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


METHODS
A 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.


RESULTS
Of 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.


CONCLUSIONS
VTE 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.
*Department of Pharmacy,Vancouver General Hospital,Vancouver,BC.
Stephanie
S
Law
*Department of Pharmacy,Vancouver General Hospital,Vancouver,BC.
Daljit
D
Ghag
†Department of Emergency Medicine,St. Paul's Hospital,Vancouver,BC.
Eric
E
Grafstein
†Department of Emergency Medicine,St. Paul's Hospital,Vancouver,BC.
Robert
R
Stenstrom
‡Department of Emergency Medicine,University of British Columbia,Vancouver,BC.
Devin
D
Harris
D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000553:Ambulatory Care; D000925:Anticoagulants / Q000191:economics* / Q000627:therapeutic use; D002170:Canada; D016022:Case-Control Studies; D015331:Cohort Studies; D017046:Cost Savings; D017850:Economics, Pharmaceutical; D004636:Emergency Service, Hospital / Q000191:economics*; D005260:Female; D017048:Health Care Costs; D017721:Hospital Costs; D006786:Hospitals, Urban; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D000069552:Rivaroxaban / Q000008:administration & dosage / Q000191:economics*; D062606:Tertiary Care Centers; D015912:Thrombolytic Therapy / Q000191:economics* / Q000379:methods
D000925:Anticoagulants; D000069552:Rivaroxaban
anticoagulants; costs and cost analysis; emergency medicine; venous thromboembolism