Savaş ÖZSU, Yılmaz BÜLBÜL, Funda ÖZTUNA, Mustafa Buğra COŞKUNER

The cost of pulmonary thromboembolism treatment

Introduction: Primary aim of this study is to determine the financial burden of Vitamin K Antagonists (VKA), low molecular weight heparins (LMWH) and new oral anticoagulants (NOAC) which are used in the treatment of the pulmonary thromboembolism (PTE). Secondary aim is to show long term complications of the treatment options. Materials and Methods: The patients who are diagnosed with PTE between May 2016 and March 2018 at Faculty of Medicine Karadeniz Technical University Hospital were observed prospectively. Hospitalization costs were calculated on patients who were treated only for PTE by hospitalized in the Chest Diseases Service in the acute period. Maintenance costs were calculated over all patients who regulary admitted to our outpatient clinic with the diagnosis of PTE. Data were presented as mean ± SD and median ± interquartilee range. A p-value of < 0.05 was accepted to be significant. Results: Fifty five (37.2%) of the patients were male, 93 (62.8%) were female and the median age was 68 (range 18-95). The median hospitalization time and cost of patients who are discharged with VKA (n: 22) compared with patients discharged with LMWH (n: 22) was found to be increased (1316.82 TL 7,5 days / 803.36 TL, 5 days p< 0.001). Statistical analysis could not be performed with NOAC (n: 2). In the analysis of sixth month costs, LMWH cost was found to be higher than VKA cost (6.927.15 ± 2.687.67 TL/698.29 ± 483.51 TL p< 0.001). However VKA treatment tended to be less expensive than treatment with NOACs (698.29 ± 483.51 TL/1.050.81 ± 300.28 TL p= 0.140). Conclusion: In the acute period of PTE, VKA increases the length of hospitalization and hospital costs in patients treated at the hospital. In the maintenance period, VKA tends to have a lower cost compared to NOACs

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1. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 7S-47S.
2. Konstantinides S, Goldhaber SZ. Pulmonary embolism: Risk assessement and management. Eur Heart J 2012; 33: 3014-22.
3. Konstantinides S, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: the task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society (ERS). Eur Heart J 2020; 41(4): 543-603.
4. Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M, et al. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med 2013; 369: 799- 808.
5. Buller HR, Prins MH, Lensin AW, Decousus H, Jacobson BF, Minar E, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 2012; 366: 1287-97.
6. Özsu S, Ozlu T, Şentürk A, Uçar EY, Kırkıl G, Ekbiç Kadıoğlu E, et al. Combination and comparison of two models in prognosis of pulmonary embolism: Results from Turkey Pulmonary Embolism Group (TUPEG) study. Thrombosis Research 2014; 133: 1006-10.
7. Kahler ZP, Beam DM, Kline JA. Cost of treating venous thromboembolism with heparin and warfarin versus home treatment with rivaroxaban. Acad Emerg Med 2015; 22: 796-802.
8. Bamber L, Muston D, McLeod E, Guillermin A, Lowin J, Patel R. Cost-effectiveness analysis of treatment of venous thromboembolism with rivaroxaban compared with combined low molecular weight heparin/ vitamin K antagonist. Thromb J 2015; 13-20.
9. Steffel J, Verhamme P, Potpara, Albaladejo P, Antz M, Desteghe L, et al. ESC Scientific Document Group. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2018; 39: 1330-93.
10. Schulman S. Advantages and limitations of the new anticoagulants. J Intern Med 2014; 275: 1-11.
11. Clay E, Jamotte A, Verhamme P, Cohen AT, Hout BV, Gumbs P. Cost-effectiveness of edoxaban compared to warfarin for the treatment and secondary prevention of venous thromboembolism in the UK. J Mark Access Health Policy 2018; 6(1):1495974.
12. Türk M, Aldağ Y, Oğuzülgen İK Ekim N. A cost comparison of warfarin vs enoxaparine or new oral anticoagulants used for the treatment of patients with pulmonary embolism. Tuberk Toraks 2016; 64(3): 198-205.
13. Mody SH, Huynh L, Zhuo DY, Tran NK, Lefebvre P, Bookhart B. A cost-analysis model for anticoagulant treatment in the hospital setting. J Med Econ 2014; 17: 492-8.
14. Lamori JC, Shoheiber O, Mody SH, Bookhart B. Inpatient resource use and cost burden of deep vein thrombosis and pulmonary embolism in the United States. Clin Ther 2015; 37: 62-70.
15. Aujesky D, Roy PM, Verschuren F, Righini M, Osterwalder J, Egloff M, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, noninferiority trial. Lancet 2011; 378: 41-8.
16. Zondag W, Kooiman J, Klok FA, Dekkers OM, Huisman MV. Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis. Eur Respir J 2013; 42(1): 134-44.
17. Beckman JA, Dunn K, Sasahara AA, Goldhaber SZ. Enoxaparin monotherapy without oral anticoagulation to treat acute symptomatic pulmonary embolism. Thromb Haemost 2003; 89: 953-8.
18. Bauersachs R, Berkowitz SD, Brenner B, The EINSTEIN Investigators. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 2010; 363: 2499-510.
19. Vanbellen B, Bamber L, Correa de Carvalho F, Prins M, Wang M, Lensing AWA. Reduction in the length of stay with rivaroxaban as a single-drug regimen for the treatment of deep vein thrombosis and pulmonary embolism. Curr Med Res Opin 2014; 30: 829-37.
20. Bookhart BK, Haskell L, Bamber L, Wang M, Schein J, Mody SH. Length of stay and economic consequences with rivaroxaban vs enoxaparin/vitamin K antagonist in patients with DVT and PE: findings from the North American EINSTEIN clinical trial program. J Med Econ 2014; 17: 691-5.
21. Kohn CG, Fermann GJ, Peacoc WF, Wells PS, Baugh CW, Ashton V. 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. Curr Med Res Opin 2017; 33(9): 1697- 703
22. van der Hulle T, Kooiman J, den Exter PL, Dekkers OM, Klok FA, Huisman MV. Effectiveness and safety of novel oral anticoagulants as compared with vitamin K antagonists in the treatment of acute symptomatic venous thromboembolism: a systematic review and meta-analysis. J Thromb Haemost 2014; 12: 320-8.
23. Nielsen A, Poulsen PB, Dybro L. et al. Total costs of treating venous thromboembolism: implication of different cost perspectives in a Danish setting. J Med Econ 2019; 22: 1321-7.
24. Santos IF, Pereira S, McLeod, Guillermin AL, Chatzitheofilou I. Economic analysis of rivaroxaban for the treatment and long-term prevention of venous thromboembolism in Portugal. Acta Med Port 2014; 27: 615-24.
25. Beyer-Westendorf J, Forster K, Pannach S, Franziska E, Gelbricht V, Thieme C, et al. Rates, management and outcome of rivaroxaban bleeding in daily care: results from the Dresden NOAC registry. Blood 2014; 124: 955-62.
26. Schulman S, Kearon C, Kakkar AK, Schellong S, Eriksson H, Baanstra D, et al. Extended use of dabigatran, warfarin, or placebo in venous thromboembolism. N Engl J Med 2013; 368: 709-18.
27. Ende-Verhaar YM, Cannegieter SC, Vonk Noordegraaf A, Delcroix M, Pruszczyk P, Mairuhu ATA, et al. Incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: a contemporary view of the published literature. Eur Respir J 2017; 49: 1601792