NEW YORK (Reuters Health) - For patients with low-risk venous thromboembolism (VTE) who can safely be discharged from the emergency department, rivaroxaban is a less costly treatment than heparin and warfarin, according to results of a case-control study.
"The biggest surprise to me was that using the Hestia criteria in the emergency department produced a low-enough risk population that we had zero incidence of either recurrent clots or bleeding," Dr. Jeffrey A. Kline, from Indiana University School of Medicine in Indianapolis, told Reuters Health by email. "The second surprise was the strength of gratitude by the patients that they did not have to have injections and take warfarin."
Dr. Kline's team developed a protocol for home treatment of low-risk patients with VTE using a target-specific anticoagulant like rivaroxaban. They compared the costs of medical care accrued by 50 patients treated with rivaroxaban and 47 matched controls who received bridging low-molecular-weight heparin (LMWH) for five to seven days and were then transitioned to warfarin.
All 50 rivaroxaban patients were discharged home from the emergency department on the day of diagnosis, whereas only 18 control patients were treated at home, according to the June 25 Academic Emergency Medicine online report.
Over the six months of follow-up, median total charges were $4787 with rivaroxaban, compared with $11,128 with LMWH-warfarin.
When the analysis was confined to patients who were never hospitalized, rivaroxaban was still less costly (median, $5932 vs $9016), although the difference was not statistically significant.
In-patient pharmacy median charges were significantly less with rivaroxaban than with LMWH-warfarin (median, $215 vs $742), but a survey of hospital outpatient pharmacies found the median cash cost of rivaroxaban to be significantly higher than that of LMWH-warfarin ($1856 vs $724 for six months).
"In low-risk patients, target-specific anticoagulants require minimal maintenance, and patients can be managed with no coagulation testing at all, and almost no other laboratory monitoring unless other factors suggest anemia or a reason to suspect change in renal function," Dr. Kline said.
Dr. Nathan T. Connell, from Brigham and Women's Hospital in Boston, told Reuters Health by email, "Recently, there has been a lot of discussion about cost differences between various anticoagulation strategies. This paper helps put the cost in perspective and that treatment with rivaroxaban may be more cost-effective in the long term."
"This difference went away when hospitalized patients were removed from the analysis, suggesting that the cost of hospitalization was the major driver for cost difference between the two strategies," Dr. Connell said. "For well-selected low-risk patients, however, rivaroxaban is an attractive choice because it often allows direct discharge from the Emergency Department. Also, we know from other studies that the risk of certain types of serious bleeding, such as intracerebral hemorrhage, is lower with rivaroxaban as compared to warfarin."
Dr. Connell noted, "This is a retrospective study, which can have issues with selection bias. The authors took several steps to minimize this bias, such as matching on a comorbidity score, in an attempt to make sure the two comparison groups were as balanced as possible."