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1.
Bull World Health Organ ; 99(9): 653-660, 2021 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-34475602

RESUMO

Poor control of cardiovascular disease accounts for a substantial proportion of the disease burden in developing countries, but often essential anticoagulant medicines for preventing strokes and embolisms are not widely available. In 2019, direct oral anticoagulants were added to the World Health Organization's WHO Model list of essential medicines. The aims of this paper are to summarize the benefits of direct oral anticoagulants for patients with cardiovascular disease and to discuss ways of increasing their usage internationally. Although the cost of direct oral anticoagulants has provoked debate, the affordability of introducing these drugs into clinical practice could be increased by: price negotiation; pooled procurement; competitive tendering; the use of patent pools; and expanded use of generics. In 2017, only 14 of 137 countries that had adopted national essential medicines lists included a direct oral anticoagulant on their lists. This number could increase rapidly if problems with availability and affordability can be tackled. Once the types of patient likely to benefit from direct oral anticoagulants have been clearly defined in clinical practice guidelines, coverage can be more accurately determined and associated costs can be better managed. Government action is required to ensure that direct oral anticoagulants are covered by national budgets because the absence of reimbursement remains an impediment to achieving universal coverage. Tackling cardiovascular disease with the aid of direct oral anticoagulants is an essential component of efforts to achieve the World Health Organization's target of reducing premature deaths due to noncommunicable disease by 25% by 2025.


Assuntos
Anticoagulantes/economia , Custos de Medicamentos , Medicamentos Essenciais/provisão & distribuição , Medicamentos Genéricos/provisão & distribuição , Acesso aos Serviços de Saúde/estatística & dados numéricos , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Custos e Análise de Custo , Medicamentos Essenciais/economia , Medicamentos Genéricos/economia , Custos de Cuidados de Saúde , Humanos
2.
J Manag Care Spec Pharm ; 27(8): 1056-1066, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34337995

RESUMO

BACKGROUND: Direct oral anticoagulants (DOACs) are an alternative to warfarin for treatment of atrial fibrillation (AF). Evidence demonstrating the efficacy and safety of DOACs has primarily been from clinical trial settings. The real-world effectiveness of DOACs in specific nontrial populations that differ in age, comorbidity burden, and socioeconomic status is unclear. OBJECTIVE: To compare total downstream medical expenditure between AF patients treated with warfarin and DOACs dually enrolled in the Veterans Affairs (VA) Healthcare System and fee-for-service Medicare. METHODS: This was an exploratory treatment effectiveness study that analyzed VA administrative data and Medicare claims. We examined patients with an incident diagnosis for AF and initiated warfarin or DOAC treatment between 2012 and 2015. The primary outcome was total medical expenditure over 3 years following treatment initiation. To address potential informative censoring, we applied a multipart estimator that extends traditional 2-part models to separate differences between groups due to survival and cost accumulation effects. Inverse probability weighting was applied to address potential treatment selection bias. RESULTS: We identified 31,276 and 17,021 patients receiving warfarin and DOACs, respectively. Mean unadjusted (SD) expenditure was higher for warfarin ($56,265 [$96,666]) compared with DOAC patients ($32,736 [$52,470]). Compared with patients receiving DOACs, adjusted 3-year expenditure was $25,688 (P < 0.001) higher for patients receiving warfarin. CONCLUSIONS: VA patients with AF initiating warfarin incurred markedly higher downstream expenditure compared with similar patients receiving DOACs. The benefits of DOACs found in previous clinical trials were present in this population, suggesting that these DOACs may be the preferred option for treatment of AF in older VA patients. DISCLOSURES: This study was funded by a VA Health Services Research and Development Investigator Initiated Research Award (IIR 15-139). Support for VA/CMS data was provided by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the University of Washington, Northeastern University, and Boston University. The authors declare no conflicts of interest. This research includes data obtained from the VHA Office of Performance Measurement (17API2), which resides within the Office of Analytics and Performance Integration (API), under the Office of Quality and Patient Safety (QPS; formerly known as RAPID). An oral presentation documenting a subset of the findings from this study was presented at the 2020 AcademyHealth Annual Research Meeting, delivered virtually on July 29, 2020.


Assuntos
Administração Oral , Anticoagulantes/economia , Fibrilação Atrial/tratamento farmacológico , Medicare , United States Department of Veterans Affairs , Varfarina/economia , Anticoagulantes/administração & dosagem , Custos e Análise de Custo , Custos de Medicamentos , Feminino , Humanos , Masculino , Estudos Retrospectivos , Estados Unidos , Varfarina/administração & dosagem
3.
Neurology ; 97(6): e608-e618, 2021 08 10.
Artigo em Inglês | MEDLINE | ID: mdl-34108269

RESUMO

OBJECTIVE: We sought to evaluate the short- and long-term resource use and costs associated with intracerebral hemorrhage (ICH) taken from an entire population. We in addition sought to evaluate the association of oral anticoagulation (OAC) and health care costs. METHODS: This was a retrospective cohort study of adult patients (≥18 years) with ICH in the entire population of Ontario, Canada (2009-2017). We captured outcomes through linkage to health administrative databases. We used generalized linear models to identify factors associated with total cost. Analysis of OAC use was limited to patients ≥66 years of age. The primary outcome was total 1-year direct health care costs in 2020 US dollars. RESULTS: Among 16,248 individuals with ICH (mean age 71.2 years, male 52.3%), 1-year mortality was 46.0%, and 24.2% required mechanical ventilation. The median total 1-year cost was $26,886 (interquartile range [IQR] $9,641-$62,907) with costs for those who died in hospital of $7,268 (IQR $4,031-$14,966) vs $44,969 (IQR $20,264-$82,414, p < 0.001) for survivors to discharge. OAC use (analysis limited to individuals ≥66 years old) was associated with higher total 1-year costs (cost ratio 1.06 [95% confidence interval 1.01-1.11]). Total 1-year costs for the entire cohort exceeded $120 million per year over the study period. CONCLUSIONS: ICH is associated with significant health care costs, and the median cost of a patient with ICH is roughly 10 times the median inpatient cost in Ontario. Costs were higher among survivors than deceased patients. OAC use is independently associated with increased costs. To maximize cost-effectiveness, future therapies for ICH must aim to reduce disability, not only improve mortality.


Assuntos
Anticoagulantes , Hemorragia Cerebral , Utilização de Instalações e Serviços , Custos de Cuidados de Saúde , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Anticoagulantes/economia , Anticoagulantes/uso terapêutico , Hemorragia Cerebral/economia , Hemorragia Cerebral/epidemiologia , Hemorragia Cerebral/terapia , Utilização de Instalações e Serviços/economia , Utilização de Instalações e Serviços/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Avaliação de Resultados em Cuidados de Saúde , Respiração Artificial/economia , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo
4.
BMC Cardiovasc Disord ; 21(1): 160, 2021 03 31.
Artigo em Inglês | MEDLINE | ID: mdl-33789592

RESUMO

OBJECTIVE: Prevention of recurrent stroke in patients with embolic stroke of undetermined source (ESUS) is challenging. The advent of safer anticoagulation in the form of direct oral anticoagulants (DOACs) has prompted exploration of prophylactic anticoagulation for all ESUS patients, rather than anticoagulating just those with documented atrial fibrillation (AF). However, recent trials have failed to demonstrate a clinical benefit, while observing increased bleeding. We modeled the economic impact of anticoagulating ESUS patients without documented AF across multiple geographies. METHODS: CRYSTAL-AF trial data were used to assess ischaemic stroke event rates in ESUS patients confirmed AF-free after long-term monitoring. Anticipated bleeding event rates (including both minor and major bleeds) with aspirin, dabigatran 150 mg, and rivaroxaban 20 mg were sourced from published meta-analyses, whilst a 30% ischaemic stroke reduction for both DOACs was assumed. Cost data for clinical events and pharmaceuticals were collected from the local payer perspective. RESULTS: Compared with aspirin, dabigatran and rivaroxaban resulted in 17.9 and 29.9 additional bleeding events per 100 patients over a patient's lifetime, respectively. Despite incorporating into our model the proposed 30% reduction in ischaemic stroke risk, both DOACs were cost-additive over patient lifetime, as the costs of bleeding events and pharmaceuticals outweighed cost savings associated with the reduction in ischaemic strokes. DOACs added £5953-£7018 per patient (UK), €6683-€7368 (Netherlands), €4933-€9378 (Spain), AUD$5353-6539 (Australia) and $26,768-$32,259 (US) of payer cost depending on the agent prescribed. Additionally, in the U.S. patient pharmacy co-payments ranged from $2468-$12,844 depending on agent and patient plan. In all settings, cost-savings could not be demonstrated even when the modelling assumed 100% protection from recurrent ischaemic strokes, due to the very low underlying risk of recurrent ischaemic stroke in this population (1.27 per 100 patient-years). CONCLUSIONS: Anticoagulation of non-AF patients may cause excess bleeds and add substantial costs for uncertain benefits, suggesting a personalised approach to anticoagulation in ESUS patients.


Assuntos
Anticoagulantes/efeitos adversos , Anticoagulantes/economia , Custos de Medicamentos , AVC Embólico/economia , AVC Embólico/prevenção & controle , Hemorragia/induzido quimicamente , AVC Isquêmico/economia , AVC Isquêmico/prevenção & controle , Prevenção Secundária/economia , Administração Oral , Anticoagulantes/administração & dosagem , Aspirina/efeitos adversos , Aspirina/economia , Ensaios Clínicos como Assunto , Análise Custo-Benefício , Dabigatrana/efeitos adversos , Dabigatrana/economia , AVC Embólico/epidemiologia , Humanos , AVC Isquêmico/epidemiologia , Modelos Econômicos , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Rivaroxabana/efeitos adversos , Rivaroxabana/economia , Fatores de Tempo , Resultado do Tratamento
5.
J Trauma Acute Care Surg ; 91(3): 537-541, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33901051

RESUMO

BACKGROUND: Low-molecular-weight heparin (LMWH) is widely used for venous thromboembolism chemoprophylaxis following injury. However, unfractionated heparin (UFH) is a less expensive option. We compared LMWH and UFH for prevention of posttraumatic deep venous thrombosis (DVT) and pulmonary embolism (PE). METHODS: Trauma patients 15 years or older with at least one administration of venous thromboembolism chemoprophylaxis at two level I trauma centers with similar DVT-screening protocols were identified. Center 1 administered UFH every 8 hours for chemoprophylaxis, and center 2 used twice-daily antifactor Xa-adjusted LMWH. Clinical characteristics and primary chemoprophylaxis agent were evaluated in a two-level logistic regression model. Primary outcome was incidence of DVT and PE. RESULTS: There were 3,654 patients: 1,155 at center 1 and 2,499 at center 2. The unadjusted DVT rate at center 1 was lower than at center 2 (3.5% vs. 5.0%; p = 0.04); PE rates did not significantly differ (0.4% vs. 0.6%; p = 0.64). Patients at center 2 were older (mean, 50.3 vs. 47.3 years; p < 0.001) and had higher Injury Severity Scores (median, 10 vs. 9; p < 0.001), longer stays in the hospital (mean, 9.4 vs. 7.0 days; p < 0.001) and intensive care unit (mean, 3.0 vs. 1.3 days; p < 0.001), and a higher mortality rate (1.6% vs. 0.6%, p = 0.02) than patients at center 1. Center 1's patients received their first dose of chemoprophylaxis earlier than patients at center 2 (median, 1.0 vs. 1.7 days; p < 0.001). After risk adjustment and accounting for center effects, primary chemoprophylaxis agent was not associated with risk of DVT (odds ratio, 1.01; 95% confidence interval, 0.69-1.48; p = 0.949). Cost calculations showed that UFH was less expensive than LMWH. CONCLUSION: Primary utilization of UFH is not inferior to LMWH for posttraumatic DVT chemoprophylaxis and rates of PE are similar. Given that UFH is lower in cost, the choice of this chemoprophylaxis agent may have major economic implications. LEVEL OF EVIDENCE: Prognostic and epidemiological, level II; Therapeutic, level III.


Assuntos
Anticoagulantes/uso terapêutico , Heparina/uso terapêutico , Embolia Pulmonar/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Ferimentos e Lesões/complicações , Adulto , Idoso , Anticoagulantes/economia , California/epidemiologia , Feminino , Heparina/economia , Heparina de Baixo Peso Molecular/economia , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/epidemiologia , Centros de Traumatologia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia
7.
Surgery ; 170(1): 173-179, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33736865

RESUMO

BACKGROUND: Recent practice guidelines recommend venous thromboembolism prophylaxis for 28 days after cancer surgery. We sought to characterize and compare awareness, agreement, adoption, and adherence to these guidelines among surgeons. METHODS: We electronically surveyed Canadian hepatobiliary surgeons registered with the Canadian Hepatopancreatobiliary Association, general and colorectal surgeons registered with the College of Physicians and Surgeons of Ontario and the Canadian Society of Colorectal Surgeons who provide colorectal cancer care with a pilot-tested questionnaire. Attitudes to relevant guideline recommendations and perceived barriers to postdischarge venous thromboembolism prophylaxis were assessed on a 5-point Likert scale. RESULTS: There were 128 responses (response rate 60%, 128 of 213), including 60 general/colorectal and 68 hepatobiliary surgeons. Most surgeons were aware (122 of 128, 95%), agreed (101 of 122, 83%), adopted (78 of 101, 77%), and adhered (74 of 78, 95%) with guidelines. Preexisting venous thromboembolism-prophylaxis hospital programs, hepatobiliary surgeons, and geographical region were associated with increased likelihood of adherence. Among respondents that did not agree, insufficient evidence (median Likert: 4, interquartile range 3-5) and low incidence of venous thromboembolism (median Likert: 4, interquartile range 3-4) were cited as the strongest barriers. Surgeons who agreed but did not adopt these programs reported that the most significant barriers were "drug cost" (median Likert: 4, interquartile range 3-4) and "subcutaneous injections" (median Likert: 4, interquartile range 3-4). Surgeons that adhered additionally reported "logistical challenges of prescribing" as the greatest implementation barrier. CONCLUSION: Surgeons who remain apprehensive about postdischarge venous thromboembolism prophylaxis cite poor evidence and cost of the medication as the major barriers. Adherence was higher among hepatobiliary surgeons and at hospitals with existing venous thromboembolism-prophylaxis programs.


Assuntos
Assistência ao Convalescente , Anticoagulantes/uso terapêutico , Procedimentos Cirúrgicos do Sistema Digestório , Complicações Pós-Operatórias/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Anticoagulantes/economia , Humanos , Alta do Paciente , Padrões de Prática Médica/estatística & dados numéricos , Cirurgiões , Inquéritos e Questionários
8.
Heart ; 107(1): 47-53, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33122302

RESUMO

OBJECTIVE: To assess temporal clinical and budget impacts of changes in atrial fibrillation (AF)-related prescribing in England. METHODS: Data on AF prevalence, AF-related stroke incidence and prescribing for all National Health Service general practices, hospitals and registered patients with hospitalised AF-related stroke in England were obtained from national databases. Stroke care costs were based on published data. We compared changes in oral anticoagulation prescribing (warfarin or direct oral anticoagulants (DOACs)), incidence of hospitalised AF-related stroke, and associated overall and per-patient costs in the periods January 2011-June 2014 and July 2014-December 2017. RESULTS: Between 2011-2014 and 2014-2017, recipients of oral anticoagulation for AF increased by 86.5% from 1 381 170 to 2 575 669. The number of patients prescribed warfarin grew by 16.1% from 1 313 544 to 1 525 674 and those taking DOACs by 1452.7% from 67 626 to 1 049 995. Prescribed items increased by 5.9% for warfarin (95% CI 2.9% to 8.9%) but by 2004.8% for DOACs (95% CI 1848.8% to 2160.7%). Oral anticoagulation prescription cost rose overall by 781.2%, from £87 313 310 to £769 444 028, (£733,466,204 with warfarin monitoring) and per patient by 50.7%, from £293 to £442, giving an incremental cost of £149. Nevertheless, as AF-related stroke incidence fell by 11.3% (95% CI -11.5% to -11.1%) from 86 467 in 2011-2014 to 76 730 in 2014-2017 with adjustment for AF prevalence, the overall per-patient cost reduced from £1129 to £840, giving an incremental per-patient saving of £289. CONCLUSIONS: Despite nearly one million additional DOAC prescriptions and substantial associated spending in the latter part of this study, the decline in AF-related stroke led to incremental savings at the national level.


Assuntos
Anticoagulantes/economia , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Orçamentos , Inibidores do Fator Xa/economia , Inibidores do Fator Xa/uso terapêutico , Custos de Cuidados de Saúde , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/prevenção & controle , Varfarina/economia , Varfarina/uso terapêutico , Inglaterra , Humanos , Estudos Prospectivos , Acidente Vascular Cerebral/etiologia
9.
J Cardiol ; 77(1): 93-99, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32859453

RESUMO

Patients undergoing percutaneous coronary intervention (PCI) have an increased risk of both ischemic events and bleeding complications resulting from antithrombotic therapy. These events are particularly common in patients with a concomitant indication for oral anticoagulation, such as those with atrial fibrillation, and are associated with a substantial healthcare resource burden. Advances in procedural aspects of PCI have led to marked improvements in outcomes and a consequent reduction in the costs resulting from PCI-associated complications. Furthermore, recent randomized clinical trials have investigated the optimal antithrombotic strategy in the specific case of patients with atrial fibrillation undergoing PCI, leading to a shift toward the tailoring of antithrombotic therapy according to the patient's individual stroke and bleeding risks. Here we review these recent advances, with a particular focus on the improvements in antithrombotic strategies offered by the non-vitamin K antagonist oral anticoagulants.


Assuntos
Anticoagulantes/economia , Fibrilação Atrial/terapia , Custos de Cuidados de Saúde/estatística & dados numéricos , Intervenção Coronária Percutânea/economia , Stents/economia , Anticoagulantes/uso terapêutico , Fibrilação Atrial/economia , Terapia Combinada/economia , Efeitos Psicossociais da Doença , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
10.
Am Heart J ; 233: 109-121, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33358690

RESUMO

BACKGROUND: In patients with atrial fibrillation, incomplete adherence to anticoagulants increases risk of stroke. Non-warfarin oral anticoagulants (NOACs) are expensive; we evaluated whether higher copayments are associated with lower NOAC adherence. METHODS: Using a national claims database of commercially-insured patients, we performed a cohort study of patients with atrial fibrillation who newly initiated a NOAC from 2012 to 2018. Patients were stratified into low (<$35), medium ($35-$59), or high (≥$60) copayments and propensity-score weighted based on demographics, insurance characteristics, comorbidities, prior health care utilization, calendar year, and the NOAC received. Follow-up was 1 year, with censoring for switching to a different anticoagulant, undergoing an ablation procedure, disenrolling from the insurance plan, or death. The primary outcome was adherence, measured by proportion of days covered (PDC). Secondary outcomes included NOAC discontinuation (no refill for 30 days after the end of NOAC supply) and switching anticoagulants. We compared PDC using a Kruskal-Wallis test and rates of discontinuation and switching using Cox proportional hazards models. RESULTS: After weighting patients across the 3 copayment groups, the effective sample size was 17,558 patients, with balance across 50 clinical and demographic covariates (standardized differences <0.1). Mean age was 62 years, 29% of patients were female, and apixaban (43%), and rivaroxaban (38%) were the most common NOACs. Higher copayments were associated with lower adherence (P < .001), with a PDC of 0.82 (Interquartile range [IQR] 0.36-0.98) among those with high copayments, 0.85 (IQR 0.41-0.98) among those with medium copayments, and 0.88 (IQR 0.41-0.99) among those with low copayments. Compared to patients with low copayments, patients with high copayments had higher rates of discontinuation (hazard ratio [HR] 1.13, 95% confidence interval [CI] 1.08-1.19; P < .001). CONCLUSIONS: Among atrial fibrillation patients newly initiating NOACs, higher copayments in commercial insurance were associated with lower adherence and higher rates of discontinuation in the first year. Policies to lower or limit cost-sharing of important medications may lead to improved adherence and better outcomes among patients receiving NOACs.


Assuntos
Fibrilação Atrial/complicações , Dedutíveis e Cosseguros/economia , Adesão à Medicação/estatística & dados numéricos , Acidente Vascular Cerebral/prevenção & controle , Anticoagulantes/economia , Anticoagulantes/uso terapêutico , Antitrombinas/economia , Antitrombinas/uso terapêutico , Estudos de Coortes , Dabigatrana/economia , Dabigatrana/uso terapêutico , Bases de Dados Factuais/estatística & dados numéricos , Dedutíveis e Cosseguros/estatística & dados numéricos , Custos de Medicamentos , Inibidores do Fator Xa/economia , Inibidores do Fator Xa/uso terapêutico , Feminino , Humanos , Masculino , Medicare Part C/estatística & dados numéricos , Pessoa de Meia-Idade , Pirazóis/economia , Pirazóis/uso terapêutico , Piridinas/economia , Piridinas/uso terapêutico , Piridonas/economia , Piridonas/uso terapêutico , Rivaroxabana/economia , Rivaroxabana/uso terapêutico , Tamanho da Amostra , Acidente Vascular Cerebral/etiologia , Tiazóis/economia , Tiazóis/uso terapêutico , Estados Unidos , Varfarina/economia , Varfarina/uso terapêutico
11.
Expert Rev Pharmacoecon Outcomes Res ; 21(2): 265-275, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32700584

RESUMO

OBJECTIVES: Several direct oral anticoagulants (DOACs) have been approved by the European Medicines Agency since 2008. The aim of the present cost-effectiveness-analysis was to analyze apixaban compared to other DOACs and vitamin K antagonists (warfarin) in Austria. METHODS: A cost-utility-model was developed to simulate lifetime-costs and quality-adjusted-life-years of DOACs and warfarin, based on a published Markov-Model and 23 randomized trials with 94,656 atrial-fibrillation (AF) patients. Each year, a patient has a probability of suffering a clinically relevant (extracranial) bleed, an intracranial hemorrhage (ICH), an ischemic stroke or a myocardial infarction (MI), remaining healthy, or deceasing. Direct-costs (2018€) were derived from published sources from the payer's perspective. RESULTS: In the base-case, warfarin had the lowest cost of 12,968 € (95%-CI±593 €) followed by apixaban (15,269 €±661 €), edoxaban (15,534 €±641 €), dabigatran (15,687 €±667 €), and rivaroxaban (17,522 €±764 €). Apixaban had the highest quality-adjusted-life-years estimate at 5.45 (SD, 0.06). In a Monte-Carlo probabilistic sensitivity analysis, apixaban was cost-effective vs. edoxaban, dabigatran, warfarin, and rivaroxaban in 85.6%, 79.0%, 76.4%, and 61.2% of the simulations, respectively. CONCLUSION: In patients with AF and an increased risk of stroke, prophylaxis with apixaban was highly cost-effective from the perspective of the Austrian health-care system.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Pirazóis/administração & dosagem , Piridonas/administração & dosagem , Acidente Vascular Cerebral/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Anticoagulantes/economia , Fibrilação Atrial/complicações , Fibrilação Atrial/economia , Áustria , Análise Custo-Benefício , Inibidores do Fator Xa/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econométricos , Pirazóis/economia , Piridonas/economia , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/etiologia , Varfarina/administração & dosagem , Varfarina/economia
12.
Am J Cardiovasc Drugs ; 21(1): 93-101, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32578166

RESUMO

BACKGROUND: Enoxaparin and unfractionated heparin (UFH) are guideline-recommended anticoagulants for patients with acute coronary syndrome (ACS), including unstable angina (UA) and myocardial infarction with (STEMI) or without ST-segment elevation (NSTEMI). Prior efficacy and safety evidence are mainly from clinical trials. Economic data are insufficient. This study examined the differences in utilization, effectiveness, safety, and costs in treating ACS between enoxaparin and UFH monotherapy using real-world data. METHODS: Using data from 859 US hospitals, inpatients ≥ 18 years of age with a diagnosis of an initial episode of ACS between 2010 and 2016 were identified. Outcomes included 30-day risk of non-fatal myocardial infarction (MI), recurrent angina, in-hospital mortality, composite ischemic complication (having MI/recurrent angina/death), major bleeding, and costs. Multivariable regression was used to compare outcomes between enoxaparin and UFH monotherapy. RESULTS: Among 1,048,053 eligible patients (UA: 219,259; NSTEMI: 582,134; STEMI: 246,660), the prevalence of enoxaparin monotherapy was 12.0%, 13.9%, and 5.1%, and the prevalence of UFH monotherapy was 45.1%, 43.1% and 59.8%, for UA, NSTEMI, and STEMI patients, respectively. Enoxaparin was associated with a lower risk of ischemic complications and death among NSTEMI, but not in UA or STEMI patients, and with a lower risk of major bleeding in all patients. Cost savings per patient during index admission and 30-day follow-up for enoxaparin over UFH was $2972 for UA, $2475 for NSTEMI, and $3050 for STEMI. CONCLUSIONS: Enoxaparin was associated with a lower risk of ischemic complications (including death), lower costs, and better safety than UFH among NSTEMI patients. Improving upstream selection of anticoagulants in appropriate populations may help optimize clinical outcomes and costs.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Anticoagulantes/uso terapêutico , Enoxaparina/economia , Enoxaparina/uso terapêutico , Heparina/economia , Heparina/uso terapêutico , Síndrome Coronariana Aguda/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Anticoagulantes/economia , Comorbidade , Enoxaparina/administração & dosagem , Enoxaparina/efeitos adversos , Feminino , Gastos em Saúde/estatística & dados numéricos , Recursos em Saúde/estatística & dados numéricos , Heparina/administração & dosagem , Heparina/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico
13.
Tuberk Toraks ; 68(3): 293-304, 2020 Sep.
Artigo em Turco | MEDLINE | ID: mdl-33295728

RESUMO

Introduction: Primary aim of this study is to determine the financial burden of Vitamin K Antagonists (VKA), low molecular weight heparins (LMWH) and new oral anticoagulants (NOAC) which are used in the treatment of the pulmonary thromboembolism (PTE). Secondary aim is to show long term complications of the treatment options. Materials and Methods: The patients who are diagnosed with PTE between May 2016 and March 2018 at Faculty of Medicine Karadeniz Technical University Hospital were observed prospectively. Hospitalization costs were calculated on patients who were treated only for PTE by hospitalized in the Chest Diseases Service in the acute period. Maintenance costs were calculated over all patients who regulary admitted to our outpatient clinic with the diagnosis of PTE. Data were presented as mean ± SD and median ± interquartilee range. A p-value of <0.05 was accepted to be significant. Result: Fifty five (37.2%) of the patients were male, 93 (62.8%) were female and the median age was 68 (range 18-95). The median hospitalization time and cost of patients who are discharged with VKA (n: 22) compared with patients discharged with LMWH (n: 22) was found to be increased (1316.82 TL 7,5 days / 803.36 TL, 5 days p<0.001). Statistical analysis could not be performed with NOAC (n: 2). In the analysis of sixth month costs, LMWH cost was found to be higher than VKA cost (6.927.15 ± 2.687.67 TL/698.29 ± 483.51 TL p<0.001). However VKA treatment tended to be less expensive than treatment with NOACs (698.29 ± 483.51 TL/1.050.81 ± 300.28 TL p= 0.140). Conclusions: In the acute period of PTE, VKA increases the length of hospitalization and hospital costs in patients treated at the hospital. In the maintenance period, VKA tends to have a lower cost compared to NOACs.


Assuntos
Anticoagulantes/economia , Heparina de Baixo Peso Molecular/economia , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/economia , Idoso , Anticoagulantes/administração & dosagem , Feminino , Custos Hospitalares , Hospitalização/economia , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Turquia
14.
Value Health Reg Issues ; 23: 105-111, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33171358

RESUMO

BACKGROUND: It's estimated that 40% to 60% of patients undergoing major orthopedic surgery of the hip or knee who do not receive thromboprophylaxis will develop deep venous thrombosis Instituto Nacional de Traumatologia e Ortopedia has established a guideline to prevent DVT with the administration of the Enoxaparin. Recently, institute stakeholders have been questioning this guideline as new oral anticoagulants that offer more comfort and efficacy, but present higher risk of bleeding, have been appearing in the market for treating deep venous thrombosis. OBJECTIVE: This study aims to validate the application of a multicriteria decision analysis in a real-world problem, the use of rivaroxaban and enoxaparin to prevent deep venous thrombosis. METHODS: The multicriteria method MACBETH (Measuring Attractiveness by a Categorical Based Evaluation Technique) was used in a decision conferencing process to develop an evaluation model for measuring the relative value of the drugs on each evaluation criterion, separately and globally. The model-building process was informed by a literature review and meta-analysis of randomized clinical trials with a critical appraisal of the evidence. RESULTS: We report a model-structure with eight criteria, each one associated with a weighting coefficient and value function. Following a simple additive aggregation process, the model-outputs showed that Rivaroxaban was considered a robust option for DVT. Sensitivity analysis and robustness analysis were performed and testify the consistency of the results. CONCLUSION: This article contributes to literature by showing how MACBETH method can be combined with scientific evidence and participatory group processes, for health technology assessment in hospitals.


Assuntos
Procedimentos Ortopédicos/economia , Preparações Farmacêuticas/normas , Complicações Pós-Operatórias/economia , Trombose Venosa/tratamento farmacológico , Anticoagulantes/efeitos adversos , Anticoagulantes/economia , Anticoagulantes/uso terapêutico , Brasil/epidemiologia , Enoxaparina/efeitos adversos , Enoxaparina/economia , Enoxaparina/uso terapêutico , Hemorragia/economia , Hemorragia/epidemiologia , Hemorragia/etiologia , Humanos , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/métodos , Preparações Farmacêuticas/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Rivaroxabana/efeitos adversos , Rivaroxabana/economia , Rivaroxabana/uso terapêutico , Trombose Venosa/epidemiologia , Trombose Venosa/prevenção & controle
15.
Expert Rev Clin Pharmacol ; 13(12): 1309-1327, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33107345

RESUMO

INTRODUCTION: Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in patients with atrial fibrillation (AF). Since NOACs are predominantly used in the elderly with AF at high risk for stroke and bleeding and with comorbidities requiring polypharmacy, it is important to assess their safety and efficacy in this population. AREAS COVERED: We review changes in pharmacokinetics and pharmacodynamics observed with senescence and the effect on NOACs and drug and food interactions. We also provide an update on challenges related to NOAC use in situations that increases the risk for bleeding or require temporary discontinuation and address practical issues in the elderly AF patients managed on NOACs. Clinical studies and trials with cardiovascular outcomes reported from January 1990 to August 2020 were identified through the Medline database using PubMed, Cochrane Library, and EMBASE database. EXPERT OPINION: NOACs are highly effective in preventing stroke in AF patients with non-inferior or superior efficacy to warfarin, with reduced risk of major bleeding. However, in the older-elderly, evidence comes mainly from observational studies or extrapolation from studies in populations with minimal functional limitations or comorbidities. The high upfront cost and out-of-pocket expense for copayment or deductibles also limit the use of this effective therapy in a substantial number of patients. The cost reduction may further improve long-term use for NOACs in stroke prevention in elderly patients with AF.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Idoso , Anticoagulantes/efeitos adversos , Anticoagulantes/economia , Fibrilação Atrial/complicações , Custos de Medicamentos , Hemorragia/induzido quimicamente , Humanos , Acidente Vascular Cerebral/etiologia
16.
Medicine (Baltimore) ; 99(36): e22054, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32899067

RESUMO

BACKGROUND: Anticoagulant therapy is used for stroke prevention and proved to be effective and safe in the long term. The study aims to analyse the cost-effectiveness relationship of using of direct-acting oral anticoagulants vs vitamin K antagonists to prevent ischaemic stroke in patients with nonvalvular atrial fibrillation, including all the active ingredients marketed in Spain, prescribed for 2 years in the Primary Care service of the Institut Català de la Salut. METHODS: Population-based cohort study, in which the cost of the 2 treatment groups will be evaluated. Direct costs (pharmacy, primary care, emergency and hospitalization) and indirect costs (lost productivity) will be included from a social perspective. Effectiveness (assessed as the occurrence of a health event, the 1 of primary interest being stroke) will be determined, with a 2-year time horizon and a 3% discount rate. The average cost of the 2 groups of drugs will be compared using a regression model to determine the factors with the greatest influence on determining costs. We will carry out a univariate ('one-way') deterministic sensitivity analysis. DISCUSSION: We hope to provide relevant information about direct and indirect costs of oral anticoagulants, which, together with aspects of effectiveness and safety, could help shape the consensual decision-making of evaluating bodies.


Assuntos
Acenocumarol/economia , Anticoagulantes/economia , Fibrilação Atrial/tratamento farmacológico , Isquemia Encefálica/patologia , Ensaios Clínicos Pragmáticos como Assunto/métodos , Varfarina/economia , Acenocumarol/administração & dosagem , Acenocumarol/uso terapêutico , Administração Oral , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/epidemiologia , Isquemia Encefálica/prevenção & controle , Análise Custo-Benefício , Inibidores do Fator Xa , Humanos , Atenção Primária à Saúde/organização & administração , Segurança , Espanha/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento , Vitamina K/antagonistas & inibidores , Varfarina/administração & dosagem , Varfarina/uso terapêutico
17.
J Am Heart Assoc ; 9(18): e017080, 2020 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-32865129

RESUMO

BACKGROUND Internationally, most atrial fibrillation (AF) management guidelines recommend opportunistic screening for AF in people ≥65 years of age and oral anticoagulant treatment for those at high stroke risk (CHA2DS2-VA≥2). However, gaps remain in screening and treatment. METHODS AND RESULTS General practitioners/nurses at practices in rural Australia (n=8) screened eligible patients (≥65 years of age without AF) using a smartphone ECG during practice visits. eHealth tools included electronic prompts, guideline-based electronic decision support, and regular data reports. Clinical audit tools extracted de-identified data. Results were compared with an earlier study in metropolitan practices (n=8) and nonrandomized control practices (n=69). Cost-effectiveness analysis compared population-based screening with no screening and included screening, treatment, and hospitalization costs for stroke and serious bleeding events. Patients (n=3103, 34%) were screened (mean age, 75.1±6.8 years; 47% men) and 36 (1.2%) new AF cases were confirmed (mean age, 77.0 years; 64% men; mean CHA2DS2-VA, 3.2). Oral anticoagulant treatment rates for patients with CHA2DS2-VA≥2 were 82% (screen detected) versus 74% (preexisting AF)(P=NS), similar to metropolitan and nonrandomized control practices. The incremental cost-effectiveness ratio for population-based screening was AU$16 578 per quality-adjusted life year gained and AU$84 383 per stroke prevented compared with no screening. National implementation would prevent 147 strokes per year. Increasing the proportion screened to 75% would prevent 177 additional strokes per year. CONCLUSIONS An AF screening program in rural practices, supported by eHealth tools, screened 34% of eligible patients and was cost-effective. Oral anticoagulant treatment rates were relatively high at baseline, trending upward during the study. Increasing the proportion screened would prevent many more strokes with minimal incremental cost-effectiveness ratio change. eHealth tools, including data reports, may be a valuable addition to future programs. REGISTRATION URL: https://www.anzctr.org.au. Unique identifier: ACTRN12618000004268.


Assuntos
Fibrilação Atrial/diagnóstico , Programas de Rastreamento/economia , Atenção Primária à Saúde/economia , Serviços de Saúde Rural/economia , Telemedicina/economia , Idoso , Anticoagulantes/economia , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/economia , Austrália/epidemiologia , Análise Custo-Benefício , Estudos Transversais , Sistemas de Apoio a Decisões Clínicas/economia , Feminino , Humanos , Masculino , Programas de Rastreamento/normas , Aplicativos Móveis , Guias de Prática Clínica como Assunto , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/normas , Serviços de Saúde Rural/normas , Smartphone
18.
J Med Econ ; 23(11): 1365-1374, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32897766

RESUMO

OBJECTIVES: To provide the most current assessment of real-world healthcare resource utilization (HRU) and costs among patients with non-valvular atrial fibrillation (NVAF) who newly initiated rivaroxaban and apixaban using a large US database. MATERIAL AND METHODS: A retrospective weighted cohort design was used with healthcare insurance claims from the Optum Clinformatics Data Mart databases (January 2012-December 2018). The index date was defined as the first dispensing of rivaroxaban or apixaban. Adult NVAF patients with an index date on or after 1 January 2016, ≥ 12 months of continuous eligibility before the index date and ≥ 1 month after, and without prior use of oral anticoagulant were included. The observation period spanned from the index date to the earliest of the end of data availability, end of insurance coverage, or death. Inverse probability of treatment weighting (IPTW) was used to adjust for differences in baseline characteristics between cohorts. All-cause healthcare resource utilization (HRU), including hospitalization, emergency room, and outpatient visits, and healthcare costs, including medical and pharmacy costs, were evaluated from the payer's perspective during the observation period up to 18 and 24 months, separately. RESULTS: In total, 23,822 rivaroxaban and 53,666 apixaban users were included. After weighting, all baseline characteristics were well balanced between cohorts (mean age: 73.8 years, female: 46.6% in both cohorts). Up to 18 months of follow-up, rivaroxaban users incurred significantly lower total healthcare costs compared to apixaban users (cost difference = -$1,121; p = 0.020), driven by significantly lower rates of outpatient hospital visits and associated costs (cost difference = -$1,579; p < 0.001). Similar results were found in the analysis conducted for up to 24 months of follow-up (total cost difference = ‒$1,111; p = 0.020). CONCLUSIONS: In this large retrospective analysis, patients with NVAF initiated on rivaroxaban incurred significantly lower healthcare costs compared to those initiated on apixaban, which were primarily driven by significantly lower outpatient visits and costs during the 18- and 24-month follow-up periods.


Assuntos
Anticoagulantes/economia , Fibrilação Atrial/tratamento farmacológico , Gastos em Saúde/estatística & dados numéricos , Pirazóis/economia , Piridonas/economia , Rivaroxabana/economia , Idoso , Anticoagulantes/uso terapêutico , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Pirazóis/uso terapêutico , Piridonas/uso terapêutico , Estudos Retrospectivos , Rivaroxabana/uso terapêutico , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/prevenção & controle , Estados Unidos
19.
Emerg Nurse ; 28(6): 35-40, 2020 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-32783433

RESUMO

Thromboprophylactic medicine is provided routinely to patients who present to emergency departments (EDs) with lower leg fractures as a preventive measure against forming blood clots in an immobilised limb. A large amount of medicine is provided to these patients at discharge, but once they have recovered their mobility the remaining medicine is unusable and must be destroyed. There is a lack of data to quantify this waste. This article reports a service evaluation that was conducted in an ED to investigate the wastage and the cost implications of this treatment protocol. It shows that over half the medicine dispensed is subsequently wasted and makes recommendations for changing dispensing practice.


Assuntos
Anticoagulantes/economia , Serviço Hospitalar de Emergência/economia , Enoxaparina/economia , Resíduos de Serviços de Saúde/economia , Tromboembolia Venosa/prevenção & controle , Anticoagulantes/administração & dosagem , Moldes Cirúrgicos , Redução de Custos , Inglaterra , Enoxaparina/administração & dosagem , Fraturas Ósseas/complicações , Fraturas Ósseas/terapia , Humanos , Imobilização , Traumatismos da Perna/complicações , Traumatismos da Perna/terapia , Auditoria Médica , Estudos Retrospectivos , Tromboembolia Venosa/etiologia
20.
J Sep Sci ; 43(20): 3902-3912, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32833304

RESUMO

A simple, rapid, and cost-effective process for the separation of an active anticoagulant fraction from the aqueous fruit extract of Momordica charantia by using rice husk as adsorbed is described. The in vitro anticoagulant activity of active anticoagulant fraction was comparable to commercial anticoagulants heparin and warfarin. Phytochemical analysis revealed the presence of alkaloids, flavonoids, and phytols in the active anticoagulant fraction, nevertheless; it was devoid of glycosides, triterpenoids, tannins, saponins, steroids, and carbohydrates. By gas chromatography with mass spectrometry analysis, decanoic acid, 1,2,3-propanetriyl ester (22.3%), dodecanoic acid, 1,2,3-propanetriyl ester-d5 (17.3%), dodecenoic acid, 1,2,3-propanetriyl ester (12.5%), and 4-B-methylandrostane 2,3-diol-1,17-dione (11.4%) were identified as the most abundant constituents of active anticoagulant fraction. Presence of αß-fibrinogenase enzyme was identified by biochemical assay but not by liquid chromatography with tandem mass spectrometry analysis suggesting presence of a novel protease enzyme in this fraction. The active anticoagulant fraction demonstrated biding to fibrinogen but not to thrombin or Factor Xa, inhibited the collagen/ADP-induced mammalian platelet aggregation, showed in vitro thrombolytic activity, noncytotoxic to mammalian cells, showed in vivo plasma defibrinogenation and anticoagulant activities, and inhibited k-carrageen-induced thrombus formation in the tails of mice. Therefore, active anticoagulant fraction (an herbal drug) may find therapeutic application for the prevention and/or treatment of hyperfibrinogenemia/thrombosis-associated cardiovascular disorders.


Assuntos
Anticoagulantes/uso terapêutico , Frutas/química , Momordica charantia/química , Extratos Vegetais/uso terapêutico , Trombose/tratamento farmacológico , Animais , Anticoagulantes/economia , Anticoagulantes/isolamento & purificação , Chondrus , Modelos Animais de Doenças , Humanos , Camundongos , Extratos Vegetais/economia , Extratos Vegetais/isolamento & purificação , Trombose/induzido quimicamente
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