A pharmacoeconomic study of traditional anticoagulation versus direct oral anticoagulation for the treatment of venous thromboembolism in the emergency department

AbstractObjectivesPatients with venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [PE]) are commonly treated as outpatients. Traditionally, patients are anticoagulated with low-molecular-weight heparin (LMWH) and warfarin, resulting in return visits to the ED. The direct oral anticoagulant (DOAC) medications do not require therapeutic monitoring or repeat visits; however, they are more expensive. This study compared health costs, from the hospital and patient perspectives, between traditional versus DOAC therapy.MethodsA chart review of VTE cases at two tertiary, urban hospitals from January 1, 2010 to December 31, 2012 was performed to capture historical practice in VTE management, using LMWH/warfarin. This historical data were compared against data derived from clinical trials, where a DOAC was used. Cost minimization analyses comparing the two modes of anticoagulation were completed from hospital and patient perspectives.ResultsOf the 207 cases in the cohort, only 130 (63.2%) were therapeutically anticoagulated (international normalized ratio 2.0–3.0) at emergency department (ED) discharge; patients returned for a mean of 7.18 (range: 1–21) visits. Twenty-one (10%) were admitted to the hospital; 4 (1.9%) were related to VTE or anticoagulation complications. From a hospital perspective, a DOAC (in this case, rivaroxaban) had a total cost avoidance of $1,488.04 per VTE event, per patient. From a patient perspective, it would cost an additional $204.10 to $349.04 over 6 months, assuming no reimbursement.ConclusionsVTE management in the ED has opportunities for improvement. A DOAC is a viable and cost-effective strategy for VTE treatment from a hospital perspective and, depending on patient characteristics and values, may also be an appropriate and cost-effective option from a patient perspective.

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Study of Cost-Consequences Analysis Between Salbutamol With Aminophyllin For Exacerbation Asthma

KELUWIH: Jurnal Kesehatan dan Kedokteran ◽

10.24123/kesdok.v1i2.2855 ◽

2020 ◽

Vol 1 (2) ◽

pp. 62-69

Author(s):

Amelia Lorensia

Keyword(s):

Emergency Department ◽

Data Analysis ◽

Medical Records ◽

Treatment Effectiveness ◽

Cost Effective ◽

Hospital Perspective ◽

Asthma Exacerbations ◽

Effectiveness Analysis ◽

Asthma Patients ◽

Keywords Cost

Abstract— Exacerbations asthma treatment can be done by giving medications therapy in the form of salbutamol and aminophyllin. This research conducted with a comparative study between two alternatives using a hospital perspective. Data were collected retrospectively based on the medical records of patients with mild-moderate exacerbations asthma who were admitted in emergency department Anwar Medika Sidoarjo Hospital during the period of January 2017 to Desember 2018. The data showing asthma exacerbations treatment effectiveness and costs were analyzed using ACER. Results of the data analysis using ACER based on total improvement of asthma sympthoms showed that in salbutamol group was Rp.2.403,75/%, and in aminophyllin group was Rp.1.688,31/%. Based on the result of study, cannot concluded which medications therapy were more cost-effective because total subject study of salbutamol and aminophyllin were different and too little. Results of the data analysis using ACER based on total improvement of asthma sympthoms showed that in salbutamol only group was Rp.2.073,18/%, and in salbutamol and corticosteroid group was Rp.1.688,31/%. Rp.2.573,40/%. Based on the result of ACER, salbutamol only group more cost-effective than salbutamol and corticosteroid group based on improvement of asthma sympthoms in mild-moderate exacerbations asthma patients in emergency department. Keywords: cost-effectiveness analysis, asthma exacerbations, salbutamol, aminophylline Abstrak— Pengobatan serangan asma dapat dilakukan dengan cara pemberian terapi pengobatan, yaitu salbutamol dan aminofilin. Penelitian ini merupakan penelitian yang dilakukan dengan studi perbandingan antara dua alternatif yang ada dengan menggunakan perspektif rumah sakit. Pengumpulan data dilakukan secara retrospektif berdasarkan basis data rekam medik pasien serangan asma mild moderate yang di IGD di Rumah Sakit Umum Anwar Medika Sidoarjo periode Januari 2017 sampai dengan Desember 2018. Data efektivitas dan biaya pengobatan serangan asma dianalisis dengan ACER. Dari hasil analisis data diperoleh nilai ACER berdasarkan total perbaikan gejala pada kelompok salbutamol sebesar Rp.2.403,75/%, dan kelompok aminofilin sebesar Rp.1.688,31/%. Berdasarkan hasil penelitian, tidak dapat disimpulkan terapi pengobatan yang lebih cost-effective karena jumlah subjek kelompok salbutamol dan kelompok aminofilin yang berbeda dan terlalu sedikit. Dari hasil analisis data diperoleh nilai ACER berdasarkan total perbaikan gejala pada penggunaan salbutamol tunggal sebesar Rp.2.073,18/%, pada kelompok salbutamol dan kortikosteroid sebesar Rp.2.573,40/%. Berdasarkan hasil nilai ACER tersebut, kelompok salbutamol tunggal lebih cost-effective dibandingkan kelompok salbutamol dan kortikosteroid berdasarkan perbaikan gejala pada pasien serangan asma mild moderate di IGD. Kata kunci: analisis efektivitas biaya, serangan asma, salbutamol, aminofilin

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P5239Cost-effectiveness of direct oral anticoagulants for cancer-associated venous thromboembolism

European Heart Journal ◽

10.1093/eurheartj/ehz746.0212 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

J King ◽

S Bhat ◽

L J Heath ◽

C G Derington ◽

Z Yu ◽

...

Keyword(s):

Venous Thromboembolism ◽

Cost Effectiveness ◽

Relative Risk ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Cost Effective ◽

Low Molecular Weight ◽

Cost Effectiveness Ratio ◽

Major Bleed ◽

Recurrent Vte

Abstract Background Direct oral anticoagulants (DOACs) are at least as effective as low-molecular weight heparins (LMWH) at preventing recurrence after cancer-associated venous thromboembolism (CA-VTE). DOACs are also oral and far less costly, but they may confer a higher bleeding risk than LMWH. Purpose To estimate the cost-effectiveness of DOACs and LMWHs for CA-VTE. Methods We developed a health state transition model to estimate recurrent VTE, bleeding events, quality-adjusted life years (QALY), and direct healthcare costs (2018 United States dollars) associated with DOACs vs. LMWH use. The model had four states: (1) long-term anticoagulation (first 3 months after VTE), (2) extended anticoagulation (more than 3 months after VTE), (3) off anticoagulants, and (4) death. We used a United States healthcare sector perspective, 3-month cycle length, and 1-year time horizon. Event probabilities were derived from the Hokusai Cancer VTE trial and other literature. Event and medication costs were obtained from national sources. We used a threshold of less than $50,000 per QALY gained to define cost-effectiveness. Results Compared to LMWH, DOACs were less costly (mean costs: $8,477 vs. $33,917 per year) and similarly effective (mean QALY: 0.616 vs. 0.622). The incremental cost-effectiveness ratio was $4,479,374 per QALY gained with LMWH, indicating that DOACs are cost-effective (Table 1). In threshold analyses, LMWH therapy only became cost-effective when DOAC recurrent VTE risk increased to at least 72% (relative risk vs. LMWH, 6.19) or DOAC clinically relevant bleeding increased to at least 39% (relative risk vs. LMWH, 10.09). Scenarios Recurrent VTE, % Major bleed, % Mean difference DOAC − LMW ICER DOAC LMWH Relative Risk DOAC LMWH Relative Risk Cost QALY Base case 8.1 11.6 0.71 6.8 4.0 1.75 −$25,440 (−26,496, −24,274) −0.006 (−0.019, 0.008) $4,479,374 DOAC outcome rate threshold at which LMWH becomes cost-effective* Recurrent VTE 71.5 11.7 6.19 – – – −$6,064 (−7,534, −4,627) −0.121 (−0.136, −0.108) $49,886 Major Bleed – – – 38.9 4.0 10.09 −$2,192 (−3,400, −704) −0.044 (−0.056, −0.030) $49,878 DOAC = direct oral anticoagulant, ICER = incremental cost-effectiveness ratio, LMWH = low-molecular-weight heparin, VTE = venous thromboembolism. Values are mean (95% Uncertainty Interval). Uncertainty was derived from 1,000 stochastic model iterations. *Represents the minimum increased risk with DOAC that would result in LMWH achieving an ICER <$50K per QALY gained. Conclusion In this simulation study, DOACs were a cost-effective oral alternative to LMWH for the treatment of CA-VTE. For LMWH to be cost-effective, DOAC event rates needed to be far higher than what is likely to be observed in clinical practice. Acknowledgement/Funding Agency for Health Research and Quality R18HS026156

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Cost-Effectiveness of Initial Revision Digit Amputation Performed in the Emergency Department Versus the Operating Room

Hand ◽

10.1177/1558944718790577 ◽

2018 ◽

Vol 15 (2) ◽

pp. 208-214 ◽

Cited By ~ 1

Author(s):

Joseph A. Gil ◽

Avi D. Goodman ◽

Andrew P. Harris ◽

Neill Y. Li ◽

Arnold-Peter C. Weiss

Keyword(s):

Emergency Department ◽

Cost Effectiveness ◽

Operating Room ◽

Cost Effective ◽

Initial Management ◽

Fingertip Amputation ◽

Significant Difference ◽

Initial Procedure ◽

The Cost ◽

Cost Effectiveness Threshold

Background: The objective of this study was to determine the comparative cost-effectiveness of performing initial revision finger amputation in the emergency department (ED) versus in the operating room (OR) accounting for need for unplanned secondary revision in the OR. Methods: We retrospectively examined patients presenting to the ED with traumatic finger and thumb amputations from January 2010 to December 2015. Only those treated with primarily revision amputation were included. Following initial management, the need for unplanned reoperation was assessed and associated with setting of initial management. A sensitivity analysis was used to determine the cost-effectiveness threshold for initial management in the ED versus the OR. Results: Five hundred thirty-seven patients had 677 fingertip amputations, of whom 91 digits were initially primarily revised in the OR, and 586 digits were primarily revised in the ED. Following initial revision, 91 digits required unplanned secondary revision. The unplanned secondary revision rates were similar between settings: 13.7% digits from the ED and 12.1% of digits from the OR ( P = .57). When accounting for direct costs, an incidence of unplanned revision above 77.0% after initial revision fingertip amputation in the ED would make initial revision fingertip amputation in the OR cost-effective. Therefore, based on the unplanned secondary revision rate, initial management in the ED is more cost-effective than in the OR. Conclusions: There is no significant difference in the incidence of unplanned/secondary revision of fingertip amputation rate after the initial procedure was performed in the ED versus the OR.

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Concurrent Spontaneous Sublingual and Intramural Small Bowel Hematoma due to Warfarin Use

Case Reports in Emergency Medicine ◽

10.1155/2015/583869 ◽

2015 ◽

Vol 2015 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Gül Pamukçu Günaydın ◽

Hatice Duygu Çiftçi Sivri ◽

Serkan Sivri ◽

Yavuz Otal ◽

Ayhan Özhasenekler ◽

...

Keyword(s):

Emergency Department ◽

Small Bowel ◽

Warfarin Therapy ◽

International Normalized Ratio ◽

Fresh Frozen Plasma ◽

Close Monitoring ◽

Observation Unit ◽

Fresh Frozen ◽

Tomography Scan ◽

Frozen Plasma

Introduction. We present a case of concurrent spontaneous sublingual and intramural small bowel hematoma due to warfarin anticoagulation.Case. A 71-year-old man presented to the emergency department complaining of a swollen, painful tongue. He was on warfarin therapy. Physical examination revealed sublingual hematoma. His international normalized ratio was 11.9. The computed tomography scan of the neck demonstrated sublingual hematoma. He was admitted to emergency department observation unit, monitored closely; anticoagulation was reversed with fresh frozen plasma and vitamin K. 26 hours after his arrival to the emergency department, his abdominal pain and melena started. His abdomen tomography demonstrated intestinal submucosal hemorrhage in the ileum. He was admitted to surgical floor, monitored closely, and discharged on day 4.Conclusion. Since the patient did not have airway compromise holding anticoagulant, reversing anticoagulation, close monitoring and observation were enough for management of both sublingual and spontaneous intramural small bowel hematoma.

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High incidence of patients lost to follow-up after venous thromboembolism diagnosis – Identifying an unmet need for targeted transition of care

Vascular ◽

10.1177/17085381211020969 ◽

2021 ◽

pp. 170853812110209

Author(s):

Rae S Rokosh ◽

Jack H Grazi ◽

David Ruohoniemi ◽

Eugene Yuriditsky ◽

James Horowitz ◽

...

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Venous Thrombosis ◽

Deep Venous Thrombosis ◽

Time Of Day ◽

Transition Of Care ◽

Initial Discharge ◽

Significant Difference

Objectives Venous thromboembolism, including deep venous thrombosis and pulmonary embolism, is a major source of morbidity, mortality, and healthcare utilization. Given the prevalence of venous thromboembolism and its associated mortality, our study sought to identify factors associated with loss to follow-up in venous thromboembolism patients. Methods This is a single-center retrospective study of all consecutive admitted (inpatient) and emergency department patients diagnosed with acute venous thromboembolism via venous duplex examination and/or chest computed tomography from January 2018 to March 2019. Patients with chronic deep venous thrombosis and those diagnosed in the outpatient setting were excluded. Lost to venous thromboembolism-specific follow-up (LTFU) was defined as patients who did not follow up with vascular, cardiology, hematology, oncology, pulmonology, or primary care clinic for venous thromboembolism management at our institution within three months of initial discharge. Patients discharged to hospice or dead within 30 days of initial discharge were excluded from LTFU analysis. Statistical analysis was performed using STATA 16 (College Station, TX: StataCorp LLC) with a p-value of <0.05 set for significance. Results During the study period, 291 isolated deep venous thrombosis, 25 isolated pulmonary embolism, and 54 pulmonary embolism with associated deep venous thrombosis were identified in 370 patients. Of these patients, 129 (35%) were diagnosed in the emergency department and 241 (65%) in the inpatient setting. At discharge, 289 (78%) were on anticoagulation, 66 (18%) were not, and 15 (4%) were deceased. At the conclusion of the study, 120 patients (38%) had been LTFU, 85% of whom were discharged on anticoagulation. There was no statistically significant difference between those LTFU and those with follow-up with respect to age, gender, diagnosis time of day, venous thromboembolism anatomic location, discharge unit location, or anticoagulation choice at discharge. There was a non-significant trend toward longer inpatient length of stay among patients LTFU (16.2 days vs. 12.3 days, p = 0.07), and a significant increase in the proportion of LTFU patients discharged to a facility rather than home ( p = 0.02). On multivariate analysis, we found a 95% increase in the odds of being lost to venous thromboembolism-specific follow-up if discharged to a facility (OR 1.95, CI 1.1–3.6, p = 0.03) as opposed to home. Conclusions Our study demonstrates that over one-third of patients diagnosed with venous thromboembolism at our institution are lost to venous thromboembolism-specific follow-up, particularly those discharged to a facility. Our work suggests that significant improvement could be achieved by establishing a pathway for the targeted transition of care to a venous thromboembolism-specific follow-up clinic.

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Assessing the discharge instructing in the emergency department: Patient perspective

International Emergency Nursing ◽

10.1016/j.ienj.2018.07.005 ◽

2019 ◽

Vol 43 ◽

pp. 40-44 ◽

Cited By ~ 2

Author(s):

M. Mäkinen ◽

M. Castrén ◽

K. Huttunen ◽

S. Sundell ◽

J. Kaartinen ◽

...

Keyword(s):

Emergency Department ◽

Patient Perspective ◽

Emergency Department Patient

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Anticoagulant therapies for acute venous thromboembolism: a comparison between those discharged directly from the emergency department versus hospital in two Canadian cities

BMJ Open ◽

10.1136/bmjopen-2018-022063 ◽

2018 ◽

Vol 8 (10) ◽

pp. e022063 ◽

Cited By ~ 3

Author(s):

Tammy J Bungard ◽

Bruce Ritchie ◽

Jennifer Bolt ◽

William M Semchuk

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Severity Index ◽

Vein Thrombosis ◽

Risk Patients ◽

Acute Venous Thromboembolism ◽

Record Review ◽

Deep Vein

ObjectiveTo compare the characteristics/management of acute venous thromboembolism (VTE) for patients either discharged directly from the emergency department (ED) or hospitalised throughout a year within two urban cities in Canada.DesignRetrospective medical record review.SettingHospitals in Edmonton, Alberta (n=4) and Regina, Saskatchewan (n=2) from April 2014 to March 2015.ParticipantsAll patients discharged from the ED or hospital with acute deep vein thrombosis or pulmonary embolism (PE). Those having another indication for anticoagulant therapy, pregnant/breast feeding or anticipated lifespan <3 months were excluded.Primary and secondary outcomesPrimarily, to compare proportion of patients receiving traditional therapy (parenteral anticoagulant±warfarin) relative to a direct oral anticoagulant (DOAC) between the two cohorts. Secondarily, to assess differences with therapy selected based on clot burden and follow-up plans postdischarge.Results387 (25.2%) and 665 (72.5%) patients from the ED and hospital cohorts, respectively, were included. Compared with the ED cohort, those hospitalised were older (57.3 and 64.5 years; p<0.0001), more likely to have PE (35.7% vs 83.8%) with a simplified Pulmonary Embolism Severity Index (sPESI) ≥1 (31.2% vs 65.2%), cancer (14.7% and 22.3%; p=0.003) and pulmonary disease (10.1% and 20.6%; p<0.0001). For the ED and hospital cohorts, similar proportions of patients were prescribed traditional therapies (72.6% and 71.1%) and a DOAC (25.8% and 27.4%, respectively). For the ED cohort, DOAC use was similar between those with a sPESI score of 0 and ≥1 (35.1% and 34.9%, p=0.98) whereas for those hospitalised lower risk patients were more likely to receive a DOAC (31.4% and 23.8%, p<0.055). Follow-up was most common with family physicians for those hospitalised (51.5%), while specialists/VTE clinic was most common for those directly discharged from the ED (50.6%).ConclusionsTraditional and DOAC therapies were proportionately similar between the ED and hospitalised cohorts, despite clear differences in patient populations and follow-up patterns in the community.

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123 Refusal of Care in the Emergency Department Setting: Patient Perspectives

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2019.08.128 ◽

2019 ◽

Vol 74 (4) ◽

pp. S50

Author(s):

C. Marco ◽

M. Bryant ◽

B. Landrum ◽

B. Drerup ◽

M. Weeman ◽

...

Keyword(s):

Emergency Department ◽

Patient Perspectives ◽

Emergency Department Setting

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Cost-Effectiveness Analysis Kloramfenikol Dan Seftriakson Untuk Pengobatan Demam Tifoid Pada Pasien Dewasa Di Rumah Sakit Sanglah Denpasar

Media Pharmaceutica Indonesiana (MPI) ◽

10.24123/mpi.v2i2.1391 ◽

2019 ◽

Vol 2 (2) ◽

pp. 105-112

Author(s):

Amelia Lorensia ◽

Doddy De Queljoe ◽

Made Dwike Swari Santi

Keyword(s):

Cost Effectiveness ◽

Length Of Stay ◽

Typhoid Fever ◽

Medical Records ◽

Cost Effective ◽

Cost Effectiveness Ratio ◽

Hospital Perspective ◽

Effectiveness Analysis ◽

The Cost ◽

Two Alternatives

The number of typhoid fever patient in Indonesia is still high. Typhoid fever can be treated by antibiotic therapy such as chloramphenicol and ceftriaxone. The purpose of this study was to compare the cost-effectiveness of chloramphenicol and ceftriaxone which was given to adult patients who were diagnosed with typhoid fever in Sanglah Denpasar Hospital. A comparative study between two alternatives was conducted using the hospital perspective. Retrospective method was used to collect data from patient medical records, who was diagnosed and hospitalized in Sanglah Denpasar Hospital during January 2017 until July 2018. The cost analysis was perform using cost-effectiveness grid and cost-effectiveness ratio (ACER) methods. Cost-effectiveness grid showed that dominant of ceftriaxone for patient with typhoid fever. ACER analysis for ceftriaxone was IDR 2,097,170.88 with effectivenes (length of stay) 4.27 days, and was IDR 2,097,170.88 with effectiveness (the time of reaching normal temperature) 2.42 days. ACER analysis for chloramphenicol was IDR 2,555,464.22 with effectivenes (length of stay) 10.22 days, and was IDR 2,555,464.22 with effectiveness (the time of reaching normal temperature) 3.44 days. ACER analysis showed lower degree of ceftriaxone and higher effectiveness based on length of stay and the time of reaching normal temperature. The conclusion of this study is that ceftriaxone is more cost-effective than chloramphenicol.

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Venous thromboembolism: The patient Perspective

Thrombosis Update ◽

10.1016/j.tru.2021.100082 ◽

2021 ◽

pp. 100082

Author(s):

Barry Kevane ◽

Ann Marie O’Neill

Keyword(s):

Venous Thromboembolism ◽

Patient Perspective

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