Hidden costs associated with venous thromboembolism: impact of lost productivity on employers and employees

A model for estimating the health economic impact of earlier diagnosis of chronic thromboembolic pulmonary hypertension

Background

Diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) exceeds 1 year, contributing to higher mortality. Health economic consequences of late CTEPH diagnosis are unknown. We aimed to develop a model for quantifying the impact of diagnosing CTEPH earlier on survival, quality-adjusted life-years (QALYs) and healthcare costs.

Material and methods

A Markov model was developed to estimate lifelong outcomes, depending on the degree of delay. Data on survival and quality of life were obtained from published literature. Hospital costs were assessed from patient records (n=498) at the Amsterdam UMC – VUmc, which is a Dutch CTEPH referral center. Medication costs were based on a mix of standard medication regimens.

Results

For 63-year-old CTEPH patients with a 14-month diagnostic delay of CTEPH (median age and delay of patients in the European CTEPH Registry), lifelong healthcare costs were estimated at EUR 117 100 for a mix of treatment options. In a hypothetical scenario of maximal reduction of current delay, improved survival was estimated at a gain of 3.01 life-years and 2.04 QALYs. The associated cost increase was EUR 44 654, of which 87% was due to prolonged medication use. This accounts for an incremental cost–utility ratio of EUR 21 900/QALY.

Conclusion

Our constructed model based on the Dutch healthcare setting demonstrates a substantial health gain when CTEPH is diagnosed earlier. According to Dutch health economic standards, additional costs remain below the deemed acceptable limit of EUR 50 000/QALY for the particular disease burden. This model can be used for evaluating cost-effectiveness of diagnostic strategies aimed at reducing the diagnostic delay.

This constructed model based on the Dutch healthcare setting can be used for evaluating cost-effectiveness of diagnostic strategies aimed at reducing the diagnostic delay of chronic thromboembolic pulmonary hypertensionhttps://bit.ly/35yXPM3

Risks and Outcomes of Perioperative Pulmonary Embolism in Major Surgeries: A Population-Based Study

PURPOSE

Perioperative pulmonary embolism (PE) is a significant cardiovascular complication in many surgeries. This study aimed to investigate the risks and outcomes of perioperative PE in major surgery.

METHODS

Discharge records of the Nationwide Readmission Database from 2010 to 2015 were extracted and analyzed. Length of stay, charges, death, and 30-day hospital readmission rate were compared for patients with and without perioperative PE. In addition, surgery-specific risk factors and therapies associated with PE were explored in a multivariable model.

FINDINGS

A total of 12,376,153 hospitalizations for major surgeries were involved, and perioperative PE occurred in 22,676 hospitalizations (0.18%). The length of stay, charges, rate of death, and 30-day hospital readmission were higher in patients with perioperative PE than in those without perioperative PE. Respiratory (odds ratios [OR], 2.09; 95% CI, 1.89-2.3), cardiovascular (OR, 1.62; 95% CI, 1.51-1.73), and musculoskeletal (OR, 1.22; 95% CI, 1.1-1.29) surgeries were risk factors for the occurrence of perioperative PE. In patients with perioperative PE, respiratory surgery was a risk factor for death (OR, 1.48; 95% CI, 1.10-2.00), whereas gynecologic/obstetric surgery was a protective factor for 30-day readmission (OR, 0.30; 95% CI, 0.10-0.88). Regarding therapy for perioperative PE, thrombolytic therapy (OR, 1.74; 95% CI, 1.26-2.42) and embolectomy (OR, 3.60; 95% CI, 2.35-5.51) were risk factors for death.

IMPLICATIONS

Respiratory, cardiovascular, and musculoskeletal surgeries were risk factors for the occurrence of perioperative PE and death. Future research on precise models to predict PE in major surgeries is needed for appropriate interventions to improve outcomes of perioperative PE.

A botanical medicine dragon's blood exhibited clinical antithrombosis efficacy similar to low molecular weight heparin

Deep vein thrombosis (DVT) is a common complication following traumatic fracture with a 0.5%-1% annual incidence. Low molecular weight heparin (LMWH) is the most commonly used anticoagulation drug for DVT prevention, but treatment with LMWH is invasive. Our aim is to compare the antithrombotic effect of dragon's blood, an oral botanical anticoagulant medicine approved by the Chinese FDA, with LMWH in patients undergoing hip fracture surgery and to explore the molecular mechanisms of anticoagulation treatment. Our study recruited patients and divided them into LMWH and dragon's blood treatment group. Coagulation index tests, Doppler ultrasound and mRNA sequencing were performed before and after anticoagulation therapy. There was no significant difference in postoperative DVT incidence between the two groups (23.1% versus 15.4%, P=0.694). D-dimer (D-D) and fibrinogen degradation product (FDP) showed significant reductions in both groups after anticoagulation treatments. We identified SLC4A1, PROS1, PRKAR2B and seven other genes as being differentially expressed during anticoagulation therapy in both groups. Genes correlated with coagulation indexes were also identified. Dragon's blood and LMWH showed similar effects on DVT and produced similar gene expression changes in patients undergoing hip fracture surgery, indicating that dragon's blood is a more convenient antithrombosis medicine (oral) than LMWH (hypodermic injection).

Cost of Healthcare Associated With Deep Vein Thrombosis in Patients Treated With Warfarin in Turkey: 2010-2013 Database Analysis of a Tertiary Care Center

OBJECTIVES

To evaluate the cost of healthcare with respect to the quality of anticoagulation in patients with deep vein thrombosis (DVT) treated with warfarin in daily practice via the database analysis of a tertiary care center in the period 2010 to 2013.

METHODS

Of 258 307 records in total, 42 582 unique patients with DVT and 32 012 patients with international normalized ratio (INR) measurements were included. Overall, 6720 unique patients with DVT diagnosis and one or more INR measurements were identified, and the records of 4377 out of 6720 unique patients were validated and included in the analysis data set. The cost analysis was based on direct medical costs from the payer's perspective. Cost items were related to healthcare resource utilization (inpatient and outpatient services) during the study period, which provided a basis for calculation of per-patient, outpatient, inpatient, and total direct medical costs.

RESULTS

Mean outpatient, inpatient, and total hospital admission costs were $578, $2195, and $2785, respectively, for patients with time in the therapeutic range of 70% or more, whereas the same costs were $571, $2163, and $3192, respectively, for patients with time in the therapeutic range of less than 70%.

CONCLUSIONS

Our findings for a retrospective cohort of patients with DVT undergoing warfarin therapy reveal that patients spent 70% or more, as opposed to less than 70%, of follow-up time within the therapeutic INR range and that outpatient care, as opposed to inpatient care, was associated with lower healthcare costs. Given the significant contribution that hospital stay makes to the cost burden of DVT, our findings also highlight the association between poor warfarin anticoagulant control and increased hospitalization costs.

A systematic review of cost-effectiveness analysis of screening interventions for assessing the risk of venous thromboembolism in women considering combined oral contraceptives

Use of combined oral contraceptives (COCs) by women increases the risk of venous thromboembolism (VTE), which can have a major impact on an individuals' quality of life. VTE is also associated with an increase in healthcare costs. Our aim was to systematically review cost-effectiveness analyses (CEAs) considering any screening for risk of VTE in women using COCs. The quality of reporting in each study was assessed, a summary of results was prepared, and the key drivers of cost effectiveness in each of the eligible CEAs were identified. A search strategy using MeSH terms was performed in MEDLINE, Embase, the Centre for Review and Dissemination (CRD) database including the Economic Evaluation Database from the UK National Health Service, and Cochrane reviews. Two reviewers independently screened and determined the final articles, and a third reviewer resolved any discrepancies. Consolidated Health Economic Evaluation Reporting Standards was used to assess the quality of reporting in terms of perspective, effectiveness measures, model structure, cost, time-horizon and discounting. Four publications (three from Europe, one from the United States) were eligible for inclusion in the review. According to current criteria, relevant elements were sometimes not captured and the sources of epidemiological and effectiveness data used in the CEAs were of limited quality. The studies varied in terms of type of costs assessed, country settings, model assumptions and uncertainty around input parameters. Key drivers of CEAs were sensitivity and specificity of the test, incidence rate of VTE, relative risk of prophylaxis, and costs of the test. The reviewed studies were too dissimilar to draw a firm conclusion on cost-effectiveness analysis about universal and selective screening in high-risk groups. The new emerging diagnostic tools for identifying women at risk of developing VTE, that are more predictive and less costly, highlight the need for more studies that apply the latest evidence and utilize robust methods for cost-effectiveness analysis. This information is required to improve decision making for this pertinent issue within personalized medicine.

Increased Post-procedural Non-gastrointestinal Adverse Events After Outpatient Colonoscopy in High-risk Patients

BACKGROUND & AIMS

The incidence and predictors of non-gastrointestinal (GI) adverse events (AEs) after colonoscopy are not well-understood. We studied the effects of antithrombotic agents, cardiopulmonary comorbidities, and age on risk of non-GI AEs after colonoscopy.

METHODS

We performed a retrospective longitudinal analysis to assess the diagnosis, procedure, and prescription drug codes in a United States commercial claims database (March 2010-March 2012). Data from patients at increased risk (n = 82,025; defined as patients with pulmonary comorbidities or cardiovascular disease requiring antithrombotic medications) were compared with data from 398,663 average-risk patients. In a 1:1 matched analysis, 51,932 patients at increased risk, examined by colonoscopy, were compared with 51,932 matched (on the basis of age, sex, and comorbidities) patients at increased risk who did not undergo colonoscopy. We tracked cardiac, pulmonary, and neurovascular events 1-30 days after colonoscopy.

RESULTS

Thirty days after outpatient colonoscopy, non-GI AEs were significantly higher in patients taking antithrombotic medications (7.3%; odds ratio [OR], 10.75; 95% confidence interval, 10.13-11.42) or those with pulmonary comorbidities (1.8%; OR, 2.44; 95% confidence interval, 2.27-2.62) vs average-risk patients (0.7%) and in patients 60-69 years old (OR, 2.21; 95% confidence interval, 2.01-2.42) or 70 years or older (OR, 6.45; 95% confidence interval, 5.89-7.06), compared with patients younger than 50 years. The 30-day incidence of non-GI AEs in patients at increased risk who underwent colonoscopy was also significantly higher than in matched patients at increased risk who did not undergo colonoscopy in the anticoagulant group (OR, 2.31; 95% confidence interval, 2.01-2.65) and in the chronic obstructive pulmonary disease group (OR, 1.33; 95% confidence interval, 1.13-1.56).

CONCLUSIONS

Increased number of comorbidities and older age (older than 60 years) are associated with increased risk of non-GI AEs after colonoscopy. These findings indicate the importance of determining comorbid risk and evaluating antithrombotic management before colonoscopy.

Evaluation of an institutional project to improve venous thromboembolism prevention

BACKGROUND

Northwestern Memorial Hospital (NMH) was historically a poor performer on the venous thromboembolism (VTE) outcome measure. As this measure has been shown to be flawed by surveillance bias, NMH embraced process-of-care measures to ensure appropriate VTE prophylaxis to assess healthcare-associated VTE prevention efforts.

OBJECTIVE

To evaluate the impact of an institution-wide project aimed at improving hospital performance on VTE prophylaxis measures.

DESIGN

A retrospective observational study.

SETTING

NMH, an 885-bed academic medical center in Chicago, Illinois PATIENTS: Inpatients admitted to NMH from January 1, 2013 to May 1, 2013 and from October 1, 2014 to April 1, 2015 were eligible for evaluation.

INTERVENTION

Using the define-measure-analyze-improve-control (DMAIC) process-improvement methodology, a multidisciplinary team implemented and iteratively improved 15 data-driven interventions in 4 broad areas: (1) electronic medical record (EMR) alerts, (2) education initiatives, (3) new EMR order sets, and (4) other EMR changes.

MEASUREMENTS

The Joint Commission's 6 core measures and the Surgical Care Improvement Project (SCIP) SCIP-VTE-2 measure.

RESULTS

Based on 3103 observations (1679 from January 1, 2013 to May 1, 2013, and 1424 from October 1, 2014 to April 1, 2015), performance on the core measures improved. Performance on measure 1 (chemoprophylaxis) improved from 82.5% to 90.2% on medicine services, and from 94.4% to 97.6% on surgical services. The largest improvements were seen in measure 4 (platelet monitoring), with a performance increase from 76.7% adherence to 100%, and measure 5 (warfarin discharge instructions), with a performance increase from 27.4% to 88.8%.

CONCLUSION

A systematic hospital-wide DMAIC project improved VTE prophylaxis measure performance. Sustained performance has been observed, and novel control mechanisms for continued performance surveillance have been embedded in the hospital system. Journal of Hospital Medicine 2016;11:S29-S37. © 2016 Society of Hospital Medicine.

Factors associated with in-hospital pulmonary embolism after shoulder arthroplasty

BACKGROUND

Despite that pulmonary embolism (PE) is a feared complication after shoulder arthroplasty, little is known about its perioperative associated factors.

MATERIALS AND METHODS

We used the Nationwide Inpatient Sample to gather a sample of 422,372 patients who underwent shoulder arthroplasty between 2002 and 2011. This population was divided into 2 cohorts on the basis of those who experienced perioperative PE (0.25%) and those who did not. Demographics were compiled for both cohorts. Multivariable logistic regression analysis was used to account for confounding variables and to determine significant predictors of perioperative PE.

RESULTS

After adjusting for patient demographic and clinical variables in multivariable regression modeling, the top 4 independent predictors for PE were primary diagnosis of proximal humerus fracture, deficiency anemia, congestive heart failure, and chronic lung disease. Other pertinent risk factors included increasing age, obesity, fluid and electrolyte abnormalities, undergoing total shoulder arthroplasty rather than hemiarthroplasty, and subsequent days of postoperative care.

CONCLUSIONS

Knowledge of these factors might help in preoperative counseling and prove useful for implementation of quality improvement strategies to reduce the occurrence of PE. Surgeons may consider initiating thromboprophylaxis in patients with any of the aforementioned comorbidities.