All-cause and disease-related health care costs associated with recurrent venous thromboembolism

New Oral Anticoagulants Open New Horizons for Cancer Patients with Venous Thromboembolism

Venous thromboembolism (VTE) is associated with increased morbidity and mortality, decreased quality of life, and higher economic burden in patients with cancer. Currently, the treatment of VTE in patients with cancer is particularly challenging. For many years, low molecular weight heparin (LMWHs) has been the standard for the treatment of cancer-associated VTE. Recently, the introduction of new oral anticoagulants (NOACs) may offer an oral anticoagulant option for some patients with cancer-associated thrombosis (CAT) as a growing body of literature supports the use of NOACs in the setting of CAT. With the use of NOAC as a new option in the management of CAT, clinicians now face several choices for the individual cancer patient with VTE. We need a more in-depth understanding of the drug properties, efficacy and safety, economic analysis that allows us to choose the most appropriate treatment for each patient. In the review, we will present an overview of CAT management, discuss the available evidence, economic costs for NOACs in the treatment of CAT, and seek to provide the best range of treatments for cancer patients.

Healthcare resource utilization in myeloproliferative neoplasms: a population-based study from Ontario, Canada

Health resource utilization (HRU) and associated factors of high cost are not well understood in myeloproliferative neoplasms (MPNs). In this population-based, retrospective matched-cohort study, we used administrative health databases of Ontario, Canada to measure treatment costs and HRU for patients with MPN from 2004 to 2016 and compared them to matched controls. In 7130 patients with MPN [essential thrombocythemia (ET) = 3481; polycythemia vera (PV) = 2618; myelofibrosis (MF) = 1031], the mean annualized treatment costs were $16,646 for ET (controls, $7070); $16,360 for PV (controls, $7293); and $25,863 for MF (controls, $7386). Out of the total costs, the largest expenditure was on acute hospital care (ET: 57%, PV: 57%, MF: 66%). Older age (≥65), male gender, patients not seen by a specialist, and greater comorbidity burden were independent predictors of higher costs (p < 0.05). In addition, history of venous thrombosis in patients with ET and PV was associated with significantly higher treatment costs (p < 0.05).

Healthcare resource utilization and costs associated with venous thromboembolism recurrence in patients with cancer

Objective: Patients with cancer are at high risk for developing primary but also recurrent venous thromboembolism (VTE). This study examined healthcare utilization (HRU) and costs related to VTE recurrence among cancer patients.Methods: Medical and pharmacy claims from the Humana Database were used to compare HRU (outpatient visits, emergency room visits, hospitalizations, and hospitalization days) and healthcare costs among cancer patients with a single VTE event (between 01/2013 and 06/2015) and those with recurrent VTE during the follow-up period (from initiation of anticoagulant therapy until end of eligibility or data availability). All-cause and VTE-related HRU and costs were evaluated using Poisson regression, and healthcare costs were compared using mean differences reported as per-patient-per-year (PPPY).Results: Of 2,428 newly diagnosed cancer patients who developed VTE, 413 (17.1%) experienced recurrent VTE during the follow-up period (mean = 9 months). Patients with recurrent VTE had higher all-cause and VTE-related HRU and costs compared to those without recurrence. Patients with recurrent VTE also had over 3.19-times more VTE-related hospitalizations (RR [95% CI] = 3.19 [2.93-3.47]), and 3.88-times more VTE-related hospitalization days (RR [95% CI] = 3.88 [3.74-4.02]) than patients without a VTE recurrence. Total VTE-related healthcare costs were $39,641 PPPY among patients with recurrent VTE, $29,142 higher compared to those without recurrence ($10,499 PPPY). This difference was mainly driven by hospitalization costs.Conclusion: Recurrent VTE among cancer patients is associated with significant HRU and healthcare costs, notably hospitalizations. Strategies to reduce VTE recurrence in patients with cancer can contribute to reducing healthcare cost.

Healthcare resource utilization and costs associated with venous thromboembolism in cancer patients treated with anticoagulants

Objective: The standard of care for cancer-related venous thromboembolism (VTE) has been low molecular weight heparin (LMWH), but oral anticoagulants are also widely prescribed. This study compared VTE-related healthcare resource utilization and costs of cancer patients treated with anticoagulants. Methods: Claims data from Humana Database (January 1, 2013-May 31, 2015) were analyzed. Based on the first anticoagulant received, patients were classified into LMWH, warfarin, or rivaroxaban cohorts. Characteristics were evaluated during the 6 months pre-index date (i.e. the first VTE); VTE-related resource utilization and costs were evaluated during follow-up. Cohorts were compared using rate ratios, and p-values and 95% confidence intervals were calculated. Healthcare costs were evaluated per-patient-per-year (PPPY) and compared using mean cost differences. Results: A total of 2,428 patients (LMWH: n = 660; warfarin: n = 1,061; rivaroxaban: n = 707) were included. Compared to patients treated with LMWH, patients treated with rivaroxaban had significantly fewer VTE-related hospitalizations, hospitalization days, and emergency room and outpatient visits, resulting in an increase of $12,000 VTE-related healthcare costs PPPY with LMWH vs rivaroxaban. Patients treated with rivaroxaban had significantly lower VTE-related resource utilization compared to patients treated with warfarin; however, VTE-related costs were similar between cohorts. The higher drug costs ($1,519) were offset by significantly lower outpatient (-$1,039) and hospitalization costs (-$522) in rivaroxaban relative to the warfarin cohort. Conclusions: Healthcare resource use and costs associated with VTE treatment in cancer patients are highest with LMWH relative to warfarin and rivaroxaban.

Risk of Recurrent Venous Thromboembolism After an Initial Episode: Risk Stratification and Implications for Long-term Treatment

PURPOSE OF REVIEW

Venous thromboembolism (VTE) is a common condition with significant associated morbidity and mortality. Recurrent VTE after an initial episode is a preventable medical condition. The following review discusses data supporting recurrence risk estimates after an initial VTE episode as well as treatment strategies to mitigate risk of recurrent VTE.

RECENT FINDINGS

This review particularly highlights methods for stratifying the risk of recurrent VTE and recent studies that have evaluated direct oral anticoagulants for the prevention of recurrent VTE. Risk assessment for VTE recurrence should guide anticoagulation duration. In patients who present with unprovoked VTE events, there remains a high risk of recurrence that is significantly mitigated with extended duration anticoagulation with either a vitamin K antagonist or direct oral anticoagulant.

Rivaroxaban Versus Warfarin and Risk of Post-Thrombotic Syndrome Among Patients with Venous Thromboembolism

BACKGROUND

The effectiveness of rivaroxaban to reduce post-thrombotic syndrome in patients with venous thromboembolism is largely unknown. We compared rates of post-thrombotic syndrome in patients given rivaroxaban versus warfarin in a cohort of patients with incident venous thromboembolism receiving routine clinical care.

METHODS

We linked Danish nationwide registries to identify all patients with incident venous thromboembolism who were new users of rivaroxaban or warfarin and compared rates of post-thrombotic syndrome using an inverse probability of treatment-weighting approach to account for baseline confounding.

RESULTS

We identified 19,957 oral anticoagulation-naive patients with incident venous thromboembolism treated with warfarin or rivaroxaban (mean age, 64 years; 48% were female, 45.5% had pulmonary embolism). The propensity-weighted rate of post-thrombotic syndrome at 3 years follow-up was 0.53 incidents per 100 person-years with rivaroxaban versus 0.55 per 100 person-years with warfarin, yielding a hazard rate of 0.88 (95% confidence interval, 0.66-1.17). This association remained consistent across types of venous thromboembolism (deep venous thrombosis vs pulmonary embolism, and provoked vs unprovoked venous thromboembolism) and when censoring patients with recurrent venous thromboembolism.

CONCLUSIONS

In this clinical practice setting, rivaroxaban was associated with lower but statistically nonsignificant rates of post-thrombotic syndrome, which did not appear to be mediated only by an effect on recurrent venous thromboembolism.

Cost comparison of continued anticoagulation with rivaroxaban versus placebo based on the 1-year EINSTEIN-Extension trial efficacy and safety results

AIMS

The EINSTEIN-Extension trial (EINSTEIN-EXT) found that continued treatment with rivaroxaban for an additional 6 or 12 months (vs placebo) after 6-12 months of initial anticoagulation significantly reduced the risk of recurrent venous thromboembolism (VTE) with a small non-significant increased risk of major bleeding (none fatal or in critical site). This study aimed to compare total healthcare cost between rivaroxaban and placebo, based on the EINSTEIN-EXT event rates.

METHODS

Total healthcare cost was calculated as the sum of treatment and clinical event costs from a US managed care perspective. Treatment duration and event rates were obtained from the EINSTEIN-EXT study. Adjustment on treatment duration was made by assuming a 10% non-adherence rate. Drug costs were based on wholesale acquisition costs. Cost estimates for clinical events (i.e. recurrent deep vein thrombosis [DVT], recurrent pulmonary embolism, major bleeding, clinically relevant non-major bleeding) were determined from the literature. Results were examined over a ±20% range of each cost component and over 95% confidence intervals (CIs) of event rate differences in deterministic (one-way) and probabilistic sensitivity analyses (PSA).

RESULTS

Total healthcare cost was $1,454 lower for rivaroxaban-treated (vs placebo-treated) patients in the base-case, with a lower clinical event cost fully offsetting drug cost. The cost savings of recurrent DVT alone (-$3,102) was greater than drug cost ($2,723). Total healthcare cost remained lower for rivaroxaban in the majority (73%) of PSA (cost difference [95% CI] = -$1,454 [-$2,396, $1,231]).

LIMITATIONS

This study was conducted over the 1-year observation period of the EINSTEIN-EXT trial, which limited "real-world" applicability and examination of long-term economic impact. Assumptions on drug and clinical event costs were US-based and, thus, not applicable to other healthcare systems.

CONCLUSIONS

Total healthcare costs were estimated to be lower for patients continuing rivaroxaban therapy compared to those receiving placebo in VTE patients who had completed 6-12 months of VTE treatment.

Postthrombotic Syndrome in Patients Treated With Rivaroxaban or Warfarin for Venous Thromboembolism

Postthrombotic syndrome (PTS) is a frequent complication of venous thromboembolism (VTE). Using MarketScan claims data from January 2012 to June 2015, we identified adults with a primary diagnosis code for VTE during a hospitalization/emergency department visit, ≥6 months of insurance coverage prior to the index event and newly started on rivaroxaban or warfarin within 30 days of the index VTE. Patients with <4-month follow-up postindex event or a claim for any anticoagulant during 6-month baseline period were excluded. Differences in baseline characteristics between rivaroxaban and warfarin users were adjusted for using inverse probability of treatment weights based on propensity scores. Patients were followed for the development of PTS starting 3 months after the index VTE. Cox regression was performed and reported as hazard ratios with 95% confidence intervals (CIs). In total, 10 463 rivaroxaban and 26 494 warfarin users were followed for a mean of 16 ± 9 (range, 4-39) months. Duration of anticoagulation was similar between cohorts (median = 6 months). Rivaroxaban was associated with a 23% (95% CI: 16-30) reduced hazard of PTS versus warfarin. Rivaroxaban was associated with a significant risk reduction in symptoms of PTS compared to warfarin in patients with VTE treated in routine practice.

Autumn season birth is associated with a lower frequency of diagnosis of unprovoked deep vein thrombosis in the emergency department

A significant association was described between lifetime frequency of several human diseases, including cardiovascular disorders, and birth season. We performed a retrospective study to establish whether an association exists between birth season and frequency of venous thromboembolism diagnosed in the emergency department. The study population consisted of all consecutive patients diagnosed with venous thromboembolism at the emergency department of the University Hospital of Parma (Italy) during the year 2014. A total number of 400 patients (217 women and 183 men; mean age 70 ± 18 years) received a final diagnosis of venous thromboembolism throughout the study period. The lowest frequency of diagnoses was observed in patients born in autumn, whereas a higher frequency was observed in those born in spring or summer. When compared with the frequency of births in the same geographical area, patients born in spring and summer exhibited a 30 and 25% higher risk of venous thromboembolism compared with those having autumn birth. A similar trend was observed in patients with unprovoked thrombosis, but not in those with provoked thrombosis. A subanalysis of patients with unprovoked deep vein thrombosis revealed that both spring birth (relative risk 1.49, 95% confidence interval 1.04-2.14) and summer birth (relative risk 1.46, 95% confidence interval 1.01-2.09) were significant risk factors for this condition compared with autumn birth. Although further studies are needed to confirm these original findings, it seems reasonable to hypothesize that birth season may influence the lifetime risk of venous thromboembolism, especially of unprovoked deep vein thrombosis.

Management of Venous Thromboembolisms: Part I. The Consensus for Deep Vein Thrombosis

Deep vein thrombosis (DVT) is a potentially catastrophic condition because thrombosis, left untreated, can result in detrimental pulmonary embolism. Yet in the absence of thrombosis, anticoagulation increases the risk of bleeding. In the existing literature, knowledge about the epidemiology of DVT is primarily based on investigations among Caucasian populations. There has been little information available about the epidemiology of DVT in Taiwan, and it is generally believed that DVT is less common in Asian patients than in Caucasian patients. However, DVT is a multifactorial disease that represents the interaction between genetic and environmental factors, and the majority of patients with incident DVT have either inherited thrombophilia or acquired risk factors. Furthermore, DVT is often overlooked. Although symptomatic DVT commonly presents with lower extremity pain, swelling and tenderness, diagnosing DVT is a clinical challenge for physicians. Such a diagnosis of DVT requires a timely systematic assessment, including the use of the Wells score and a D-dimer test to exclude low-risk patients, and imaging modalities to confirm DVT. Compression ultrasound with high sensitivity and specificity is the front-line imaging modality in the diagnostic process for patients with suspected DVT in addition to conventional invasive contrast venography. Most patients require anticoagulation therapy, which typically consists of parenteral heparin bridged to a vitamin K antagonist, with variable duration. The development of non-vitamin K oral anticoagulants has revolutionized the landscape of venous thromboembolism treatment, with 4 agents available,including rivaroxaban, dabigatran, apixaban, and edoxaban. Presently, all 4 drugs have finished their large phase III clinical trial programs and come to the clinical uses in North America and Europe. It is encouraging to note that the published data to date regarding Asian patients indicates that such new therapies are safe and efficacious. Ultimately, our efforts to improve outcomes in patients with DVT rely on the awareness in the scientific and medical community regarding the importance of DVT.

KEY WORDS

Combination therapy; Hypertension; α1-blocker.

Value of Red Blood Cell Distribution Width on Emergency Department Admission in Patients With Venous Thrombosis

Red blood cell distribution width (RDW) was found to be a useful parameter in a variety of cardiovascular and thrombotic disorders. Therefore, we conducted a retrospective case-control study to establish whether an association exists between RDW and venous thrombosis. The study population consisted of 431 consecutive patients who received a diagnosis of venous thrombosis in the emergency department (ED), thus including cases of superficial venous thrombosis, deep vein thrombosis (DVT), and/or pulmonary embolism (PE). The control population consisted of 967 matched outpatients who underwent routine laboratory testing. The RDW values were found to be significantly increased in patients with venous thrombosis compared to controls, with an incremental trend of values from patients with superficial thrombosis, isolate DVT, to PE. Increased RDW values were an independent risk factor for isolate DVT and PE, displaying a relative risk that was greater in patients with provoked DVT and PE that in those with unprovoked thrombosis after multiple adjustment for age, gender, hemoglobin, and mean corpuscular volume. Interestingly, RDW also exhibited a significant diagnostic performance at ED admission, displaying an area under the curve of 0.65 (95% confidence interval [CI] 0.62 to 0.68; p <0.001) for all cases of venous thrombosis, 0.63 (95% CI 0.59 to 0.68; p <0.001) for isolate DVT, and 0.70 (95% CI 0.65 to 0.75; p <0.001) for PE. The results of this study suggest that increased RDW not only is associated with venous thrombosis but may also increase the efficiency of baseline risk assessment of patients with suspected venous thrombosis on ED admission.

The economic burden of incident venous thromboembolism in the United States: A review of estimated attributable healthcare costs

Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is an important cause of preventable mortality and morbidity. In this study, we summarize estimates of per-patient and aggregate medical costs or expenditures attributable to incident VTE in the United States. Per-patient estimates of incremental costs can be calculated as the difference in costs between patients with and without an event after controlling for differences in underlying health status. We identified estimates of the incremental per-patient costs of acute VTEs and VTE-related complications, including recurrent VTE, post-thrombotic syndrome, chronic thromboembolic pulmonary hypertension, and anticoagulation-related adverse drug events. Based on the studies identified, treatment of an acute VTE on average appears to be associated with incremental direct medical costs of $12,000 to $15,000 (2014 US dollars) among first-year survivors, controlling for risk factors. Subsequent complications are conservatively estimated to increase cumulative costs to $18,000-23,000 per incident case. Annual incident VTE events conservatively cost the US healthcare system $7-10 billion each year for 375,000 to 425,000 newly diagnosed, medically treated incident VTE cases. Future studies should track long-term costs for cohorts of people with incident VTE, control for comorbid conditions that have been shown to be associated with VTE, and estimate incremental medical costs for people with VTE who do not survive. The costs associated with treating VTE can be used to assess the potential economic benefit and cost-savings from prevention efforts, although costs will vary among different patient groups.

Real-World Medical Cost Avoidance When New Oral Anticoagulants are Used Versus Warfarin for Venous Thromboembolism in the United States

OBJECTIVE

Real-world medical cost avoidances from a US payer perspective were estimated when new oral anticoagulants (NOACs) are used instead of warfarin for the treatment of patients with venous thromboembolism (VTE).

METHODS

Reductions in real-world event rates of recurrent VTE and MB were obtained by applying rate reductions from the NOACs versus warfarin trials to the Worcester population. Incremental annual medical costs among patients with VTE and MB from a US payer perspective were obtained from the literature or claims databases. Differences in total medical costs for patients treated with NOACs versus warfarin were then estimated. Univariate and Monte Carlo sensitivity analyses were additionally carried out.

RESULTS

The annual total medical cost avoidances versus warfarin were greatest for VTE patients treated with apixaban (-US$4440 per patient-year [ppy]), followed by those treated with rivaroxaban (-US$2971 ppy), edoxaban (-US$1957 ppy), and dabigatran (-US$572 ppy). The medical cost avoidances remained consistent under sensitivity analyses.

CONCLUSION

Based on real-world data, when any of the evaluated NOACs are used instead of warfarin for treatment of patients with acute VTE, annual medical costs are reduced. Of the NOACs, apixaban has the greatest real-world medical cost avoidance, as its use is associated with substantial reductions in both VTE and MB event rates.

Evaluation of medical costs associated with use of new oral anticoagulants compared with standard therapy among venous thromboembolism patients

OBJECTIVE

This study evaluated differences in medical costs associated with clinical end-points from randomized clinical trials that compared the new oral anticoagulants (NOACs), dabigatran, rivaroxaban, apixaban, and edoxaban, to standard therapy for treatment of patients with venous thromboembolism (VTE).

RESEARCH DESIGN AND METHODS

Event rates of efficacy and safety end-points from the clinical trials (RE-COVER, RE-COVER II, EINSTEIN-Pooled, AMPLIFY, Hokusai-VTE trial) were obtained from published literature. Incremental annual medical costs among patients with clinical events from a US payer perspective were obtained from the literature or healthcare claims databases and inflation adjusted to 2013 costs. Differences in total medical costs associated with clinical end-points for the NOACs vs standard therapy were then estimated. One-way and Monte Carlo sensitivity analyses were carried out.

RESULTS

A lower rate of major bleedings was associated with use of any of the NOACs vs standard therapy. Except for dabigatran, use of NOACs was also associated with a lower rate of recurrent VTE/death. As a result of the reduction in clinical event rates, the overall medical cost differences were -$146, -$482, -$918, and -$344 for VTE patients treated with dabigatran, rivaroxaban, apixaban, and edoxaban, respectively, vs patients treated with standard therapy.

CONCLUSIONS

When any of the four NOACs are used instead of standard therapy for acute VTE, treatment medical costs are reduced. Apixaban is associated with the greatest reduction in medical costs, which is driven by medical cost reductions associated with both efficacy and safety end-points. Further evaluation may be needed to validate these results in the real-world setting.

Duration of anticoagulant therapy for deep vein thrombosis and pulmonary embolism

It takes about 3 months to complete “active treatment” of venous thromboembolism (VTE), with further treatment serving to prevent new episodes of thrombosis (“pure secondary prevention”). Consequently, VTE should generally be treated for either 3 months or indefinitely (exceptions will be described in the text). The decision to stop anticoagulants at 3 months or to treat indefinitely is dominated by the long-term risk of recurrence, and secondarily influenced by the risk of bleeding and by patient preference. VTE provoked by a reversible risk factor, or a first unprovoked isolated distal (calf) deep vein thrombosis (DVT), has a low risk of recurrence and is usually treated for 3 months. VTE associated with active cancer, or a second unprovoked VTE, has a high risk of recurrence and is usually treated indefinitely. The decision to stop anticoagulants at 3 months or to treat indefinitely is more finely balanced after a first unprovoked proximal DVT or pulmonary embolism (PE). Indefinite anticoagulation is often chosen if there is a low risk of bleeding, whereas anticoagulation is usually stopped at 3 months if there is a high risk of bleeding. The decision to continue anticoagulation indefinitely after a first unprovoked proximal DVT or PE is strengthened if the patient is male, the index event was PE rather than DVT, and/or d-dimer testing is positive 1 month after stopping anticoagulant therapy.