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

Rivaroxaban treatment for young patients with pulmonary embolism (Review)

Pulmonary embolism (PE) is a serious, life-threatening condition that affects young populations (>18 and <50 years old, according to most literature reviews) with improved recognition of its clinical manifestations and the widespread use of sensitive imaging techniques, PE is increasingly diagnosed in younger patients. At present, there is limited understanding of the clinical features and adequate anticoagulant treatment options for this population. Most studies to date have yet to demonstrate significant differences in PE pathophysiology or symptoms between young and elderly patients. Although the overall incidence of PE is lower in young populations compared with elderly patients, important risk factors also apply for young patients. Hereditary thrombophilia is common and is a major cause of PE in younger patients. Immobilization, trauma, obesity, smoking and infection are also becoming increasingly frequent in young patients with PE. Among female patients, oral contraceptive use, pregnancy and postpartum status are predominant risk factors underlying PE. Rivaroxaban is a direct oral anticoagulant with a rapid onset of action that is associated with less drug-drug interactions compared with other therapies. Because the drug is administered at fixed doses with no requirement for routine coagulation monitoring, it is becoming an attractive option for anticoagulation treatment in young patients with PE. Therefore, the present literature review focuses on the clinical characteristics of PE and rivaroxaban therapy in younger patients.

Current status of rivaroxaban in elderly patients with pulmonary embolism (Review)

Acute pulmonary embolism (PE) occurs with a high incidence rate in elderly patients, demonstrating complex clinical manifestations, as well as a difficult anticoagulant treatment strategy. Currently, there is limited understanding of the selection criteria for anticoagulant treatment in elderly patients with PE. In fact, the vitamin K antagonist warfarin, a commonly prescribed anticoagulant, has multiple disadvantages, including a narrow therapeutic range, unpredictable pharmacokinetics, multiple food and drug interactions and genetic polymorphisms resulting in poor response to this therapy; therefore, routine laboratory monitoring is required. Most elderly patients with PE fail to adhere to the treatment regimen or even discontinue it, and clinicians are equally hesitant to initiate oral anticoagulants in elderly patients with PE. This leads to a dilemma regarding the use of anticoagulation therapies and a worse prognosis for the patients. Rivaroxaban, a direct Xa factor inhibitor, has demonstrated considerable practical and clinical advantages, exhibits fast-start action pharmacokinetic and pharmacodynamic characteristics, and has an enhanced predictable anticoagulant effect with fewer drug-drug interactions. Based on randomized controlled trials and real-world clinical practice, rivaroxaban has also been recognized as a safe and effective anticoagulant, and these advantages have improved the therapeutic compliance of elderly patients with PE. Thus, this review focused on the current status of rivaroxaban treatment for elderly patients with PE, and described its significance in changing the current anticoagulation treatment regimens for patients. It is expected that rivaroxaban will become a good choice for the treatment of PE in elderly patients.

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.

Development and Evaluation of a Pharmacist-Driven Screening Tool to Identify Patients Presenting to the Emergency Department Who Are Eligible for Outpatient Treatment of Deep Vein Thrombosis

BACKGROUND

Deep vein thrombosis (DVT) is a critical and costly health issue. Treatment in the outpatient setting is preferred compared to the inpatient setting. However, there is a lack of evidence regarding how best to identify patients who are ideal for outpatient DVT treatment.

OBJECTIVE

To design and evaluate a pharmacist-driven screening tool for the identification of patients presenting to the emergency department (ED) at a community hospital with DVT who are appropriate for outpatient treatment.

METHODS

This study was conducted in sequential phases: compilation and vetting of screening criteria, descriptive evaluation of criteria through retrospective chart review, and quantification of potential cost savings by avoiding admissions. Criteria were collected via literature search and assembled into a screening tool, which was applied retroactively to a cohort of ED patients admitted with DVT diagnosis.

RESULTS

A screening tool was developed with multidisciplinary input and consisted of 5 categories with individual patient and disease state criteria. The majority (91%) of patients reviewed would not have qualified for outpatient DVT treatment based on the retrospective application of the screening tool. The most common disqualification criteria category was high risk of bleeding/clotting (n = 81), and the most frequently represented parameter within that category was antithrombotic therapy prior to admission (n = 53).

CONCLUSION

A screening tool may not be the most efficient method for health-care practitioners such as pharmacists to identify ED patients appropriate for outpatient management of DVT. Other avenues should be explored for improving the cost-effective management of these 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.

Effectiveness and Safety of Apixaban versus Warfarin as Outpatient Treatment of Venous Thromboembolism in U.S. Clinical Practice

In the AMPLIFY clinical trial, apixaban was non-inferior to warfarin plus subcutaneous enoxaparin bridge therapy in the treatment of acute venous thromboembolism (VTE) and was associated with significantly less bleeding. This study evaluated their comparative effectiveness and safety in routine clinical practice. A matched-cohort design and data from four U.S. private health care claims databases were employed. Study population comprised patients who initiated outpatient treatment with apixaban versus warfarin (plus parenteral anticoagulant bridge therapy) within 30 days of their initial VTE episode; apixaban and warfarin patients were matched on age, characteristics of VTE episode, study database and propensity score. Major bleeding, clinically relevant non-major (CRNM) bleeding and recurrent VTE during the 180-day (maximum) follow-up period were compared using shared frailty models. During mean follow-up of 143 days among apixaban patients (n = 17,878) and 152 days among warfarin patients (n = 17,878), incidence proportions for apixaban versus warfarin, respectively, were 1.7% versus 2.3% for major bleeding, 7.0% versus 9.4% for CRNM bleeding and 2.3% versus 2.9% for recurrent VTE. In shared frailty models, risks of major bleeding (hazard ratio [HR] = 0.75, 95% confidence interval [CI] = 0.64-0.87), CRNM bleeding (HR = 0.77, 95% CI = 0.71-0.83) and recurrent VTE (HR = 0.80, 95% CI = 0.70-0.91) were lower for apixaban versus warfarin. In this large-scale evaluation of VTE patients receiving outpatient treatment with apixaban or warfarin in U.S. clinical practice, risks of major bleeding, CRNM bleeding and recurrent VTE were significantly lower among patients who received apixaban.

Current practice patterns and patient persistence with anticoagulant treatments for cancer-associated thrombosis

BACKGROUND

Recommended therapeutic options for the management of venous thromboembolism (VTE) in patients with cancer are burdensome, and compliance with guidelines is unknown.

OBJECTIVES

To describe current treatment patterns and to evaluate patient persistence on various anticoagulants.

PATIENTS/METHODS

Medical and pharmacy claims from the Humana Database were analyzed (01/2007-12/2014). Newly diagnosed cancer patients treated with anticoagulants were categorized into one of the following cohorts: low-molecular-weight heparin (LMWH), warfarin, and rivaroxaban. Discontinuation, switching, and persistence with the index therapy were analyzed.

RESULTS

A total of 2941 newly diagnosed patients with cancer who developed VTE and received anticoagulation in outpatient settings were identified. Of these, 97% initiated anticoagulation with LMWH (n=735; 25%), warfarin (n=1403; 47.7%), or rivaroxaban (n=709; 24.1%). Median treatment durations for the LMWH, warfarin, and rivaroxaban cohorts were 3.3, 7.9, and 7.9 months, respectively; Kaplan-Meier rates of persistence to the initial therapy were 37%, 61%, and 61% at 6 months. Warfarin and rivaroxaban users were significantly more likely to remain on initial therapy compared to LMWH (adjusted hazard ratios [HRs; 95% CI]: warfarin, 0.33 [0.28-0.38]; rivaroxaban, 0.38 [0.32-0.46]). The proportion of patients that switched from their initial treatment to another anticoagulation treatment was 22.9%, 7.9%, and 4.7% in the LMWH, warfarin, and rivaroxaban cohorts, respectively.

CONCLUSIONS

This real-world analysis showed that, despite guideline recommendations, warfarin and rivaroxaban are at least as equally utilized as LMWH for the treatment of cancer-associated thrombosis. LMWH was associated with significantly lower persistence, shorter duration of treatment, and more switching than warfarin and rivaroxaban.

Spotlight on real-world evidence for the treatment of DVT: XALIA

Venous thromboembolism (VTE), comprising both deep-vein thrombosis (DVT) and pulmonary embolism (PE), is a serious and common cardiovascular disease associated with the risk of chronic complications, recurrent VTE events and even death. The treatment landscape has, in recent years, seen a paradigm shift from the use of traditional anticoagulants (low-molecular-weight heparin [LMWH] overlapping with and followed by a vitamin K antagonist [VKA]) to non-VKA oral anticoagulants (NOACs). This class of agents, encompassing direct factor Xa inhibitors and direct thrombin inhibitors have shown non-inferior efficacy and better safety to standard of care in randomised controlled trials (RCTs). The direct, oral factor Xa inhibitor rivaroxaban was the first to be approved for treatment of acute DVT and PE and secondary prevention of recurrent VTE events based on data from EINSTEIN DVT and EINSTEIN PE, respectively. Real-world evidence now helps to further support data from RCTs, and also bridges the gap for physicians regarding any areas of clinical uncertainty that may not be addressed by RCTs. XA inhibition with rivaroxaban for Long-term and Initial Anticoagulation in venous thromboembolism (XALIA) was the first large, prospective, observational, real-world study that has investigated the safety and effectiveness profile of rivaroxaban in patients with DVT and PE associated with DVT in routine clinical practice. This article will present the key clinical outcomes from this important global non-interventional study, and will discuss remaining questions to be addressed in Phase IV studies.