECTIVE: To evaluate the use of dabigatran versus warfarin on time to elective direct current cardioversion (DCCV). METHODOLOGY: This retrospective observational study was conducted at a single Veterans Affairs hospital in the Southwestern region of the U.S. Patients with atrial fibrillation or atrial flutter who were initiated on either warfarin or dabigatran prior to DCCV were reviewed. The time to cardioversion was compared between warfarin and dabigatran, as well as costs of therapy, rescheduling rates, and adverse events. RESULTS: Out of 258 patients reviewed, a total of 68 patients were included in the study. All patients were male with an average age of 68 years (SD=8.6). A total of 38 patients (56%) received dabigatran and 30 patients (44%) received warfarin. Patients in both groups had a median CHADS2 and HASBLED score of 2. The median number of days to cardioversion was 34.5 (range=22-148) for dabigatran compared to 66.5 (range=32-183) for warfarin (p<0.01). Total costs of anticoagulation for warfarin averaged $183.50 (SD=95.02) from initiation of anticoagulation to the end of the required four week period following cardioversion, whereas dabigatran costs averaged $193.20 (SD=59.38). Three patients (10%) in the warfarin group had DCCV rescheduled compared to none in the dabigatran group. There was one bleeding event in the warfarin group and no thromboembolic events in either group. CONCLUSION: The use of dabigatran prior to elective DCCV results in a significant decrease in number of days from initiation of anticoagulation to cardioversion as compared to warfarin, with a minor increase in total costs.

Clinical and financial outcomes of switching insulin glargine to insulin detemir in a veteran population with type 2 diabetes.

BACKGROUND: Although glargine and detemir are both FDA-approved in the U.S. as long-acting insulin analogues, inherent differences in the insulins may lead to varying outcomes. This study examined changes in clinical measures and associated costs for veterans with type 2 diabetes on insulin therapy converted from insulin glargine to insulin detemir. METHODS: A retrospective before-and-after comparison study was performed at a single-site medical center located in the southwestern U.S., comprising 133 Veterans diagnosed with type 2 diabetes receiving insulin therapy with glargine and converted to insulin detemir using a 1:1 unit dosage ratio. Patients' A1c, weight, body mass index, total daily dose, and estimated monthly insulin costs during and after conversion were compared employing Wilcoxon signed-rank tests. These measures were similarly assessed in patients at A1c goal (<7 %) prior to conversion. RESULTS: When switched from insulin glargine to insulin detemir, an increase in A1c (median of 7.7 % to 8.3 %, p < 0.01) and total daily dose (TDD: 40 to 46 units/day, p < 0.01) resulted. Monthly insulin costs decreased 19 % ($47 to $38, p < 0.01), or roughly a one-year savings of $110 per patient. An increase in A1c was similarly observed for patients at-goal prior to conversion but remained at-goal post-conversion (6.5 % to 6.7 %, p = 0.02). CONCLUSION: The increase in A1c and TDD following conversion from insulin glargine to insulin detemir suggests that glargine requires a smaller amount of units to reach the same glycemic-lowering ability compared to detemir. Despite the observed insulin cost savings associated with detemir, future studies should also determine overall costs (including indirect) and benefits associated with switching from glargine to detemir among Veteran with Type 2 diabetes.