Cost-Utility Analysis of Apixaban versus Warfarin in Atrial Fibrillation Patients with Chronic Kidney Disease

Background

Warfarin use for stroke prevention in atrial fibrillation (AF) patients with chronic kidney disease is debated. Apixaban was shown to be safer than warfarin, with superior reduction in the risk of stroke, systemic embolism, mortality, and major bleeding irrespective of kidney function.

Apixaban for stroke prevention in atrial fibrillation: a review of the clinical trial evidence

The objective of this review is to summarize data from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) and Apixaban Versus Acetylsalicylic Acid to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment (AVERROES) trials of apixaban for stroke prevention in patients with atrial fibrillation (AF). The ARISTOTLE trial compared apixaban with warfarin in 18 201 patients with AF and ≥ 1 additional risk factor for stroke. The AVERROES trial compared apixaban with aspirin in 5599 patients with AF who were at increased risk of stroke and for whom vitamin K antagonists were unsuitable. In ARISTOTLE, apixaban reduced the risk of stroke or systemic embolism by 21% compared with warfarin (1.27% vs 1.60% per year; hazard ratio, 0.79; 95% confidence interval, 0.66-0.95). The reduction was significant and demonstrated the superiority of apixaban over warfarin for the primary outcome of preventing stroke or systemic embolism (P = 0.01 for superiority). Apixaban also reduced all-cause mortality by 11% (P = 0.047) and major bleeding by 31% (P < 0.001) compared with warfarin. The benefits of apixaban observed in ARISTOTLE are further supported by the results from AVERROES, which demonstrated a 55% reduction in the risk of stroke or systemic embolism compared with aspirin. Risk of major bleeding was not significantly different between apixaban and aspirin. Subgroup analyses in both trials demonstrated that the effects of apixaban are highly consistent across various patient subpopulations. Discontinuation of study medication was significantly lower with apixaban than with either warfarin in ARISTOTLE or aspirin in AVERROES. Apixaban is the first new oral anticoagulant that has been shown to be superior to warfarin in reducing stroke or systemic embolism, all-cause mortality, and major bleeding in patients with AF. Moreover, in patients with AF who are considered unsuitable for warfarin therapy, apixaban was more effective than aspirin for stroke prevention and had a similar rate of major bleeding.     

Efficacy and Safety of Oral Anticoagulants in Older Adult Patients With Atrial Fibrillation: Pairwise and Network Meta-Analyses

ObjectiveTo evaluate the efficacy and safety of oral anticoagulants for older adult patients with atrial fibrillation (AF).DesignPairwise and network meta-analyses.Setting and ParticipantsPatients with AF aged ≥75 years.MethodsPubMed, Embase, and the Cochrane library were searched for published randomized controlled trials and adjusted observational studies evaluating the use of a non–vitamin K antagonist oral anticoagulants (NOACs), vitamin K antagonist, or antiplatelet drug for the prevention of stroke. The primary efficacy and safety outcomes were the composite of stroke and systemic embolism (SSE) and major bleedings.ResultsThis study included 38 studies enrolling 1,022,908 older adult patients with AF. Results from pairwise meta-analyses showed that NOACs were superior to warfarin for all outcomes, except that dabigatran increased the risk of gastrointestinal (GI) bleedings. Aspirin was associated with a higher risk of SSE and ischemic stroke than warfarin or NOACs. Results of network meta-analyses indicated that apixaban significantly reduced the risk of SSE, major bleedings, and GI bleedings than warfarin, rivaroxaban, and dabigatran. Apixaban, edoxaban, rivaroxaban, and dabigatran reduced the risk of ischemic stroke and intracranial bleeding compared to warfarin. Dabigatran showed lower risk of all-cause mortality than warfarin and of intracranial bleeding than rivaroxaban.Conclusions and ImplicationsNOACs are of at least equal efficacy, or even superior to warfarin. The safety profile of individual NOAC agents was significantly different, as apixaban performs better than the other oral anticoagulants in reducing major bleeding and GI bleeding, whereas dabigatran increased the risk of GI bleeding.     

Apixaban versus other anticoagulants in patients with nonvalvular fibrillation: a comparison of all-cause and event-related costs in real-life setting in France

Objectives

Compare costs associated with all-cause healthcare resource use (HCRU), stroke/systemic thromboembolism (STE) and major bleedings (MB) between patients with non-valvular atrial fibrillation (NVAF) initiating apixaban or other oral anticoagulants (OACs).

Methods

We performed a retrospective cohort study using the French healthcare claims database, including NVAF patients between 2014/01/01 and 2016/12/31, followed until 2016/12/31. We used 4 sub-cohorts of OAC-naive patients, respectively initiating apixaban, dabigatran, rivaroxaban or VKAs. We matched patients initiating apixaban with patients initiating each other OACs using 1:n propensity score matching. All-cause HCRU and event-related costs by OAC treatment were estimated and compared between matched patients using generalised-linear models with gamma-distribution and two-part models.

Results

There were 175,766 patients in the apixaban–VKA, 181,809 in the apixaban–rivaroxaban, and 42,490 in the apixaban–dabigatran matched cohorts. Patients initiating apixaban had significantly lower HCRU costs than patients initiating VKA (€1,105 vs. €1,578, p < 0.0001), dabigatran (€993 vs. €1,140, p < 0.0001) and rivaroxaban (€1,013 vs. €1,088 p < 0.0001). They have had significantly lower costs related to stroke/STE and MB than patients initiating VKA (respectively, €183 vs. €449 and €147 vs. €413; p < 0.0001), rivaroxaban (respectively, €145 vs. €197 and €129 vs. €193; p < 0.0001), and lower costs related to stroke/STE than patients initiating dabigatran (€135 vs. €192, p < 0.02). Costs related to MB were not significantly different in patients initiating apixaban and those initiating dabigatran (€119 vs. €149, p = 0.07).

Conclusions

HCRU and most event-related costs were lower in patients initiating apixaban compared to other OACs. Apixaban may be cost-saving compared to VKAs, and significantly cheaper than other DOACs, although cost differences are limited.

     

Rates of hospitalization among patients with deep vein thrombosis before and after the introduction of rivaroxaban

Background. Compared to warfarin, the non-vitamin K antagonist oral anticoagulant rivaroxaban may have advantages in treating patients with venous thromboembolism, because injectable bridging therapy and routine laboratory monitoring are not required. The objective of this study was to compare the rate of hospitalization in patients treated with rivaroxaban after its introduction with what it would have been before the introduction of rivaroxaban. Methods. A retrospective claims analysis was conducted using the MarketScan Hospital Drug Database from January 2011 to December 2013. Adult patients with a primary diagnosis of deep vein thrombosis (DVT) treated with rivaroxaban or low-molecular-weight heparin (LMWH) bridged to warfarin during the first day of an evaluation at a hospital were identified. Based on propensity-score methods, historical LMWH/warfarin patients (i.e., patients who received LMWH/warfarin before the approval of rivaroxaban) were matched 4:1 to rivaroxaban patients, and the rates of hospitalization were compared. Results. All rivaroxaban-treated patients (n = 134) in the database were well matched with four historical LMWH/warfarin-treated patients (n = 536). Among the rivaroxaban cohort, 60% of the patients were admitted to the hospital, compared to 82% of the historical patients treated with LMWH/warfarin in the matched cohort. The difference was statistically significant and corresponded to a 27% reduction in hospital admissions (rate ratio [95% confidence interval]: 0.73 [0.62–0.84]). Hospital admission rates adjusted for time-trend analyses also led to similar results. Conclusion. The availability of rivaroxaban significantly reduced the hospitalization rate in patients with DVT treated with rivaroxaban compared to what it would have been if only LMWH/warfarin were available.     

Factors associated with low health-related quality of life among younger and older Thai patients with non-valvular atrial fibrillation

Purpose

The aim of this study was to investigate the factors associated with low health-related quality of life (HRQoL) compared between younger and older Thai patients with non-valvular atrial fibrillation (NVAF).

Methods

This is a cross-sectional analysis of baseline data from a prospective NVAF registry from 24 hospitals located across Thailand. Patient demographic, clinical, lifestyle, and medication data were collected at baseline. EuroQOL/EQ-5D-3L was used to assess HRQoL. Health utility was calculated for the entire study population, and low HRQoL was defined as the lowest quartile. Multivariate logistic regression was used to identify factors that significantly predict low HRQoL among younger and older (≥?65 years) patients with NVAF.

Results

Among the 3218 participants that were enrolled, 61.0% were aged older than 65 years. Mean HRQoL was lower in older than in younger patients (0.72?±?0.26 vs. 0.84?±?0.20; p?<?0.001). Factors associated with low HRQoL among younger NVAF patients were the treatment-related factors bleeding history (p?=?0.006) and taking warfarin (p?=?0.001). Among older patients, the NVAF-related complications ischemic stroke or TIA, heart failure (HF), and dementia (all p?<?0.001) were all significantly associated with low HRQoL. Dementia is the factor that most adversely influences low HRQoL among older NVAF. Interestingly, symptomatic NVAF was found to be a protective factor for low HRQoL (p?<?0.001).

Conclusions

Bleeding history and taking warfarin among younger patients, and ischemic stroke/TIA, HF, and dementia among older patients are significant predictors of low HRQoL. These factors should be taken into consideration when selecting treatment options for patients with NVAF.

     

Evaluation of Dabigatran for Appropriateness of Use and Bleeding Events in a Community Hospital Setting

Background

Warfarin has been the predominant anticoagulant for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF). Its disadvantages are well-known and include a narrow therapeutic index, drug interactions, and the need for frequent monitoring. Dabigatran etexilate, a direct thrombin inhibitor, presents less complexity in prescribing and has emerged as an alternate therapy to warfarin. Although dabigatran does not require routine monitoring, concerns associated with its use include the lack of a reversal agent, complex dose adjustments, and limited guidance to the management of drug interactions.

Objectives

The goals of this study are to describe and to evaluate the use of dabigatran at a community hospital to identify areas for improvement in its prescribing.

Methods

This retrospective chart review of patients at a community hospital in St Louis, MO, included patients who received at least 1 dose of dabigatran between December 2010 and June 2012. The appropriateness of dabigatran was evaluated based on recommendations approved by the US Food and Drug Administration for stroke prophylaxis in the setting of NVAF. The composite end point of bleeding included hospital readmission within 1 year of receiving at least 1 dose of dabigatran at the study institution secondary to bleeding, bleeding associated with a decrease in hemoglobin level by ≥2 g/dL or transfusion of ≥2 units of blood, or a notation of bleeding in the patient''s medical record.

Results

Of the 458 patients included in the evaluation, 76 (16.6%) patients receiving dabigatran were using an inappropriate regimen of this drug, based on dose and frequency on the first day of therapy of dabigatran or the presence of valvular disease. Many patients (42.3%) received at least 1 dose of a concomitant parenteral anticoagulant. The composite end point for bleeding was reported in 66 (14.4%) patients, including 23 (5%) with confirmed gastrointestinal bleeding.

Conclusions

High-risk medications such as dabigatran require monitoring of prescribing habits to improve patient safety and outcomes. Various initiatives, such as pharmacist interventions, therapeutic interchanges, and obtaining appropriate patient parameters, can be implemented in the practice setting to ensure the appropriate use of oral anticoagulants and improved patient outcomes.Oral anticoagulation has changed drastically in the past 4 years with the US Food and Drug Administration (FDA) approval of 3 new agents—dabigatran, rivaroxaban, and apixaban. Warfar-in has had a primary role in oral anticoagulation therapy for many decades. Although its efficacy and safety have been established, therapy with warfarin is associated with significant challenges, including the need for frequent monitoring, drug interactions, a delayed time to onset, and a narrow therapeutic index.1,2 The challenges associated with warfarin not only affect its efficacy, but they also impact patient satisfaction. These concerns have contributed to the development of novel oral anticoagulants, beginning with dabigatran etexilate.Dabigatran etexilate, a direct thrombin inhibitor, was approved by the FDA in October 2010 and is the first novel oral anticoagulant approved to reduce the risk for stroke in patients with nonvalvular atrial fibrillation (NVAF).3 Results from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) study demonstrated the superiority of dabigatran 150 mg orally twice daily compared with warfarin for the prevention of stroke and systemic embolism in patients with NVAF.4 In that study, the rate of major bleeding was similar between the agents; however, dabigatran demonstrated a lower risk for intracranial hemorrhage, but with an increased risk for major gastrointestinal (GI) bleeding, compared with warfarin.4A recent analysis performed by the FDA confirmed these findings.5,6 In this analysis, compared with warfarin, dabigatran demonstrated lower rates of ischemic stroke, intracranial hemorrhage, and death; however, dabigatran was associated with a significant increase in major GI bleeding.5,6 In April 2014, dabigatran received new FDA indications for the treatment of patients with deep-vein thrombosis (DVT) and pulmonary embolism (PE) and for the risk reduction of recurrent DVT and PE in previously treated patients. Two studies, RE-COVER and RE-COVER II, compared dabigatran 150 mg twice daily with warfarin for the treatment of DVT and PE after 5 to 10 days of parenteral anticoagulation. Both studies demonstrated dabigatran''s noninferiority to warfarin.7,8 When the RE-COVER study was initiated, dabigatran was the only agent approved by the FDA for the risk reduction of recurrent venous thromboembolism (VTE).In November 2011, rivaroxaban, a factor Xa inhibitor, was the second novel oral anticoagulant to receive FDA approval to reduce the risk for stroke in patients with NVAF.9 Results from the ROCKET AF trial demonstrated the noninferiority of rivaroxaban to warfarin for the first occurrence of stroke or systemic embolism.10 In November 2012, rivaroxaban received an additional indication for the treatment of and reduction in the risk for recurrent VTE. Two studies, EINSTEIN-DVT and EINSTEIN-PE, compared rivaroxaban (at an initial dose of 15 mg twice daily for 3 weeks, followed by 20 mg once daily) with enoxaparin 1 mg/kg twice daily for at least 5 days with warfarin and then continued with warfarin after the target international normalized ratio (INR) of 2.0 to 3.0 was reached.11,12 Both studies demonstrated the noninferiority of rivaroxaban to warfarin in time to first recurrent DVT or PE event.11,12In December 2012, the factor Xa inhibitor apixaban was the newest novel oral anticoagulant to receive FDA approval to reduce the risk for stroke in patients with NVAF.13 The ARISTOTLE trial compared apixaban 5 mg twice daily (or 2.5 mg twice daily in select patients) with warfarin.14 Apixaban was superior to warfarin for the primary end point of reducing the risks for stroke and systemic embolism. Superiority to warfarin was primarily attributable to reductions in hemorrhagic stroke and ischemic stroke with hemorrhagic transformation compared with warfarin.14In AVERROES, patients with NVAF who were not candidates for therapy with warfarin were randomized to treatment with apixaban 5 mg twice daily (or 2.5 mg twice daily in select patients) or to aspirin 81 mg to 324 mg once daily.15 The primary objective of the study was to determine if apixaban was superior to aspirin for preventing the outcomes of stroke or systemic embolism. This trial was stopped early on the basis of a prespecified interim analysis that showed significant reductions in stroke and systemic embolism with apixaban compared with aspirin, but apixaban was associated with a modest increase in major bleeding.15

KEY POINTS

• ▸ Anticoagulation has changed drastically in the past 4 years in the United States with the FDA approval of novel oral anticoagulants, starting with dabigatran in 2010, rivaroxaban in 2011, and apixaban in 2012.
• ▸ These new anticoagulants present a safe alternative to warfarin for the prevention of stroke and systemic embolism in the setting of nonvalvular atrial fibrillation (NVAF).
• ▸ However, although anticoagulation has been simplified with the novel oral drugs, many safety issues must be considered when prescribing these agents.
• ▸ This retrospective chart review at a community hospital analyzed the appropriateness use of dabigatran, the first novel anticoagulant to receive FDA approval for the treatment of NVAF.
• ▸ Of the 458 patients included in this study, 76 patients were prescribed an inappropriate, mostly too high, dose of dabigatran.
• ▸ Although dabigatran is only approved for the treatment of NVAF, 13 patients had valvular disease.
• ▸ The majority of the patients were also receiving concomitant medications that are known to have drug interactions with dabigatran.
• ▸ These results indicate that high-risk medications require better monitoring of prescribing habits to improve patient safety and outcomes.

The current guidelines for the treatment of atrial fibrillation provide a class I recommendation for warfarin (level of evidence A) and dabigatran, rivaroxaban, and apixaban (level of evidence B) for the prevention of thromboembolism in patients with a CHA₂DS₂-VAS_c score of ≥2.16Dabigatran provides an effective alternative therapy to warfarin. It offers a predictable pharmacokinetic profile, which eliminates the need for routine monitoring of serum drug concentrations. Approximately 80% of dabigatran is excreted renally and requires dose reductions for patients with reduced creatinine clearance.17 Although dabigatran addresses some of the challenges associated with warfarin, there are remaining issues regarding the use of dabigatran.Warfarin interacts with numerous medications, disease states, and a variety of foods containing vitamin K; however, there is a great deal of clinical experience and resources available to effectively manage many of warfarin''s interactions.1 Unlike warfarin, dabigatran is not metabolized by cytochrome P450 enzymes and has fewer drug interactions. Although several drug interactions with dabigatran and P-glycoprotein inducers and inhibitors have been identified, little guidance has been provided on how to address them in practice.18Additional concerns surrounding dabigatran include the lack of a reversal agent and the lack of availability of laboratory testing to determine its degree of anticoagulation activity. Dabigatran prolongs markers of coagulation, such as the activated partial thromboplastin time (aPTT) and ecarin clotting time, and may potentially impact INR values. The aPTT can only provide an approximation of the anticoagulation effect of dabigatran, and the INR is relatively insensitive to the degree of anticoagulation. The ecarin clotting time is a more specific parameter to determine the effect of anticoagulation19; however, most laboratories are not adequately equipped to perform the laboratory test. Without laboratory parameters to guide dosing adjustments, it is unclear how to balance the drug interactions that have been identified to potentially increase or decrease dabigatran serum concentrations. The lack of monitoring also makes it difficult to manage special populations that typically require dosage adjustments (eg, the elderly, obese patients, underweight patients, and those with renal dysfunction).Since dabigatran became the first oral anticoagulant to be introduced to the US market, and the first to be included on hospital formularies, there has been a dramatic shift in the approach to anticoagulation. Laboratory markers of anticoagulation effect are no longer reliable, drug interactions require significantly less dose adjustments, and renal function continually needs to be addressed.20 The purpose of this study was to evaluate the use of dabigatran at a community hospital between December 2010 and June 2012 and to identify prescribing areas that can be improved to ensure appropriate use and patient outcomes.     

Impact of Palliative Care Utilization for Surgical Patients Receiving Prolonged Mechanical Ventilation: National Trends (2009–2013)

BackgroundPatients requiring mechanical ventilation (MV) have high morbidity and mortality. Providing palliative care has been suggested as a way to improve comprehensive management. The objective of this retrospective cross-sectional study was to identify predictors for palliative care utilization and the association with hospital length of stay (LOS) among surgical patients requiring prolonged MV (≥ 96 consecutive hours).MethodsNational Inpatient Sample (NIS) data 2009–2013 was used to identify adults (age ≥ 18) who had a surgical procedure and required prolonged MV (≥ 96 consecutive hours), as well as patients who also had a palliative care encounter. Outcomes were palliative care utilization and association with hospital LOS.ResultsUtilization of palliative care among surgical patients with prolonged MV increased yearly, from 5.7% in 2009 to 11.0% in 2013 (p < 0.001). For prolonged MV surgical patients who died, palliative care increased from 15.8% in 2009 to 33.2% in 2013 (p < 0.001). Median hospital LOS for patients with and without palliative care was 16 and 18 days, respectively (p < 0.001). Patients discharged to either short or long term care facilities had a shorter LOS if palliative care was provided (20 vs. 24 days, p < 0.001). Factors associated with palliative care utilization included older age, malignancy, and teaching hospitals. Non-Caucasian race was associated with less palliative care utilization.ConclusionsAmong surgical patients receiving prolonged MV, palliative care utilization is increasing, although it remains low. Palliative care is associated with shorter hospital LOS for patients discharged to short or long term care facilities.     

Differences in quality of care among patients hospitalized with atrial fibrillation as primary or secondary cause for admission.

OBJECTIVE: Several factors have been linked to the variation in the quality of care for patients with atrial fibrillation (AF). Whether hospitalization primarily for AF (primary diagnosis of AF) as opposed to another primary diagnosis but having concomitant AF (secondary diagnosis of AF) impacts quality of care for AF is not known. Accordingly, we sought to evaluate the differences in quality of care of Medicare patients admitted with primary diagnosis versus secondary diagnosis of AF. DESIGN AND SETTING: We studied a random sample of Medicare fee-for-service discharges from Michigan's acute care hospitals over a 1-year period with a primary or secondary diagnosis of AF (ICD-9-CM 427.31). Main outcome measure. Warfarin use at the time of discharge. RESULTS: Of 5993 patients in the study, 772 had a primary diagnosis of AF and 5221 had a secondary diagnosis of AF. Patients with a secondary diagnosis of AF were older, more likely to be male, and less likely to be hypertensive. Patients with a secondary diagnosis of AF 'ideal' for anticoagulation (n = 1648) were less likely to receive warfarin compared with 'ideal' patients with primary diagnosis of AF (n = 363) (52.6% versus. 59.8%, P < 0.001). Adherence to test indicators was lower in patients with secondary diagnosis of AF. CONCLUSION: Secondary diagnosis of AF rather than AF as a primary diagnosis appears to account for most Medicare patients with AF admitted to hospitals. Whereas quality of care is lower in patients with secondary diagnosis of AF, opportunity for quality improvement exists for both groups of patients with AF.     

Does hospital discharge policy influence sick-leave patterns in the case of female breast cancer?

The objective was to investigate how differences among hospitals in the shift from in-patient care to day surgery and a reduced hospital length of stay affect the sick-leave period for female patients surgically treated for breast cancer. All women aged 18-64 who were diagnosed with breast cancer in 2000 were selected from the National Cancer Register and combined with data from the sick-leave database of the National Social Insurance Board and the National Hospital Discharge Register (N = 1834). A multi-factorial model was fitted to the data to investigate how differences in hospital care practice affected the length of sick-leave. The main output measure was the number of sick-leave days after discharge during the year following surgery. The confounders used included age, type of primary surgical treatment, whether or not lymph node dissection was performed, labour-market status, county, and readmission. Women treated with breast-conserving surgery had a 54.7-day (-71.9 < or = CI(95%) < or = -37.5) shorter sick-leave period than those with more invasive surgery. The day-surgery cases had 24.3 (-47.5 < or = CI(95%) < or = -1.1) days shorter sick-leave than those who received overnight care. The effect of the hospital median length of stay (LOS) was U-shaped, suggesting that hospitals with a median LOS that is either short or long are associated with longer sick-leave. In the intermediate range, women treated in hospitals with a median LOS of 2 days had 22 days longer sick-leave than those treated in hospitals with a mean LOS of 3 days. This is possibly a sign of sub-optimising.     

Is nutritional depletion by Nutritional Risk Index associated with increased length of hospital stay? A population‐based study

BACKGROUND: Malnutrition is common at hospital admission and tends to worsen during hospitalization. This controlled population study aimed to determine if serum albumin or moderate and severe nutritional depletion by Nutritional Risk Index (NRI) at hospital admission are associated with increased length of hospital stay (LOS) (and increased hospital cost) in patients admitted to hospitals in 2 European countries. METHODS: Serum albumin levels and recent weight loss were prospectively determined at hospital admission in Geneva (n = 652) and Berlin (n = 621). Patients were classified as no, mild, moderate or severe risk by NRI. Multiple logistic regressions were used to determine the association between albumin and nutritional risk category and LOS. RESULTS: Patients (24%) were at moderate or severe nutritional risk by NRI. Nutritional risk by NRI, adjusted for age, was associated with LOS of 11 days (moderate: odds ratio [OR] 1.9, 95% confidence interval [CI] 1.4 to 2.7, p < .005; severe: OR 2.9, 95% CI 1.6 to 5.3, p < .005). Serum albumin was also significantly associated with increased LOS (p < .001). CONCLUSIONS: The prevalence of nutritional depletion assessed by NRI and albumin was increased with longer LOS. Albumin alone underestimated nutritional risk. Severe nutritional depletion by NRI was significantly associated with LOS > or = 11 days in Geneva and Berlin patients. Nutrition screening should take place at hospital admission to determine nutritional risk and risk for longer LOS.     

Ischemic stroke hospital stay and discharge destination

PURPOSE: Stroke hospitalizations are among the most expensive, with a mean length of stay (LOS) higher than other hospitalizations. This retrospective study assesses factors influencing ischemic stroke LOS taking into consideration the discharge destination of patients. METHODS: Linked hospital separation records between July 1995 and December 1999 were extracted to determine the first admission for ischemic stroke in Western Australia. Multiple hospitalization records for the same patient were screened to obtain the total duration of hospitalization. Demographic characteristics, hospital type, and medical history of patients were also retrieved. In the presence of censoring and without prior assumption on the time-to-discharge distribution, the Cox's proportional hazards model was used to assess the factors affecting LOS. RESULTS: During the study period, 6469 patients with a first-ever admission for ischemic stroke were identified, with average LOS being 28 days (95% CI, 26-30 days). Hospital stays were significantly longer for females and patients directly admitted to hospitals maintaining a specialist stroke unit, whereas patients residing in rural areas had shorter stays. CONCLUSIONS: The impact of stroke severity and placement in nursing homes after discharge need to be understood to manage LOS and the cost of acute care. Accurate diagnosis upon initial presentation would benefit both the efficiency of hospitals and the outcomes of rural ischemic stroke patients.     

Association of hospital resource use with comorbidity status and patient age among hip fracture patients in Japan

OBJECTIVES: This study examined the association of resource use with comorbidity status and patient age among hip fracture patients who underwent surgical treatment. DESIGN: We used a database from the Voluntary Hospitals of Japan Quality Indicator Project that involved 10 privately owned leading teaching hospitals in Japan. SETTING: Four of these hospitals in Japan. PARTICIPANTS: We selected 778 operable hip fracture patients aged 65 or older who were admitted to these hospitals between January 1996 and August 2000 (mean age: 80.3 +/- 7.3 years). MEASUREMENTS: A linear mixed model was performed to identify factors associated with the resource use, such as total length of stay (LOS), LOS before surgery, LOS after surgery, total hospital charges, charges for diagnostic examinations, charges for surgery, and length of theater time, among operable hip fracture patients. RESULTS: The mean LOS was 45.9 days, and the mean total hospital charges were US dollars 14,495.0. Results from linear mixed models revealed that higher age was significantly associated with shorter length of theater time (P < 0.01), and that the presence of comorbidity among hip fracture patients was significantly associated with longer total LOS (P < 0.01), longer LOS after surgery (P < 0.001), higher charges for diagnostic examinations (P < 0.001), and shorter length of theater time (P < 0.01). CONCLUSION: These results suggest that the presence of comorbidity among operable hip fracture patients requires greater resource use during their hospital stay, but higher age is not significantly associated with greater resource use at all.     

Improving thromboprophylaxis in elderly patients with non-valvular atrial fibrillation

BACKGROUND: Non-valvular atrial fibrillation (NVAF) is more common in elderly people, and is one of the most powerful independent risk factors predisposing to stroke. This risk increases with age. Despite evidence that full dose anticoagulation reduces this risk, and Scottish Intercollegiate Guidelines, warfarin is still being under prescribed, especially in elderly individuals. OBJECTIVES: To audit warfarin prescribing in elderly hospital patients with NVAF, and assess whether audit feedback and evidence based guidelines improved warfarin usage. METHODS: Discharge summaries and medical notes were reviewed, and warfarin prescribing identified, for all patients with NVAF discharged from the Medicine for the Elderly Department between January 2001 and December 2002. This was done before (16 months) and after (7 months) audit results were presented at a departmental meeting, and evidence basedguidelines were produced. RESULTS: Warfarin prescribing significantly increased from 38/121 (31.4%) prior to audit feedback and the introduction of guidelines to 30/55 (54.5%), Chi2-test, p < 0.01. CONCLUSIONS: Older patients with NVAF were under prescribed warfarin. Audit feedback and the introduction of evidence based guidelines significantly increased anticoagulation usage.     

Asthma And Depression

Abstract

Thromboprophylaxis with oral anticoagulants (OACs) is an important but under-used element of atrial fibrillation (AF) treatment. Reduction of stroke risk with anticoagulants comes at the price of increased bleeding risk. Patients with AF receiving anticoagulants require heightened attention with transition from one care setting to another. Patients presenting for emergency care of anticoagulant-related bleeding should be triaged for the severity and source of the bleeding using appropriate measures, such as discontinuing the OAC, administering vitamin K, when appropriate, to reverse warfarin-induced bleeding, or administering clotting factors for emergent bleeding. Reversal of OACs in patients admitted to the hospital for surgery can be managed similarly to patients with bleeding, depending on the urgency of the surgical procedure. Patients with AF who are admitted for conditions unrelated to AF should be assessed for adequacy of stroke risk prophylaxis and bleeding risk. Newly diagnosed AF should be treated in nearly all patients with either warfarin or a newer anticoagulant. Patient education is critically important with all anticoagulants. Close adherence to the prescribed regimen, regular international normalized ratio testing for warfarin, and understanding the stroke risk conferred by both AF and aging are goals for all patients receiving OACs. Detailed handoff from the hospitalist to the patient's primary care physician is required for good continuity of care. Monitoring by an anticoagulation clinic is the best arrangement for most patients. The elderly, or particularly frail or debilitated patients who are transferring to long-term care, need a detailed transfer of information between settings, education for the patient and family, and medication reconciliation. Communication and coordination of care among outpatient, emergency, inpatient, and long-term care settings are vital for patients with AF who are receiving anticoagulants to balance stroke prevention and bleeding risk.     

Length of in-patient stay in teaching hospitals in Japan

Summary. The average length of in-patient stay (LOS) in Japan is longer than that of the other Organization for Economic Cooperation and Development (OECD) countries. The tendency towards long LOS is also apparent in teaching hospitals in Japan. This paper examines factors responsible for the long LOS in teaching hospitals, focusing on conditions of residency training. The study was conducted as a part of the first nation-wide study of teaching hospitals for postgraduate medical education in Japan and covered most teaching hospitals (61 university hospitals out of 80 and 153 non-university general hospitals out of 193). The multivariate analysis suggested that longer LOS was more common in the hospitals with lower autopsy rate per bed, higher operation rate per admission, and smaller number of in-patients (P < 0.01 , respectively). It was also suggested that those hospitals where residents decided a work-up plan and where residents were engaged in out-patient clinics tended to show shorter LOS (P < 0.05 , respectively). The results indicated that LOS was related to not only general characteristics of the hospitals but also the conditions of residency training.     

Determinants of the Length of Stay in Stroke Patients

ObjectivesThe study objective was to identify the factors that influence the length of stay (LOS) in hospital for stroke patients and to provide data for managing hospital costs by managing the LOS.MethodsThis study used data from the Discharge Injury Survey of the Korea Centers for Disease Control and Prevention, which included 17,364 cases from 2005 to 2008.ResultThe LOS for stroke, cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage was 18.6, 15.0, 28.9, and 25.3 days, respectively. Patients who underwent surgery had longer LOS. When patients were divided based on whether they had surgery, there was a 2.4-time difference in the LOS for patients with subarachnoid hemorrhage, 2.0-time difference for patients with cerebral infarction, and 1.4-time difference for patients with intracerebral hemorrhage. The emergency route of admission and other diagnosis increased LOS, whereas hypertension and diabetic mellitus reduced LOS.ConclusionIn the present rapidly changing hospital environments, hospitals approach an efficient policy for LOS, to maintain their revenues and quality of assessment. If LOS is used as the indicator of treatment expenses, there is a need to tackle factors that influence the LOS of stroke patients for each disease group who are divided based on whether surgery is performed or not for the proper management of the LOS.     

Relationship of Nutritional Status to Length of Stay, Hospital Costs, and Discharge Status of Patients Hospitalized in the Medicine Service

Objective This study was conducted to determine the relationship, if any, between nutritional status, length of stay (LOS) in hospital, discharge placement, readmission rates, and hospital costs and charges in patients hospitalized in the medicine service.Design Data regarding medical diagnosis, LOS, hospital costs, charges, discharge destination, and readmission rates were collected prospectively from medical records and through patient interviews on patients admitted to the medical service who were classified to be at risk or not at risk for malnutrition on the basis of established criteria (weight for height <75% ideal body weight, admission serum albumin level <30 g/L, or ≥10% unintentional weight loss within 1 month before admission).Subjects All patients admitted directly to any of three medicine units during December 1994 who met study criteria were included in the study. Off-service patients, transfer patients, and patients discharged before screening (usually admitted and discharged within 72 hours) were excluded. Data were collected on 173 patients.Statistical analysis performed At-risk and not at-risk patients were compared for LOS, costs and reimbursement, and discharge placement (to home, to home with home health care services, or to another facility for further care). Two sample t tests and α survival analysis technique were used to compare continuous variables between the two study cohorts. Nonparametric tests were used for LOS and readmission data. χ² Tests were used for categoric variables. An a level of 0.05 was used throughout to determine statistical significance.Results Median LOS in the not-at-risk population (n=56) was significantly greater than in the not-at-risk population (n= 117): 6 days (25th percentile=4 days, 75th percentile-8 days) vs 4 days (25th percentile=3 days, 75th percentile=7 days) (P<0.01).Mean hospitalization cost per patient was also higher in the at-risk group ($6,196 vs $4,563, P<0.02). Readmission rate per month of follow-up was not significantly different. At-risk patients were significantly less likely to be discharged home with self-care (23 [41%] vs 77 [66%], P<0.05). At-risk patients were significantly more likely to use home health care service than not-at-risk patients (17 [31%] vs 14 or [12%], P<0.001).Applications Patients at risk for malnutrition had significantly higher LOS, costs, and home health care needs, despite the fact that 51, or 91%, received nutrition intervention while hospitalized. Further research should explore the use of nutrition screening and intervention before, during, and after hospitalization to ensure that appropriate nutrition intervention, as indicated by medical patients’ clinical condition and nutritional risk status, is initiated and continued.