https://digitalcommons.wustl.edu/cgi/viewcontent.cgi?article=10660&context=open_access_pubs

American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism.

Summary.  Background: Few studies have evaluated the long‐term economic consequences of deep vein thrombosis (DVT). None of them have incorporated prospectively collected clinical data to ensure accurate identification of incident cases of DVT and DVT‐related health outcomes of interest, such as post‐thrombotic syndrome (PTS). Objectives: To prospectively quantify medical and non‐medical resource use and costs related to DVT during 2 years following diagnosis, and to identify clinical determinants of costs. Methods: Three hundred and fifty‐five consecutive patients with acute DVT were recruited at seven Canadian hospital centers. Resource use and cost information were retrieved from three sources: weekly patient‐completed cost diaries, nurse‐completed case report forms, and the Quebec provincial administrative healthcare database (RAMQ). Results: The rate of DVT‐related hospitalization was 3.5 per 100 patient‐years (95% confidence interval [CI] 2.2–4.9). Patients reported a mean (standard deviation) of 15.0 (14.5) physician visits and 0.7 (1.2) other healthcare professional visits. The average cost of DVT was $5180 (95% CI $4344–6017) in Canadian dollars, with 51.6% of costs being attributable to non‐medical resource use. Multivariate analysis identified four independent predictors of costs: concomitant pulmonary embolism (relative increase in cost [RIC] 3.16; 95% CI 2.18–4.58), unprovoked DVT (RIC 1.65; 95% CI 1.28–2.13), development of PTS during follow‐up (RIC 1.35; 95% CI 1.05–1.74), and management of DVT in the inpatient setting (RIC 1.79; 95% CI 1.33–2.40). Conclusions: The economic burden of DVT is substantial. The use of measures to prevent the occurrence of PTS and favoring outpatient care of DVT has the potential to diminish costs.

Guanella R, Ducruet T, Johri M, et al. Economic burden and cost determinants of deep vein thrombosis during 2 years following diagnosis: a prospective evaluation

BACKGROUNDEmpiric enoxaparin dosing is inadequate for most trauma patients, leading to below target initial anti-Xa levels and requiring dose adjustment for optimal venous thromboembolism prophylaxis. We hypothesize that patient factors affecting initial anti-Xa levels can be identified based on dru

If some is good, more is better: An enoxaparin dosing strategy to improve pharmacologic venous thromboembolism prophylaxis

Venous thromboembolism (VTE) is a major preventable disease that affects hospitalized inpatients. Risk stratification and prophylactic measures have good evidence supporting their use, but multiple reasons exist that prevent full adoption, compliance, and efficacy that may underlie the persistence of VTE over the past several decades. This policy statement provides a focused review of VTE, risk scoring systems, prophylaxis, and tracking methods. From this summary, 5 major areas of policy guidance are presented that the American Heart Association believes will lead to better implementation, tracking, and prevention of VTE events. They include performing VTE risk assessment and reporting the level of VTE risk in all hospitalized patients, integrating preventable VTE as a benchmark for hospital comparison and pay-for-performance programs, supporting appropriations to improve public awareness of VTE, tracking VTE nationwide with the use of standardized definitions, and developing a centralized data steward for data tracking on VTE risk assessment, prophylaxis, and rates.

Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association

Patients with inflammatory bowel disease (IBD) are at an increased risk for venous thromboembolism (VTE). VTE events carry significant morbidity and mortality, and have been associated with worse outcomes in patients with IBD. Studies have suggested that the hypercoagulable nature of the disease stems from a complex interplay of systems that include the coagulation cascade, natural coagulation inhibitors, fibrinolytic system, endothelium, immune system, and platelets. Additionally, clinical factors that increase the likelihood of a VTE event among IBD patients include older age (though some studies suggest younger patients have a higher relative risk of VTE, the incidence in this population is much lower as compared to the older IBD patient population), pregnancy, active disease, more extensive disease, hospitalization, the use of certain medications such as corticosteroids or tofacitinb, and IBD-related surgeries. Despite the increased risk of VTE among IBD patients and the safety of pharmacologic prophylaxis, adherence rates among hospitalized IBD patients appear to be low. Furthermore, recent data suggests that there is a population of high risk IBD patients who may benefit from post-discharge prophylaxis. This review will provide an overview of patient specific factors that affect VTE risk, elucidate reasons for lack of VTE prophylaxis among hospitalized IBD patients, and focus on recent data describing those at highest risk for recurrent VTE post-hospital discharge.

Venous thromboembolism in inflammatory bowel disease

Background
Venous thromboembolism (VTE) is the second most common medical complication and a cause of excess length of hospital stay. Its incidence and economic burden are expected to increase as the population ages. We reviewed the recent literature to provide updated cost estimates on VTE management.

/pdf/review-of-the-cost-of-venous-thromboembolism-483dxxai14.pdf

Review of the cost of venous thromboembolism.

Venous thromboembolism (VTE) is associated with almost 300,000 deaths per year in the United States. Novel oral anticoagulants (NOACs) offer an alternative to warfarin-based therapy without monitoring requirements and with fewer drug and food interactions. Edoxaban, a direct Xa inhibitor, is approved by the Food and Drug Administration (FDA), based upon results of the Hokusai-VTE Phase 3 trial. The trial demonstrated that edoxaban administered once daily after initial treatment with heparin was non-inferior in reducing the risk of VTE recurrence and caused significantly less major and clinically relevant non-major (CRNM) bleeding compared to warfarin. The objective of this study was to evaluate the cost-effectiveness of edoxaban versus warfarin for the treatment of adults with VTE.A cost-effectiveness model was developed using patient-level data from the Hokusai-VTE trial, clinical event costs from real-world databases, and drug acquisition costs for warfarin of $0.36 and edoxaban of $9.24 per tablet.From a U.S. health-care delivery system perspective, the incremental cost-effectiveness ratio (ICER) was $22,057 per quality adjusted life year (QALY) gained. Probabilistic sensitivity analysis showed that edoxaban had an ICER <$50,000 per QALY gained relative to warfarin in 67% of model simulations. The result was robust to variation in key model parameters including the cost and disutility of warfarin monitoring.Despite its higher drug acquisition cost, edoxaban is a cost-effective alternative to warfarin for the treatment of VTE.

/pdf/cost-effectiveness-of-edoxaban-for-the-treatment-of-venous-51rrarv6kp.pdf

Cost-effectiveness of edoxaban for the treatment of venous thromboembolism based on the Hokusai-VTE study

Purpose An analysis of resource utilization and hospital costs associated with recurrent venous thromboembolism (VTE) is presented.

Methods A retrospective cohort analysis was conducted using a large U.S. hospital database. Patients with VTE-related hospitalization events during the period January–December 2010 were identified; data collection extended for up to 12 months after the index event. Postdischarge hospital resource use and total costs were compared in cohorts of patients with and without recurrent VTE. Regression analysis was performed to compare hospital costs and length of stay (LOS) during initial and subsequent VTE encounters.

Results Among the study population of 43,734 patients, 4% had postdischarge VTE-related events during the data collection period. The median and mean ± S.D. times to VTE recurrence were 48 days and 98 ± 106 days, respectively. Patients with recurrent VTE had more all-cause hospitalizations than those without recurrent VTE (mean ± S.D., 1.07 ± 0.96 versus 0.15 ± 0.53; p < 0.0001), more all-cause emergency room visits (mean ± S.D., 0.31 ± 0.66 versus 0.05 ± 0.31; p < 0.0001), and greater total costs (mean ± S.D., $28,353 ± $39,624 versus $17,712 ± $33,461; p < 0.0001). Relative to initial VTE admissions, admissions for recurrent VTE were, on average, associated with a 14% longer LOS ( p = 0.0002) and a 22% higher total cost ( p < 0.001).

Conclusion Patients with recurrent VTE used more hospital resources than those without recurrent VTE. Readmissions for VTE were significantly longer and more costly than index encounters.

Economic burden of recurrent venous thromboembolism: Analysis from a U.S. hospital perspective

Venous thromboembolism (VTE) encompasses deep-vein thrombosis (DVT) and pulmonary embolism (PE). VTE is a chronic disease that is associated with a high risk for recurrence, especially during the initial months of therapy.1–7 The risk for VTE recurrence is higher for patients with “unprovoked” VTE (ie, VTE occurring in the absence of malignancy or any of the factors of “provoked” VTE) than for patients with provoked VTE (ie, VTE occurring within 3 months of hospitalization, major surgery, pregnancy, trauma, or fracture).8 The rates of VTE recurrence in patients with unprovoked VTE have been estimated at 10% after 1 year and 30% after 5 years of the first VTE event compared with patients with VTE provoked by surgery, in whom the recurrence rates are estimated to be 1% after 1 year and 3% after 5 years.8

VTE recurrence is recognized as an important risk factor for mortality and long-term complications, such as postthrombotic syndrome after DVT and pulmonary hypertension after PE. Recurrent VTE events also pose a significant economic burden to the healthcare system. In a recent retrospective analysis of claims data, patients with VTE recurrence were found to have 2.2-fold to 3-fold higher healthcare costs in the 1 year after their first VTE event, which was primarily driven by an increase in inpatient services utilization.7

The American College of Chest Physicians (ACCP) recommends initial parenteral anticoagulant therapy as an option for the initial treatment of acute DVT or PE.8 The ACCP guidelines recommend the early initiation of warfarin therapy rather than delayed initiation (eg, on the same day as parenteral therapy is started), and the continuation of parenteral anticoagulation therapy for a minimum of 5 days until the international normalized ratio (INR) is ≥2.0 for at least 24 hours. The ACCP also recommends continuation of anticoagulation therapy for 3 months in patients with acute DVT and PE to allow for the complete treatment of the acute episode of VTE and to prevent recurrent episodes of VTE.8

The outpatient treatment of uncomplicated VTE has become more common since the availability of subcutaneous low-molecular-weight heparin (LMWH) therapy as an alternative to intravenous unfractionated heparin for the treatment of VTE.8–10 Although the administration of heparin therapy and INR monitoring are much easier in the inpatient setting, there are challenges associated with the outpatient treatment of VTE. The outpatient use of LMWH requires the coordination of care, laboratory monitoring, and patient education and participation in treatment.11

It remains unclear how well parenteral anticoagulation therapy utilization in the outpatient clinical practice is consistent with the treatment guidelines for VTE. In addition, although previous randomized clinical trials suggest that the early initiation of warfarin therapy with a shorter course of heparin therapy for approximately 5 days is as effective as the delayed initiation of warfarin with a 10-day course of heparin, and that this approach has the benefit of reducing the risk for heparin-induced thrombocytopenia,8 it remains unclear how well this recommendation has been adopted in real-world clinical settings.

The objectives of this study were to assess the utilization of parenteral anticoagulation therapy and the timing of the initiation of warfarin for the treatment of VTE in the outpatient setting, and to examine the effects of parenteral anticoagulation therapy and the timing of warfarin initiation relative to a diagnosis of VTE on the risk of VTE recurrence.


KEY POINTS
▸ Recurrent venous thromboembolism (VTE) is a risk factor for mortality and long-term, serious complications; the risk for recurrence is especially high in the early months of an acute VTE event.
▸ Recurrent VTE poses a significant economic burden to the healthcare system.
▸ Current clinical guidelines recommend the early addition of warfarin to parenteral anticoagulation to reduce the risk for VTE recurrence.
▸ In this study of 4403 patients with acute VTE who received parenteral anticoagulants in the outpatient setting, only 25% of patients received warfarin on the same day of initiating parenteral anticoagulant therapy; 52% received warfarin 3 days after initiating parenteral anticoagulant therapy.
▸ Overall, parenteral anticoagulation plus warfarin reduced the risk for recurrent VTE by 49% over 1 year.
▸ In this study, each day that the initiation of warfarin was delayed from the VTE diagnosis translated to a 1% increase in VTE recurrence risk.

Utilization of Parenteral Anticoagulants and Warfarin: Impact on the Risk of Venous Thromboembolism Recurrence in the Outpatient Setting

Background: With the advent of new treatment options for venous thromboembolism (VTE), it is valuable to gain insights into current clinical practices. Objective: Assess treatment patterns and recurrence among patients hospitalized for VTE. Methods: This retrospective study evaluated patients hospitalized with an incident VTE diagnosis (index) from 2008 to 2012 in a de-identified electronic health record database. Patients were further required to receive anticoagulant treatment and/or a VTE-related procedure for study inclusion. Patients were excluded if they: (1) did not have a medical encounter in the 6 months before index (baseline); (2) had a prior VTE diagnosis or used an anticoagulant during the baseline period; or (3) had a diagnosis of atrial fibrillation/flutter, cardiomyopathy, or a coagulation disorder during baseline or the year after index (follow-up). Hospitalization for recurrent VTE and bleeding were evaluated. Results: A total of 2060 patients were identified (mean age, 60.9 year...

Treatment patterns and outcomes among hospitalized patients with venous thromboembolism in the United States: an analysis of electronic health records data.

Ronald Preblick

Papers

Review of the cost of venous thromboembolism.

Cost-effectiveness of edoxaban for the treatment of venous thromboembolism based on the Hokusai-VTE study

Economic burden of recurrent venous thromboembolism: Analysis from a U.S. hospital perspective

Utilization of Parenteral Anticoagulants and Warfarin: Impact on the Risk of Venous Thromboembolism Recurrence in the Outpatient Setting

Treatment patterns and outcomes among hospitalized patients with venous thromboembolism in the United States: an analysis of electronic health records data.