0.12% Can Still Add Up to Big Dollars
Tuesday, November 1, 2005
PTINR.com Staff
Even the best clinics experience the consequences of over anticoagulation. Costs in today's environment can erase any chance of profitability.
Anticoagulation clinics have always wondered how they compare to others in their own city, state of region. Systematic clinic care has prevailed as the standard of care providing improved patient outcomes over usual care. Cost and time-savings are byproducts of improved clinic efficiencies in managing chronic warfarin (Coumadin ®) patients.The American College of Chest Physicians sites fewer hospitalizations and emergency department visits resulting in anticoagulation management services. A cost saving of $1,000 in “cost-avoidance” per patient year was observed in a 1998 published study by Chiquette & Bussey in Archives of Internal Medicine.
Brigham and Women’s anticoagulation service represents one of the more highly developed clinic models and a review of their bleeding events and costs appeared recently in the American Journal of Cardiology.
An increase in major bleeding prompted a study to evaluate the causes of hospital admissions. Over a 3-year period the investigators evaluated 2,460 clinic patients managed by a multidisciplinary team of nurses, pharmacists and physician assistants. The clinic operates on a 1 health care provider for every 350 patients ratio. The following represents a breakdown of their patient mix.
- Patients by Indication
- Atrial Fibrillation 30%
- Venous Thromboembolic Disease 28%
- Mechanical Heart Valve 15%
- Other 27%
The clinic recorded a very low 0.12%/year major bleeding rate for their population. There were a total of 11 patients that experienced a major bleeding events requiring hospitalization. Despite the extremely low incidence of major bleeding requiring hospitalization – healthcare costs were extremely high.
Not surprising, the majority of bleeding events resulted when patients were out of their respective target range. Eighty-three percent of the bleeds resulted when patients were higher than INR = 3.0. Two of the 5 intracranial hemorrhages occurred in INR values above 4.0.
Cost Analysis
Despite lower than average major bleeding complications and no patient deaths, costs escalated quickly. The average cost per bleed was $15,988 - far greater than the revenue generated by 20 patients that never experienced an adverse event. The length of stays ranged between 1 to 14 days. The least expensive cost was $2,707 resulting in a 29-year old woman with an aortic valve replacement. Her INR at the time of her event was 3.2 against a target range of 2.0-2.5. The total cost of the 12 hospital admissions (one patient was admitted twice) during the four-year study was: $175,873.
(Am J Cardiology, 2005:96:595-598)
Even the most dedicated and well-trained anticoagulation professionals face challenges of reducing major bleeds requiring hospitalization. Forty-two percent of bleeding events were intracranial bleeds. This rate was on the higher side of other comparative studies. Intracranial bleeds resulted in a higher than average length of stay compared to GI bleeds or transfusions.
- Key Learnings Include:
- Even highly advanced clinics experience significant bleeding costs
- 50% of bleeding events occurred during the first 90 days of treatment
- Only 1 patient suffered a major bleed in target range
- 0 events were a result of drug-drug interactions
- There was no correlation between duration of therapy and hospital cost
Evidence has always supported a close relationship between time in range and avoidance of major bleeding events. The time between INR tests remains a critical factor in improving INR control and reducing major bleeding.
Eleven trials have demonstrated improved INR control leading to fewer bleeds and strokes. Shortening the interval of testing is suggested as a cost-effective tool for patients. Education, training and shortening the interval between testing will decrease major bleeding risks further and make warfarin an even more cost-effective therapy.