Hospital length-of-stay and costs among pulmonary embolism patients treated with rivaroxaban versus parenteral bridging to warfarin

Association of Different Anticoagulation Strategies With Outcomes in Patients Hospitalized With Acute Pulmonary Embolism

Background Therapeutic anticoagulation is the cornerstone of treatment for pulmonary embolism (PE), but the impact of different anticoagulation strategies on patient outcomes remains unclear. In this study, we assessed the association of different anticoagulation strategies with the outcomes of patients with acute PE. Methods A retrospective chart review of 207 patients with acute PE who were admitted to one of three urban teaching hospitals in the Mount Sinai Health System (in New York City) from January 2020 to September 2022 was performed. Demographic, clinical, and radiographic data were recorded for all patients. Multivariate regression analyses were performed to assess the association of different outcomes with the approach of therapeutic anticoagulation used. Results The median age of the included patients was 65 years, and 50.2% were women. The most common approach (n = 153, 73.9%) to therapeutic anticoagulation was initial treatment with unfractionated or low molecular weight heparin followed by a direct-acting oral anticoagulant (DOAC), while heparin alone (either unfractionated or low molecular weight heparin) was used in 37 (17.9%) patients, and another 17 (8.2%) patients were treated with heparin followed by bridging to warfarin. Hospital length of stay was longer for patients in the "heparin to warfarin" group (risk-adjusted incidence rate ratio of 2.52). The rates of in-hospital bleeding, all-cause 30-day mortality, and all-cause 30-day re-admissions did not have any significant association with the therapeutic anticoagulation approach used. Conclusion Patients with acute PE who were initially treated with heparin and subsequently bridged to warfarin had a longer hospital stay. Rates of in-hospital bleeding, 30-day mortality, and 30-day re-admission were not associated with the strategy of therapeutic anticoagulation employed.

Home Treatment Compared to Initial Hospitalization in Normotensive Patients with Acute Pulmonary Embolism in the Netherlands: A Cost Analysis

BACKGROUND

 Venous thromboembolism constitutes substantial health care costs amounting to approximately 60 million euros per year in the Netherlands. Compared with initial hospitalization, home treatment of pulmonary embolism (PE) is associated with a cost reduction. An accurate estimation of cost savings per patient treated at home is currently lacking.

AIM

 The aim of this study was to compare health care utilization and costs during the first 3 months after a PE diagnosis in patients who are treated at home versus those who are initially hospitalized.

METHODS

 Patient-level data of the YEARS cohort study, including 383 normotensive patients diagnosed with PE, were used to estimate the proportion of patients treated at home, mean hospitalization duration in those who were hospitalized, and rates of PE-related readmissions and complications. To correct for baseline differences within the two groups, regression analyses was performed. The primary outcome was the average total health care costs during a 3-month follow-up period for patients initially treated at home or in hospital.

RESULTS

 Mean hospitalization duration for the initial treatment was 0.69 days for those treated initially at home (n = 181) and 4.3 days for those initially treated in hospital (n = 202). Total average costs per hospitalized patient were €3,209 and €1,512 per patient treated at home. The adjusted mean difference was €1,483 (95% confidence interval: €1,181-1,784).

CONCLUSION

 Home treatment of hemodynamically stable patients with acute PE was associated with an estimated net cost reduction of €1,483 per patient. This difference underlines the advantage of triage-based home treatment of these patients.

The value of sPESI for risk stratification in patients with pulmonary embolism

INTRODUCTION

Various risk stratification methods exist for patients with pulmonary embolism (PE). We used the simplified Pulmonary Embolism Severity Index (sPESI) as a risk-stratification method to understand the Veterans Health Administration (VHA) PE population.

MATERIALS AND METHODS

Adult patients with ≥ 1 inpatient PE diagnosis (index date = discharge date) from October 2011-June 2015 as well as continuous enrollment for ≥ 12 months pre- and 3 months post-index date were included. We defined a sPESI score of 0 as low-risk (LRPE) and all others as high-risk (HRPE). Hospital-acquired complications (HACs) during the index hospitalization, 90-day follow-up PE-related outcomes, and health care utilization and costs were compared between HRPE and LRPE patients.

RESULTS

Of 6746 PE patients, 95.4% were men, 67.7% were white, and 22.0% were African American; LRPE occurred in 28.4% and HRPE in 71.6%. Relative to HRPE patients, LRPE patients had lower Charlson Comorbidity Index scores (1.0 vs. 3.4, p < 0.0001) and other baseline comorbidities, fewer HACs (11.4% vs. 20.0%, p < 0.0001), less bacterial pneumonia (10.6% vs. 22.3%, p < 0.0001), and shorter average inpatient lengths of stay (8.8 vs. 11.2 days, p < 0.0001) during the index hospitalization. During follow-up, LRPE patients had fewer PE-related outcomes of recurrent venous thromboembolism (4.4% vs. 6.0%, p = 0.0077), major bleeding (1.2% vs. 1.9%, p = 0.0382), and death (3.7% vs. 16.2%, p < 0.0001). LRPE patients had fewer inpatient but higher outpatient visits per patient, and lower total health care costs ($12,021 vs. $16,911, p < 0.0001) than HRPE patients.

CONCLUSIONS

Using the sPESI score identifies a PE cohort with a lower clinical and economic burden.

Use of rivaroxaban in patients attending a hematology unit in clinical practice

Aim: To determine drug persistence and rates of events among patients treated with rivaroxaban in a hematology unit. Methods: Retrospective study of patients that started treatment with rivaroxaban, in the hematology unit of a tertiary hospital. Results: A total of 161 patients were included, of whom 83.9% had atrial fibrillation and 11.2% venous thromboembolism, and 76.4% of patients were taking rivaroxaban 20 mg, 22.4% 15 mg and 1.2% 10 mg. After a follow-up of 1.8 ± 1.1 years, only four patients (2.5%) discontinued treatment. Rates of thromboembolic events, major bleeding/clinically relevant nonmajor bleeding and intracranial hemorrhage were 1.1, 2.8, 0.3 events per 100 patient-years, respectively. Conclusion: In patients attended in a hematology unit, medication persistence was high, and the incidence of outcomes low.

Impact of oral anticoagulants on 30-day readmission: a study from a single academic centre

Researchers are extensively searching for modifiable risk factors including high-risk medications such as anticoagulation to avoid rehospitalisation. The influence of oral anticoagulant therapy on hospital readmission is not known. We investigated the impact of warfarin and direct oral anticoagulants (DOACs) on all cause 30-day hospital readmission retrospectively in an academic centre. We study the eligible cohort of 1781 discharges over 2-year period. Data on age, gender, diagnoses, 30-day hospital readmission, discharge medications and variables in the HOSPITAL score (Haemoglobin level at discharge, Oncology at discharge, Sodium level at discharge, Procedure during hospitalisation, Index admission, number of hospital Admissions, Length of stay) and LACE index (Length of stay, Acute/emergent admission, Charlson comorbidity index score, Emergency department visits in previous 6 months), which have higher predictability for readmission were extracted and matched for analysis. Warfarin was the most common anticoagulant prescribed at discharge (273 patients) with a readmission rate of 20% (p<0.01). DOACs were used by 94 patients at discharge with a readmission rate of 4% (p=0.219). Multivariate logistic regression showed an increased risk of readmission with warfarin therapy (OR 1.36, p=0.045). Logistic regression did not show DOACs to be a risk factor for hospital readmission. Our data suggests that warfarin therapy is a risk factor for all-cause 30-day hospital readmission. DOAC therapy is not found to be associated with a higher risk of hospital readmission. Warfarin anticoagulation may be an important target for interventions to reduce hospital readmissions.

Rivaroxaban for the treatment of venous thromboembolism in real life: A single-center prospective study

The clinical profile, evolution and complications of treatment with rivaroxaban in a cohort of patients presenting with venous thromboembolism (VTE) were analyzed in an observational, non-interventional and prospective study.A total of 111 patients were included in the study. Clinical data were collected from the medical history of the patients and recorded in a specific database.Mean age was 63.8 ± 17.4 years, 53.2% of patients were men, 55.9% had at least another concomitant condition, and 40.9% at least 1 VTE risk factor. 54.1% of patients presented with deep venous thrombosis, 32.4% with pulmonary embolism and 13.5% with both conditions simultaneously. The 61% of patients were admitted to hospital and mean hospital length-of-stay was 8.8 ± 9.9 days. After a mean follow-up 530 ± 464 days (median follow-up of 405 days), 3.9% of patients died and VTE recurrence occurred in 2.9% of patients. While receiving rivaroxaban, a first bleeding complication occurred in 8.1%; all events were minor bleeding.Our study supports the current literature data and confirms the similar results of real-life VTE patients with those enrolled in the rivaroxaban pivotal clinical trials. Rivaroxaban may facilitate outpatient treatment and might be considered as a first-line therapy for the management of VTE patients.

Predictors of Hospital Length of Stay among Patients with Low-risk Pulmonary Embolism

BACKGROUND

Increased hospital length of stay is an important cost driver in hospitalized low-risk pulmonary embolism (LRPE) patients, who benefit from abbreviated hospital stays. We sought to measure length-of-stay-associated predictors among Veterans Health Administration LRPE patients.

METHODS

Adult patients (aged ≥18 years) with ≥1 inpatient pulmonary embolism (PE) diagnosis (index date = discharge date) between 10/2011-06/2015 and continuous enrollment for ≥12 months pre- and 3 months post-index were included. PE patients with simplified Pulmonary Embolism Stratification Index score 0 were considered low risk; all others were considered high risk. LRPE patients were further stratified into short (≤2 days) and long length of stay cohorts. Logistic regression was used to identify predictors of length of stay among low-risk patients.

RESULTS

Among 6746 patients, 1918 were low-risk (28.4%), of which 688 (35.9%) had short and 1230 (64.1%) had long length of stay. LRPE patients with computed tomography angiography (Odds ratio [OR]: 4.8, 95% Confidence interval [CI]: 3.82-5.97), lung ventilation/perfusion scan (OR: 3.8, 95% CI: 1.86-7.76), or venous Doppler ultrasound (OR: 1.4, 95% CI: 1.08-1.86) at baseline had an increased probability of short length of stay. Those with troponin I (OR: 0.7, 95% CI: 0.54-0.86) or natriuretic peptide testing (OR: 0.7, 95% CI: 0.57-0.90), or more comorbidities at baseline, were less likely to have short length of stay.

CONCLUSION

Understanding the predictors of length of stay can help providers deliver efficient treatment and improve patient outcomes which potentially reduces the length of stay, thereby reducing the overall burden in LRPE patients.

Systematic literature review of treatment patterns for venous thromboembolism patients during transitions from inpatient to post-discharge settings

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.

Apixaban or Rivaroxaban Versus Warfarin for Treatment of Submassive Pulmonary Embolism After Catheter-Directed Thrombolysis

Background:

Little data exist on the use of direct oral anticoagulant (DOAC) factor Xa inhibitors for submassive pulmonary embolism (PE) after catheter-directed thrombolysis (CDT). The objective of this evaluation was to determine whether the transition from parenteral anticoagulation to DOACs for submassive PE after CDT would decrease hospital length of stay (LOS) compared to warfarin.

Methods:

A retrospective review of patients diagnosed with submassive PE who underwent CDT was conducted from January 1, 2012, to February 28, 2017. Hospital LOS and major and minor bleeding events were recorded during hospitalization and at 90 days.

Results:

Sixty-two patients met the inclusion criteria, 36 in warfarin group and 26 in the DOAC group. Overall, patients receiving rivaroxaban or apixaban had a shorter median hospital LOS compared to warfarin (4.0 vs 6.1 days, P = .002). In the multivariate regression analysis, administration of DOAC was an independent predictor of decreased hospital LOS, β: −2.1, 95% confidence interval (−3.5 to −0.7).

Conclusion:

Among patients with submassive PE, initiation of a DOAC shortly after CDT may result in a decreased hospital LOS compared to parenterally bridged warfarin.

Association between rivaroxaban use and length of hospital stay, treatment costs and early outcomes in patients with pulmonary embolism: a systematic review of real-world studies

BACKGROUND

In the EINSTEIN-Pulmonary Embolism (PE) trial, subjects randomized to rivaroxaban versus enoxaparin bridging to vitamin K antagonist (VKA) therapy experienced a reduced index hospital length of stay (LOS). We sought to conduct a systematic review of real-world studies comparing LOS, costs and early outcomes among patients treated with rivaroxaban or parenterally bridged VKA in routine practice.

METHODS

We searched Medline and Scopus from 1 January 2011 to 30 November 2016 to identify observational studies comparing acute PE patients anticoagulated with rivaroxaban or parenterally bridged VKA and reporting data on index hospital LOS, costs and/or early post-PE outcomes. Studies not using appropriate methods for minimizing confounding bias or not published in English were excluded.

RESULTS

Five studies met inclusion criteria. Rivaroxaban use was associated with decreased index hospital LOS (range: 1.36-1.70 days) and treatment costs (range: $1818-$2688) during an index stay compared to parenterally bridged warfarin. No differences in early readmission for recurrent thrombosis were noted between anticoagulation strategies. Readmission for major bleeding was rare in both cohorts. Similar reductions in LOS (range: 0.23-4.3 days) and costs (range: $251-$7094) were observed with rivaroxaban in studies restricted to patients deemed low risk for early complications by clinical gestalt or by a clinical- or claims-based risk stratification tool.

CONCLUSIONS

Regardless of patient predicted risk of post-PE complications, real-world studies suggest that rivaroxaban is associated with a reduced hospital LOS and costs versus parenterally bridged warfarin, without increasing readmission.

Comparison of hospital length of stay in patients treated with non-vitamin K oral anticoagulants or parenteral agents plus warfarin for venous thromboembolism

Objectives:

Existing research comparing hospital length of stay for patients treated with non–vitamin K oral anticoagulants or parenteral bridging to warfarin has been conducted primarily with the agent rivaroxaban. The objective of this study was to compare hospital length of stay between patients initiated on the non–vitamin K oral anticoagulants, apixaban or rivaroxaban, and patients initiated on parenteral anticoagulation agents plus warfarin for the treatment of venous thromboembolism.

Methods:

A retrospective cohort study was conducted at an 859-bed, not-for-profit, teaching hospital. Adult patients admitted for a primary diagnosis of venous thromboembolism between 1 November 2012 and 31 August 2015 and treated with apixaban or rivaroxaban or a parenteral anticoagulant plus warfarin were included in the study. Eligible patients were identified using International Classification of Diseases, Ninth Revision codes for a primary diagnosis of acute thromboses and emboli and medication administration record data. Individuals using anticoagulation therapy prior to admission, released from the emergency department, or treated with thrombectomy or fibrinolytic therapy were excluded.

Results:

A total of 152 patients were included in this study. Patient characteristics, including renal function, were similar between study arms. Venous thromboembolism treatment with apixaban or rivaroxaban compared to a parenteral anticoagulant plus warfarin was associated with a reduced hospital length of stay (2.63 vs 5.33 days; p < 0.05) and decreased total hospital cost adjusted to 2015 dollars (US$21,694 vs US$38,851; p = 0.013).

Conclusion:

These results suggest that treatment with a non–vitamin K anticoagulant may significantly reduce hospital length of stay and total hospital cost compared to a parenteral anticoagulant plus warfarin for patients admitted for venous thromboembolism.