Hospital length of stay: is rivaroxaban associated with shorter inpatient stay compared to warfarin among patients with non-valvular atrial fibrillation?

Direct Medical Cost of Stroke and the Cost-Effectiveness of Direct Oral Anticoagulants in Atrial Fibrillation-Related Stroke: A Cross-Sectional Study

BACKGROUND

Stroke has significant direct medical costs, and direct oral anticoagulants (DOACs) are better alternatives to warfarin for stroke prevention in atrial fibrillation (AF). This study aimed to determine the direct medical costs of stroke, with emphasis on AF stroke and the cost-effectiveness of DOACs among stroke patients in a tertiary hospital in Malaysia.

METHODS

This study utilised in-patient data from the case mix unit of Universiti Kebangsaan Malaysia Medical Centre (UKMMC) between 2011 and 2018. Direct medical costs of stroke were determined using a top-down costing approach and factors associated with costs were identified. Incremental cost effectiveness ratio (ICER) was calculated to compare the cost-effectiveness between DOACs and warfarin.

RESULTS

The direct medical cost of stroke was MYR 11,669,414.83 (n = 3689). AF-related stroke cases had higher median cost of MYR 2839.73 (IQR 2269.79-3101.52). Regression analysis showed that stroke type (AF versus non-AF stroke) (p = 0.013), stroke severity (p = 0.010) and discharge status (p < 0.001) significantly influenced stroke costs. DOACs were cost-effective compared to warfarin with an ICER of MYR 19.25.

CONCLUSIONS

The direct medical cost of stroke is substantial, with AF-stroke having a higher median cost per stroke care. DOACs were cost effective in the treatment of AF-related stroke in UKMMC.

Comparison of hospital length of stay of acute ischemic stroke patients with non-valvular atrial fibrillation started on rivaroxaban or warfarin treatment during hospitalization

OBJECTIVE

To compare the hospital length of stay (LOS) between rivaroxaban and warfarin in hospitalized acute stroke patients with non-valvular atrial fibrillation (NVAF) in Japan.

METHODS

This was a retrospective, observational study using a Japanese hospital claims database. Data of NVAF patients who were started on oral anticoagulant (OAC) treatment during hospitalization were extracted and LOS-OAC (period from the initiation of index OAC therapy to the end of hospitalization or censoring date) and medical costs were compared between rivaroxaban and warfarin treatments. To compare LOS-OAC, a time-to-event analysis was performed using the Kaplan-Meier method. The analysis period was from April 2012 to December 2015.

RESULTS

This study included 773 rivaroxaban users and 1077 warfarin users. After the propensity score matching, 546 patients for each treatment constituted the matched cohorts. Although the rivaroxaban users had a similar LOS-OAC to warfarin users (median, 18 vs. 19 days, p = .657) in the matched cohorts, 3 days shorter LOS-OAC was observed in the rivaroxaban users (median, 17 vs. 20 days, p = .043) after IPTW adjustment. Subgroup analysis by the severity of stroke after IPTW adjustment demonstrated that rivaroxaban users had a shorter LOS-OAC than warfarin users among patients with mild (median, 10 vs. 14 days) and moderate stroke severity (22 vs. 27 days), but not among those with severe stroke severity (26 vs. 25 days).

LIMITATIONS

It is not possible to say that the only confounder was stroke severity and therefore other possible known and unknown confounders could not be ruled out.

CONCLUSIONS

The rivaroxaban users had a 3-day shorter LOS-OAC after IPTW-adjustment. Using rivaroxaban was associated with 4-5 days shorter LOS-OAC than using warfarin in patients with mild or moderate stroke, though treatment selection did not have a large impact in patients with severe stroke.

Cardiovascular- and Bleeding-Related Hospitalization Rates With Edoxaban Versus Warfarin in Patients With Atrial Fibrillation Based on Results of the ENGAGE AF–TIMI 48 Trial

Background

The ENGAGE AF–TIMI 48 trial (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation–Thrombolysis in Myocardial Infarction 48) demonstrated noninferiority of once-daily 60 mg (30 mg dose-reduced) edoxaban compared with warfarin for prevention of stroke/systemic embolism in patients with atrial fibrillation. No previous analysis has explored the impact of treatment with edoxaban versus warfarin on rates of hospitalizations.

Methods

Detailed healthcare resource utilization data from ENGAGE AF–TIMI 48 for the 14 024 randomized patients who received at least one dose of study drug were used to compare the rates of bleeding- and cardiovascular-related hospitalizations for edoxaban versus warfarin. Hospitalization rates were calculated for each treatment group, and relative rates were estimated using Poisson regression. The influence of patient characteristics on the impact of edoxaban versus warfarin was evaluated through the inclusion of interaction terms.

Results

The overall rate of cardiovascular- or bleeding-related hospitalization was significantly lower for edoxaban than warfarin (relative rate [RR], 0.91 [95% CI, 0.85–0.97], P =0.003). Rates of hospitalizations for cardiovascular reasons (RR, 0.91 [95% CI, 0.85–0.97], P =0.004), stroke (RR, 0.80 [95% CI, 0.72–0.88], P <0.0001), and for each stroke subtype (ischemic: RR, 0.89 [95% CI, 0.81–0.99], P =0.03; hemorrhagic: RR, 0.60 [95% CI, 0.54–0.68], P <0.0001) were also lower for edoxaban. Notably, significantly greater reductions with edoxaban versus warfarin were seen for ischemic stroke–related hospitalizations in vitamin K antagonist naive patients and patients with CHADS 2 scores 4 to 6, previous stroke or transient ischemic attack, age ≥75, and no previous coronary artery disease. For nonstroke bleeding–related hospitalizations, greater reductions with edoxaban were seen in vitamin K antagonist naive patients, patients with CHADS 2 scores 4 to 6, and patients with moderate renal dysfunction.

Conclusions

Edoxaban 60 mg (30 mg dose-reduced) was associated with a significantly lower overall rate of cardiovascular- or bleeding-related hospitalization and significant reductions in the subcategories of cardiovascular-related, stroke-related, bleed-related, and nonstroke cardiovascular–related hospitalizations, when compared with warfarin. These results suggest the potential for cost offsets with edoxaban, with even greater reductions in higher-risk patients.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT00781391

Hospitalization period and direct medical cost in patients using warfarin or novel oral anti-coagulants after a cerebral embolism

Background Warfarin has been used in Japan for a long time in patients after cerebral embolism to prevent recurrence. Recently, several novel oral anti-coagulants (NOACs) have been approved for use and are gradually replacing warfarin. However, it remains unclear whether warfarin and other NOACs differ from each other with respect to drug costs and length of stay (LOS) during treatment in Japan. Objective To assess differences in LOS and direct medical cost between patients after cerebral embolism treated with warfarin and those treated with NOACs. Setting Thirteen acute care hospitals in Japan. Method For hospitalized patients with cerebral embolisms who were treated with NOACs and/or warfarin between April 2012 and March 2014, we assessed LOS for patients with warfarin and NOAC using log-rank test, and stratified proportional hazard regression. Also, we assess direct medical cost using paired-t test. Main Outcome measure LOS and medical cost after first treatment with warfarin and NOAC. Results The median LOS for NOACs-treated patients was 12.5 days and that for warfarin treated patients was 19.0 days while the corresponding mean medical costs were USD 7151 ± 6228 [JPY 736,546 ± 641,437] and USD 8950 ± 5891 [JPY 921,830 ± 606,765]. The drug cost for NOACs-treated patients was higher but costs for laboratory-test and hospitalization were lower than those for warfarin-treated patients. Conclusions For NOAC-treated patients, LOS was shorter, and medical cost during hospitalization tended to be lower than those for warfarin-treated patients, whereas NOACs prices were higher than warfarin price.

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.

Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation

Vitamin K antagonists (VKAs) have been the mainstay of anticoagulation therapy for more than 50 years. VKAs are mainly used for the prevention of stroke in patients with atrial fibrillation (AF) and the treatment and secondary prevention of venous thromboembolism. In the past 5 years, four new agents-the direct factor Xa inhibitors apixaban, edoxaban and rivaroxaban and the direct thrombin inhibitor dabigatran [collectively known as direct oral anticoagulants (DOACs) or non-VKA oral anticoagulants]-have been approved for these and other indications. Despite these new treatment options, the VKA warfarin currently remains the most frequently prescribed oral anticoagulant. The availability of DOACs provides an alternative management option for patients with AF, especially when the treating physician is hesitant to prescribe a VKA owing to associated limitations, such as food and drug interactions, and concerns about bleeding complications. Currently available real-world evidence shows that DOACs have similar or improved effectiveness and safety outcomes compared with warfarin. Treatment decisions on which DOAC is best suited for which patient to maximize safety and effectiveness should take into account not only clinically relevant patient characteristics but also patient preference. This article reviews and highlights real and perceived implications of VKAs for the prevention of stroke in patients with non-valvular AF, with specific reference to their strengths and weaknesses compared with DOACs.

Shortened hospital length of stay and lower costs associated with rivaroxaban in patients with pulmonary embolism managed as observation status

BACKGROUND

Unlike rivaroxaban, treatment of patients with pulmonary embolism (PE) with warfarin requires parenteral bridging and coagulation monitoring that may prolong length-of-stay (LOS) and increase hospital costs.

AIMS

The aim of this study was to compare LOS, hospital costs and readmissions in PE patients managed through observation stays treated with rivaroxaban or parenterally bridged warfarin.

METHODS

Premier Hospital claims data from November 2012 to March 2015 were used to identify patients with a primary diagnosis code for PE managed through an observation stay and with ≥1 claim for a PE-related diagnostic test on day 0-2. Rivaroxaban users, allowing ≤2 days of prior parenteral therapy, were 1:1 propensity-score matched to patients receiving parenterally bridged warfarin. LOS, the proportion of encounters lasting >2 midnights, total hospital costs of the index visit and risk of readmission for venous thromboembolism (VTE) or major bleeding during the same month or 2 months subsequent to the index event were compared between matched cohorts using multivariable regression.

RESULTS

A total of 312 rivaroxaban users were matched to 312 patients receiving parenterally bridged warfarin. Rivaroxaban was associated with an average of 0.27-day shorter LOS, a 52% decreased odds of an encounter lasting >2 midnights and a $403 mean reduction in costs vs parenterally bridged warfarin (P≤.002 for all). The readmission rate for VTE during the same or subsequent 2 months following the index PE was similar between cohorts (P=.75). No patient in either cohort was readmitted for major bleeding.

CONCLUSION

Rivaroxaban was associated with shortened LOS and lowered cost vs parenterally bridged warfarin in PE observation stay patients, without increases in the short-term rate of complications or readmission.

Rivaroxaban versus Heparin Bridging to Warfarin Therapy: Impact on Hospital Length of Stay and Treatment Costs for Low-Risk Patients with Pulmonary Embolism

STUDY OBJECTIVE

To compare hospital length of stay (LOS) and hospital treatment costs in low-risk patients with pulmonary embolism (PE) anticoagulated with rivaroxaban or heparin bridging to warfarin therapy.

DESIGN

Retrospective review of electronic health records and hospital billing records.

SETTING

Large, teaching hospital in the northeastern United States.

PATIENTS

One hundred ninety adults with objectively confirmed acute PE presenting to the emergency department between November 1, 2012, and May, 12, 2015, who were classified as low risk of early mortality and received anticoagulation with either rivaroxaban or heparin (i.e., unfractionated heparin or low-molecular-weight heparin) bridging to warfarin therapy were included in the analysis. Patients were identified as low risk by at least one of the following prediction rules: simplified Pulmonary Embolism Severity Index (sPESI; 115 patients), Hestia criteria (87 patients), or In-hospital Mortality for Pulmonary Embolism using Claims Data (IMPACT; 108 patients); these were not mutually exclusive, as patients could be classified as low risk by more than one risk stratification tool.

MEASUREMENTS AND MAIN RESULTS

We divided low-risk patients identified by each prediction rule into two cohorts: those receiving rivaroxaban (allowing ≤ 2 days of prior heparin use) or heparin bridging to warfarin therapy. The primary end points for this study were LOS (number of days from the patient's arrival at our institution until discharge) and total hospital treatment costs (our institution's actual costs to provide treatment) for the index PE hospital encounter. Using multivariable generalized linear model regression (gamma-distributed error and log-link), we estimated differences in LOS and hospital costs (in 2015 U.S. dollars) between the two cohorts after covariate adjustment. Rivaroxaban was associated with significantly shorter adjusted LOS (range -2.1 to -4.3 days) and significantly lower index hospital costs (range -$3835 to -$7094) versus heparin bridging to warfarin, regardless of the prediction rule used to identify low-risk patients.

CONCLUSION

Among low-risk PE patients identified by using sPESI, Hestia or IMPACT, rivaroxaban was associated with significantly shorter LOS and lower hospital treatment costs versus heparin bridging to warfarin.

Comparison of hospital length of stay and hospitalization costs among patients with non-valvular atrial fibrillation treated with apixaban or warfarin: An early view

OBJECTIVE

To quantify and compare hospital length of stay (LOS) and costs between hospitalized non-valvular atrial fibrillation (NVAF) patients treated with either apixaban or warfarin via a large claims database.

METHODS

Adult patients hospitalized with AF were selected from the Premier Perspective Claims Database (01JAN2013-31MARCH2014). Patients with evidence of valvular heart disease, valve replacement procedures, or pregnancy during the index hospitalization were excluded. Patients treated with apixaban or warfarin during hospitalization were identified. Propensity score matching (PSM) was performed to control for baseline imbalances between patients treated with apixaban or warfarin. Primary outcomes were hospital LOS (days), post-medication administration LOS, and index hospitalization costs, and were compared using paired t-tests in the matched sample.

RESULTS

Before PSM, 2894 apixaban and 124,174 warfarin patients were identified. Patients treated with warfarin were older and sicker compared to those treated with apixaban. After applying PSM, a total of 2886 patients were included in each cohort, and baseline characteristics were balanced. The mean (standard deviation [SD] and median) hospital LOS was significantly (p = 0.002) shorter for patients treated with apixaban for 5.1 days (5.7 and 3) compared to warfarin for 5.5 days (4.8 and 4). The trend appeared consistent in the hospital LOS from point of apixaban or warfarin administration to discharge (4.5 vs 4.7 days, p = 0.051). Patients administered apixaban incurred significantly lower hospitalization costs compared to those administered warfarin ($11,262 vs $12,883; p < 0.001).

CONCLUSIONS

Among NVAF patients, apixaban treatment was associated with significantly shorter hospital LOS and lower costs when compared to warfarin treatment.

Vitamin K antagonist use: evidence of the difficulty of achieving and maintaining target INR range and subsequent consequences

Vitamin K antagonists (VKAs) are effective oral anticoagulants that are titrated to a narrow therapeutic international normalized ratio (INR) range. We reviewed published literature assessing the impact of INR stability - getting into and staying in target INR range - on outcomes including thrombotic events, major bleeding, and treatment costs, as well as key factors that impact INR stability.

A time in therapeutic range (TTR) of ≥65 % is commonly accepted as the definition of INR stability. In the real-world setting, this is seldom achieved with standard-of-care management, thus increasing the patients’ risks of thrombotic or major bleeding events. There are many factors associated with poor INR control. Being treated in community settings, newly initiated on a VKA, younger in age, or nonadherent to therapy, as well as having polymorphisms of CYP2C9 or VKORC1, or multiple physical or mental co-morbid disease states have been associated with lower TTR. Clinical prediction tools are available, though they can only explain <10 % of the variance behind poor INR control.

Clinicians caring for patients who require anticoagulation are encouraged to intensify diligence in INR management when using VKAs and to consider appropriate use of newer anticoagulants as a therapeutic option.

Costs of hospital visits among patients with deep vein thrombosis treated with rivaroxaban and LMWH/warfarin

BACKGROUND

For many years, the standard of care for patients diagnosed with deep vein thrombosis (DVT) has been low-molecular-weight heparin (LMWH) bridging to an oral Vitamin-K antagonist (VKA). The availability of new non-VKA oral anticoagulants (NOAC) agents as monotherapy may reduce the likelihood of hospitalization for DVT patients.

OBJECTIVE

To compare hospital visit costs of DVT patients treated with rivaroxaban and LMWH/warfarin.

METHODS

A retrospective claim analysis was conducted using the MarketScan Hospital Drug Database for care provided between January 2011 and December 2013. Adult patients using rivaroxaban or LMWH/warfarin with a primary diagnosis of DVT during the first day of a hospital visit were identified (i.e., index hospital visit). Based on propensity-score methods, historical LMWH/warfarin patients (i.e., patients who received LMWH/warfarin before the approval of rivaroxaban) were matched 4:1 to rivaroxaban patients. The hospital-visit cost difference between these groups was evaluated for the index hospital visit, as well as for total hospital-visit costs (i.e., including index and subsequent hospital visit costs).

RESULTS

All rivaroxaban users (n = 134) in the database were well-matched with four LMWH/warfarin users (n = 536). The mean hospital-visit costs were $5257 for the rivaroxaban cohort and $6764 in the matched-cohort of patients using LMWH/warfarin. The $1508 cost difference was statistically significant between cohorts (95% CI = [-$2296; -$580]; p-value = 0.002). Total hospital-visit costs were lower for rivaroxaban compared to LMWH/warfarin users within 1, 2, 3, and 6 months after index visit (significantly lower within 1 and 3 months, p-values <0.05) LIMITATIONS: Limitations were inherent to administrative-claims data, completeness of baseline characteristics, adjustments restricted to observational factors, and lastly the sample size of the rivaroxaban cohort.

CONCLUSION

The availability of rivaroxaban significantly reduced the costs of hospital visits in patients with DVT treated with rivaroxaban compared to LMWH/warfarin.

Length of Stay Comparison between Rivaroxaban and Warfarin in the Treatment of Pulmonary Embolism: Results from a Real-World Observational Cohort Study

Background. Trials have shown that novel oral anticoagulants may decrease length of stay versus warfarin. A comparison of length of stay in the treatment of pulmonary embolism (PE) has not been performed outside post hoc analysis of a large clinical trial. Objective. To evaluate if rivaroxaban decreases length of stay compared to warfarin plus enoxaparin in the treatment of PE. Methods. This was a multicenter, retrospective, observational cohort study. Patients were identified based on discharge diagnosis of PE and were excluded if they received anticoagulants prior to admission and had additional indications for anticoagulation or reduced creatinine clearance. The primary endpoint was length of stay. Secondary endpoints included time from initial dose of oral anticoagulant to discharge and length of stay comparison between subgroups. Results. Inclusion criterion was met by 158 patients (82 warfarin, 76 rivaroxaban). The median length of stay was 4.5 days (interquartile range [IQR], 2.7, 5.9) in the warfarin group and 1.8 days (IQR, 1.2, 3.7) in the rivaroxaban group (P < 0.001). Time interval from first dose of oral anticoagulant to discharge was shorter with rivaroxaban (P < 0.001). Conclusions. Patients given rivaroxaban had decreased length of stay versus those given warfarin plus enoxaparin for the treatment of PE.

Burden of stroke and other cardiovascular complications in patients with atrial fibrillation hospitalized in France

AIMS

Atrial fibrillation (AF) is associated with numerous cardiovascular complications. We sought to estimate the annual burden of cardiovascular complications in AF patients in French hospitals.

METHODS AND RESULTS

All AF patients hospitalized in France in 2012 were identified from the national public/private hospital database. Comorbid conditions and medical histories were documented using medical records dating back 5 years. Reasons for hospitalization, type of admission (emergency or otherwise), length of stay, rehabilitation transfers, and death at discharge were identified and costs of acute and rehabilitation care determined (2012 Euros). In total, 533 044 AF patients (mean age ± SD 78.0 ± 11.4 years, 47.1% women) were hospitalized in 2012 for any reason. Hospitalizations were cardiovascular-related in 267 681 patients [22.5% cardiac dysrhythmia, 18.3% heart failure, 7.1% vascular/ischaemic diseases, 6.9% stroke/transient ischaemic attack (TIA)/systemic embolism (SE), and 1.3% haemorrhages]. Patients with stroke/TIA/SE had higher rates of emergency admission (68.1%), transfer to rehabilitation unit (28.1%), and death at discharge (13.7%) than those with other cardiovascular complications, with the exception of haemorrhages, where emergency admission rates were similar. They also had longer mean lengths of stay (12.6 ± 13.2 days for acute care and 46.8 ± 42.5 days for rehabilitation). The annual total cost (acute care and rehabilitation) for all hospitalized cardiovascular events was €1.94 billion, of which heart failure represented €805 million, vascular/ischaemic diseases €386 million, stroke €362 million, cardiac dysrhythmia €341 million, and haemorrhage €48 million.

CONCLUSION

Half a million patients with AF were hospitalized in France in 2012. Cardiovascular-related hospitalizations involved half of these admissions, for a global burden of almost €2 billion, equivalent to 2.6% of total expenditure in French hospitals. Among these hospitalizations stroke/TIA/SE represented costly, but potentially preventable, complications.

Comparison of hospital length of stay between hospitalized non-valvular atrial fibrillation patients treated with either apixaban or warfarin

BACKGROUND

Hospital length of stay (LOS) is an important cost driver for hospitals and payers alike. Hospitalized non-valvular atrial fibrillation (NVAF) patients treated with apixaban may have shorter LOS than those treated with warfarin because of the absence of need for INR monitoring in apixaban. Thus, this study compared hospital LOS between hospitalized NVAF patients treated with either apixaban or warfarin.

METHODS

This was a retrospective, observational cohort study based on a large US database including diagnosis, procedure, and drug administration information from >600 acute-care hospitals. Patients selected for study were aged ≥18 years and had a hospitalization record with an ICD-9-CM diagnosis code for atrial fibrillation (AF) in any position from 1 January 2013 to 28 February 2014 (index hospitalization). Patients with diagnoses indicative of rheumatic mitral valvular heart disease or a valve replacement procedure during index hospitalization were excluded. Patients were required to have been treated with either apixaban or warfarin, and not treated with rivaroxaban or dabigatran, during index hospitalization. Apixaban patients were propensity score (PS) matched to warfarin patients at a 1:1 ratio, using patient demographic/clinical and hospital characteristics. The study outcome was hospital LOS, calculated as discharge date minus admission date; a sensitivity analysis calculated hospital LOS as discharge date minus first anticoagulant administration date. Sub-analyses were conducted among patients with a primary diagnosis of AF.

RESULTS

The study included 832 apixaban patients matched to 832 warfarin patients. Mean [standard deviation (SD)] and median hospital LOS were significantly (p < 0.001) shorter in apixaban patients (4.5 [4.2] and 3 days) than in warfarin patients (5.4 [5.0] and 4). Results were consistent in the sensitivity and sub-analyses.

CONCLUSIONS

Among NVAF patients, apixaban treatment was associated with shorter hospital LOS when compared with warfarin treatment. These findings may have important clinical and economic implications for hospitals, payers, and patients.

Rates of hospitalization among patients with deep vein thrombosis before and after the introduction of rivaroxaban

BACKGROUND

Compared to warfarin, the non-vitamin K antagonist oral anticoagulant rivaroxaban may have advantages in treating patients with venous thromboembolism, because injectable bridging therapy and routine laboratory monitoring are not required. The objective of this study was to compare the rate of hospitalization in patients treated with rivaroxaban after its introduction with what it would have been before the introduction of rivaroxaban.

METHODS

A retrospective claims analysis was conducted using the MarketScan Hospital Drug Database from January 2011 to December 2013. Adult patients with a primary diagnosis of deep vein thrombosis (DVT) treated with rivaroxaban or low-molecular-weight heparin (LMWH) bridged to warfarin during the first day of an evaluation at a hospital were identified. Based on propensity-score methods, historical LMWH/warfarin patients (i.e., patients who received LMWH/warfarin before the approval of rivaroxaban) were matched 4:1 to rivaroxaban patients, and the rates of hospitalization were compared.

RESULTS

All rivaroxaban-treated patients (n = 134) in the database were well matched with four historical LMWH/warfarin-treated patients (n = 536). Among the rivaroxaban cohort, 60% of the patients were admitted to the hospital, compared to 82% of the historical patients treated with LMWH/warfarin in the matched cohort. The difference was statistically significant and corresponded to a 27% reduction in hospital admissions (rate ratio [95% confidence interval]: 0.73 [0.62-0.84]). Hospital admission rates adjusted for time-trend analyses also led to similar results.

CONCLUSION

The availability of rivaroxaban significantly reduced the hospitalization rate in patients with DVT treated with rivaroxaban compared to what it would have been if only LMWH/warfarin were available.

Effects of rivaroxaban versus warfarin on hospitalization days and other health care resource utilization in patients with nonvalvular atrial fibrillation: an observational study from a cohort of matched users

PURPOSE

Compared with warfarin, the new target-specific oral anticoagulant agents may have advantages, such as shorter hospital length of stay, in patients with nonvalvular atrial fibrillation (NVAF). The objective of the present study was to assess, among patients with NVAF, the effects of rivaroxaban versus warfarin on the number of hospitalization days and other health care resource utilization in a cohort of rivaroxaban users and matched warfarin users.

METHODS

Data from health care claims dated from May 2011 to December 2012 from the Humana database were analyzed. Adult patients newly initiated on treatment with rivaroxaban or warfarin, with ≥2 diagnoses of AF (ICD-9-CM code 427.31), and without valvular AF were identified. Based on propensity score methods, warfarin recipients were matched 1:1 to rivaroxaban recipients. The end of the observation period was defined as the end of data availability, the end of insurance coverage, death, the date of a switch to another anticoagulant agent, or day 14 of treatment nonpersistence. The total number of hospitalization days and other health care resource utilization parameters (numbers of hospitalizations, emergency department [ED] visits, and outpatient visits) were evaluated using the method by Lin et al.

FINDINGS

Matches for all rivaroxaban recipients were found, and the characteristics of the matched groups (n = 2253 per group) were well balanced. The mean age of both cohorts was 74 years; 46% were female. The estimated mean total numbers of hospitalization days were significantly less in rivaroxaban users compared with those in warfarin users (all-cause, 2.71 vs 3.87 days [P = 0.032]; AF-related, 2.11 vs 3.02 days [P = 0.014]). The numbers of outpatient visits were also significantly less (all-cause, 25.26 vs 35.79 visits [P < 0.001]; AF-related, 5.48 vs 9.06 visits [P < 0.001]). Rivaroxaban users had a lesser estimated mean number of all-cause hospitalizations compared with warfarin users (0.55 vs 0.73; P = 0.084), and a significantly lesser estimated mean number of AF-related hospitalizations (0.40 vs 0.57; P = 0.022). The difference in the estimated mean numbers of all-cause ED visits was not statistically significant between the rivaroxaban and warfarin users.

IMPLICATIONS

In this study conducted in clinical practice, the estimated mean numbers of hospitalization days, outpatient visits, and AF-related hospitalizations associated with rivaroxaban were significantly less than were those associated with warfarin in these patients with NVAF. The corresponding estimated difference in all-cause ED visits was not statistically significant.

Daily costs of hospitalization in non-valvular atrial fibrillation patients treated with anticoagulant therapy

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac rhythm disturbance in the US, with an estimated prevalence of 2.7-6.1 million persons in 2010.

OBJECTIVE

This study evaluates the progression of daily hospitalization costs among non-valvular atrial fibrillation (NVAF) patients treated with anticoagulant therapy.

METHODS

A claims analysis was conducted with Premier Perspective Comparative Hospital Database records from January 2009-March 2013. Patients of 18 years or older who were diagnosed with NVAF and used anticoagulant therapy were studied. Treatment patterns and mean daily costs of hospitalization per patient as well as total costs of hospitalization were reported. Comparisons of mean daily costs with those of the previous day were presented to identify statistical cost differences between hospitalization days.

RESULTS

A total of 375,560 patients were identified; 67,017 with AF as admitting/primary diagnosis, and 308,543 with AF as a secondary diagnosis. The mean age of the overall population, primary AF diagnosis cohort, and secondary AF diagnosis cohort was 73.8, 67.9, and 75.0 years, while their proportion of females was 46.3%, 45.6%, and 46.5%, respectively. The mean length of stay was 6.8 days, 3.7 days, and 7.5 days for the overall population, the primary AF diagnosis cohort, and the secondary AF diagnosis cohort, respectively. For all cohorts, mean daily costs stabilized on the third day (overall population: $2103; primary AF diagnosis cohort: $1505; secondary AF diagnosis cohort: $2208).

LIMITATIONS

Claims data may have contained inaccuracies or omissions in coded procedures, diagnoses, or pharmacy claims.

CONCLUSION

The study showed that daily hospitalization costs for NVAF patients stabilized on the third day of hospitalization and that any reduction or prolongation in hospital length of stay could have a significant impact on the cost burden associated with AF.

Pharmacy quality alliance measure: adherence to non-warfarin oral anticoagulant medications

BACKGROUND

The Pharmacy Quality Alliance (PQA) recently endorsed adherence to non-warfarin anticoagulant agents as a new performance measure, but the Medicare Part D Star Ratings program has not yet adopted the measure. The current study aims to assess the real-world adherence to medication of patients who used non-vitamin-K-antagonist oral anticoagulants (NOACs) based on the PQA's adherence measure.

METHODS

Healthcare claims from the Humana database during the year of 2013 were analyzed. Patients older than 18 with ≥2 dispensings of NOAC agents, at least 180 days apart between two NOAC dispensings in 2013 (a criterion to include chronic users), with ≥60 days of supply, and ≥180 days of continuous enrollment prior to the index NOAC were identified. The PQA measure on the index therapy was calculated as the percentage of patients who had a proportion of days covered (PDC) ≥0.8 during their follow-up.

RESULTS

A total of 9948 NOAC users (rivaroxaban: n = 4194, dabigatran: n = 5489, apixaban: n = 265) were identified. For rivaroxaban users, the proportion of patients with a PDC ≥0.8 (PQA measure) at 75.4% was significantly higher compared to dabigatran users (67.6%; P < 0.001) and higher compared to apixaban users (70.6%; P = 0.076). When allowing switches to other NOAC agents in the PQA measure, rivaroxaban users had a significantly higher PQA measure at 76.9% compared to both dabigatran (72.9%; P < 0.001) and apixaban (71.3%; P = 0.037) users. Multivariate logistic regression analyses corroborated the findings that rivaroxaban had a significantly higher adherence compared to the other NOAC agents.

LIMITATIONS

Claims data may have contained inaccuracies, possible change in patterns over time, and the impossibility of knowing whether all supplied tablets were taken.

CONCLUSION

Based on the PQA's adherence measure, rivaroxaban users were found to have a higher adherence compared to dabigatran and apixaban users. Healthcare providers may want to consider the impact of anticoagulation selection on their ability to achieve quality metrics.

Daily hospitalization costs in patients with deep vein thrombosis or pulmonary embolism treated with anticoagulant therapy

BACKGROUND

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), affects about 900,000 persons in the United States each year.

OBJECTIVES

To quantify the progression of daily hospitalization costs among DVT and PE patients.

PATIENTS/METHODS

A retrospective claims analysis was conducted from 01/01/2009 to 03/01/2013 using the Premier Perspective Comparative Hospital Database. Patients≥ 18years of age with an admitting/primary diagnosis of DVT or PE and receiving anticoagulant therapy were identified. Treatment patterns, mean daily costs, and total hospitalization costs were reported for the DVT and PE populations. Comparisons of mean daily costs with those of the previous day were presented to identify statistical cost differences between hospitalization days.

RESULTS

A total of 28,953 and 35,550 patients were identified with a diagnosis of DVT and PE, respectively. The daily costs were at their highest during the first three days for DVT patients at $2,321, $1,875, and $1,558, respectively. Similar results were found for PE patients with costs at their highest in the first three days, at $2,981, $2,034, and $1,564, respectively. Among the DVT and PE populations, mean daily costs were $1,594 and $1,735, respectively, and daily hospitalization costs became stable on the third day of the hospitalization (standardized differences<10%).

CONCLUSIONS

Daily hospitalization costs of patients with an admitting/primary diagnosis of DVT or PE were high in the first days and became stable on the third day. It was further suggested that any change in the LOS could significantly affect hospitalization costs.

Is rivaroxaban associated with lower inpatient costs compared to warfarin among patients with non-valvular atrial fibrillation?

BACKGROUND

Warfarin has been the mainstay treatment used by patients with a moderate-to-high risk of stroke due to non-valvular atrial fibrillation (NVAF). Unlike rivaroxaban, laboratory monitoring to allow the attainment of the prothrombin time international normalized ratio goal is required with warfarin, thereby potentially increasing a patient's hospitalization costs.

OBJECTIVE

To compare hospitalization costs between hospitalized NVAF patients using rivaroxaban versus warfarin in a real-world setting.

METHODS

A retrospective claims analysis was conducted using the Premier Perspective Comparative Hospital Database from November 2010 to September 2012. The study included adult patients hospitalized for NVAF after November 2011. Patients using rivaroxaban during hospitalization were matched with up to four warfarin users by propensity score analyses. Hospitalization costs were compared between the matched cohorts using generalized estimating equations. A sub-analysis was performed for patients who were first administered their treatment on day three or later of their hospital stay. Sensitivity analyses were conducted on matched cohorts with a primary diagnosis of AF.

RESULTS

The matched cohorts' (2809 rivaroxaban and 11,085 warfarin users) characteristics were well balanced. The mean age of cohorts was 71 years and 49% of patients were female. The average hospitalization cost of rivaroxaban users was $11,993 compared to $13,255 for warfarin users. The cost difference was significantly lower by $1284 (P < 0.001). Patients who were administered rivaroxaban treatment on day three or after incurred significantly lower hospitalization costs (cost difference: $4350; P < 0.001) compared to warfarin users. Rivaroxaban users with a primary diagnosis of AF also had significantly lower costs compared to warfarin users.

LIMITATIONS

These included possible inaccuracies or omissions in diagnoses, completeness of baseline characteristics, and a study population that included patients newly initiated on and patients who continued anticoagulant therapy.

CONCLUSION

Hospitalization costs for rivaroxaban were significantly lower than those for warfarin in NVAF patients treated with rivaroxaban.

Hospital length of stay of nonvalvular atrial fibrillation patients who were administered Rivaroxaban versus Warfarin with and without pretreatment parenteral anticoagulants therapies

BACKGROUND

Warfarin has been the only anticoagulant used for decades to prevent strokes and systemic embolisms in nonvalvular atrial fibrillation (NVAF) patients. Compared with rivaroxaban, warfarin has a narrow therapeutic range and many genetic and food-drug interactions that could potentially prolong hospital length of stay (LOS).

OBJECTIVE

To compare hospital LOS between NVAF patients who were administered rivaroxaban versus warfarin with and without pretreatment of parenteral anticoagulant agents in a population of rivaroxaban-treated patients.

METHODS

A retrospective matched-cohort analysis was conducted using the Premier Perspective Comparative Hospital Database from November 2010 to September 2012. Adult patients were included in the study if they had a hospitalization for NVAF. Rivaroxaban users were matched with up to 4 warfarin users based on propensity score analyses. Patients with and without pretreatment of parenteral anticoagulant agents were evaluated separately. Hospital LOS was compared between treatment groups using generalized estimating equations.

RESULTS

The matched cohorts' characteristics were well balanced. Among the matched rivaroxaban and warfarin users who were administered parenteral agents, the mean age of the cohorts was 70 years and 47% of patients were female, whereas in the sample of patients who were not administered parenteral agents, the mean age was 72 years and 50% of patients were female. In the sample of patients who were administered parenteral agents, rivaroxaban users had significantly shorter hospital LOS (LOS difference: 1.38 days, P < 0.001) compared with warfarin users among rivaroxaban-treated patients. No significant difference in LOS was found in the sample of patients who were not administered parenteral anticoagulant agents (P = 0.169).

CONCLUSION

In the study sample of NVAF patients who were administered parenteral anticoagulant agents, rivaroxaban was associated with a significantly shorter hospital LOS compared with warfarin. The difference in LOS was not statistically significant in the sample of patients who were not administered parenteral anticoagulant agents.