Category Archives: Anticoagulant Therapy

Long-term Oral Anticoagulant Therapy: Conclusions

Long-term Oral Anticoagulant Therapy: ConclusionsNot adjusting costs, however, biases in the direction of a more conservative estimate of cost savings with LMWH use. Adjusting the inpatient costs of the UH group for inflation would have served to increase the costs of the UH group, with the result that LMWH use would have been associated with an even greater cost savings. Third, although there was no difference in the rates of total adverse events between groups, we did not have sufficient numbers to determine whether there were differences in the rates of subcategories of adverse clinical events (eg, arterial events, venous events, major bleeds, minor bleeds, and thrombocytopenia). life without allergy

Long-term Oral Anticoagulant Therapy: Thromboprophylaxis

Last, there was a higher than expected incidence of significant thrombocytopenia in both heparin groups (UH group, 7.7%; LMWH group, 2.5% [representing a total of three patients]). Although the true incidence of heparin-induced thrombocytopenia could not be ascertained in the absence of serologic studies, previous studies have suggested a lower incidence of serologic conversion and clinical heparin-induced thrombocytopenia in patients treated with LMWH vs those treated with UH for postoperative thromboprophylaxis. asthma inhalers

Long-term Oral Anticoagulant Therapy: UH group and LMWH group

Long-term Oral Anticoagulant Therapy: UH group and LMWH groupOur study also revealed no difference in the overall rate of clinical adverse events between the UH group and LMWH group (34.6% vs 40.0%, respectively; p = 0.67). The rate of thromboembolic complications in the UH group (three events among 26 patients) is higher than that reported in previous studies of perioperative bridging therapy using LMWH, although most studies represented small case series. One possible factor leading to increased rates of thrombotic events with IV UH use may be the difficulty of achieving adequate dosing in the perioperative period, despite the use of a weight-based nomogram. Montalescot et al reported a 9% therapeutic rate during the second study day in patients who were treated postoperatively during cardiac valve replacement using weight-adjusted IV UH therapy as a bridge to warfarin therapy vs an 87% therapeutic rate in those patients treated with LMWH (p < .0001), with > 91% of patients being subtherapeutic with a regimen of IV UH.

Long-term Oral Anticoagulant Therapy: LMWH

The results of our study reveal substantial mean total health-care cost savings ($13,114) in favor of the LMWH group. Costs were based on charges in administrative claims accrued during the bridging episode. The lower costs in the LMWH group resulted from the lower costs for inpatient care, despite higher costs for outpatient surgery and outpatient pharmacy. In addition, cost savings were achieved even though almost half of the patients in the LMWH group were hospitalized, which reflects a “real-world” experience with the perioperative management of at-risk patients with thromboembolic disease. In a multivariate regression model, arterial/cardiac risk was associated with increased costs, while age was not. Two outcome variables in the model (ie, surgery lasting a 2 h and experiencing an adverse event) also were associated with increased costs, as would be expected. After adjusting for the effect of existing risk (arterial/cardiac), duration of procedure, and occurrence of an adverse event, the model showed that the use of UH still had a statistically significant association with increased costs.

Long-term Oral Anticoagulant Therapy: Discussion

Long-term Oral Anticoagulant Therapy: DiscussionOutpatient pharmacy costs were $133 for the UH group (95% CI, $80 to $186) and $649 for the LMWH group (95% CI, $460 to $838; p < 0.01). In a multivariate regression model in which the log transformation of mean total health-care costs was the dependent variable, the predictors of higher costs during the bridging episode were the following: (1) being in the UH group, (2) having an arterial/ cardiac indication for long-term OA therapy, (3) having a procedure > 2 h in duration, and (4) having any postprocedure adverse event (Table 5). The model had an adjusted R2 value of 0.53.

Long-term Oral Anticoagulant Therapy: Adverse Events

The occurrence of adverse events is shown in Table 3. There was no difference in the overall rate of events, with 34.6% of patients in the UH group and 40.0% in the LMWH group experiencing an adverse event within 30 days postprocedure (p = 0.67). One patient in each group experienced two adverse events. Due to the small sample size, we were unable to determine whether the rates of types of adverse events differed between groups, but we describe the events below.

Long-term Oral Anticoagulant Therapy: Results

We identified 90 potential patients for the UH group and 71 potential patients for the LMWH group who had been receiving long-term OAC therapy prior to undergoing an elective surgical procedure. A review of medical records resulted in 64 patients being found to be ineligible for inclusion in the UH group (31 had not been receiving OAC therapy for 3 months prior to the procedure, and 33 did not receive heparin in the perioperative period) and 31 patients being found to be ineligible for inclusion in the LMWH group (14 had not received OAC therapy for 3 months prior to undergoing the procedure, 14 did not receive heparin in the perioperative period, 1 person had a body weight of > 330 lb, and the procedure was performed outside Lovelace Health Systems and the chart was therefore unavailable for 2 patients). A total of 26 patients were eligible for inclusion in the UH group, and 40 patients were eligible for inclusion in the LMWH group.

Long-term Oral Anticoagulant Therapy: Statistical Analysis

Administrative Data: We obtained cost data for the bridging episode from administrative claims. These data are housed in the Lovelace Patient Database that is maintained by the Lovelace Respiratory Research Institute Center for Pharmacoeconomic and Outcomes Research. We extracted charges for inpatient care, outpatient care, and outpatient drug dispensing for the period from 10 days preprocedure through 30 days postprocedure. We calculated the outpatient costs for the following subcategories: primary care; specialty care; outpatient surgery; laboratory tests; radiology; emergency department care; and all other outpatient care. We calculated pharmacy costs by summing the average wholesale price of LMWH and all other outpatient drugs dispensed during the bridging episode. contraceptive pills

Long-term Oral Anticoagulant Therapy: Data Collection

Long-term Oral Anticoagulant Therapy: Data CollectionFor the LMWH group, after first identifying patients who had filled prescriptions for warfarin on an outpatient basis between 1998 and 2000, we identified the subset of patients who had filled those prescriptions with enoxaparin. We also reviewed the anticoagulation therapy clinic records to identify additional patients who had received bridge therapy not captured by prescription drug claims for LMWH. The paper medical charts of all potential LMWH group patients then were reviewed to determine whether the patient had received bridge therapy with LMWH for an elective surgical procedure, and to ascertain the status of all other inclusionary and exclusionary study criteria. acular eye drops

Long-term Oral Anticoagulant Therapy: Identification of Subjects

The LMWH group included patients who had been treated with the LMWH agent enoxaparin mostly on an outpatient basis between January 1, 1998, and December 31, 2000. During this time, perioperative anticoagulation management guidelines, which defined at-risk patients who were suitable candidates for LMWH therapy, were in use at Lovelace Health Systems. The guidelines specify that warfarin therapy be discontinued at least 4 days prior to the patient undergoing the procedure and that enoxaparin therapy be started at least 2 days prior to the patient undergoing the procedure at a therapeutic dose of 1 mg/kg subcutaneously bid. A prophylactic dose of 30 mg then was administered on the evening of surgery if the patient was deemed to have adequate hemostasis. Otherwise, the usual therapeutic dose of enoxaparin was administered concomitantly with the patient’s maintenance dose of warfarin the morning after surgery and was continued until the INR was in the therapeutic range (ie, > 2.0 for most cases) for > 2 consecutive days. alphagan eye drops

Pages: 1 2 Next