1
|
Martinazzi BJ, Kirchner GJ, Stauch CM, Lorenz FJ, Manto KM, Bonaddio V, Koroneos Z, Aynardi MC. Cost-Effective Modeling of Thromboembolic Chemoprophylaxis for Total Ankle Arthroplasty. Foot Ankle Int 2022; 43:1379-1384. [PMID: 35899685 PMCID: PMC9527361 DOI: 10.1177/10711007221112922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Symptomatic venous thromboembolism (VTE) following total ankle arthroplasty (TAA) can cause substantial morbidity and mortality. To prevent this complication, surgeons often prescribe postoperative chemoprophylaxis. However, much controversy exists regarding the efficacy of chemoprophylaxis because of the limited studies exploring its use. Furthermore, even less is known about its cost-effectiveness. Therefore, this study sought to determine the cost-effectiveness of commonly prescribed chemoprophylactic agents using a break-even analysis economic model. METHODS The literature was searched, and an online database was used to identify patients who developed a symptomatic VTE after undergoing TAA. Our institutional records were used to estimate the cost of treating a symptomatic VTE, and an online drug database was used to obtain the cost of commonly prescribed chemoprophylactic agents. A break-even analysis was then performed to determine the final break-even rate necessary to make a drug cost-effective. RESULTS The low and high rates of symptomatic VTE were determined to be 0.46% and 9.8%. From 2011 to 2021, a total of 3455 patients underwent total ankle arthroplasty. Of these patients, 16 developed a postoperative symptomatic VTE (1.01%). Aspirin 81 mg was cost-effective if the initial symptomatic VTE rates decreased by an absolute risk reduction (ARR) of 0.0003% (NNT = 31 357). Aspirin 325 mg was also cost-effective if the initial rates decreased by an ARR 0.02% (NNT = 5807). Likewise, warfarin (5 mg) was cost-effective at all initial rates with an ARR of 0.02% (NNT = 4480). In contrast, enoxaparin (40 mg) and rivaroxaban (20 mg) were only cost-effective at higher initial symptomatic VTE rates with ARRs of 1.48% (NNT = 68) and 5.36% (NNT = 19). Additional analyses demonstrated that enoxaparin (40 mg) and rivaroxaban (20 mg) become cost-effective when costs of treating a symptomatic VTE are higher than our estimates. CONCLUSION Chemoprophylaxis following TAA can be cost-effective. A tailored approach to VTE prophylaxis with cost-effectiveness in mind may be beneficial to the patient and health system.
Collapse
Affiliation(s)
- Brandon J Martinazzi
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Gregory J Kirchner
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Christopher M Stauch
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - F Jeffrey Lorenz
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Kristen M Manto
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Vincenzo Bonaddio
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Zachary Koroneos
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Michael C Aynardi
- Department of Orthopaedics & Rehabilitation, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
2
|
Kamath CC, Giblon R, Kunneman M, Lee AI, Branda ME, Hargraves IG, Sivly AL, Bellolio F, Jackson EA, Burnett B, Gorr H, Torres Roldan VD, Spencer-Bonilla G, Shah ND, Noseworthy PA, Montori VM, Brito JP. Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2116009. [PMID: 34255051 PMCID: PMC8278261 DOI: 10.1001/jamanetworkopen.2021.16009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
IMPORTANCE How patients with atrial fibrillation (AF) and their clinicians consider cost in forming care plans remains unknown. OBJECTIVE To identify factors that inform conversations regarding costs of anticoagulants for treatment of AF between patients and clinicians and outcomes associated with these conversations. DESIGN, SETTING, AND PARTICIPANTS This cohort study of recorded encounters and participant surveys at 5 US medical centers (including academic, community, and safety-net centers) from the SDM4AFib randomized trial compared standard AF care with and without use of a shared decision-making (SDM) tool. Included patients were considering anticoagulation treatment and were recruited by their clinicians between January 30, 2017, and June 27, 2019. Data were analyzed between August and November 2019. MAIN OUTCOMES AND MEASURES The incidence of and factors associated with cost conversations, and the association of cost conversations with patients' consideration of treatment cost burden and their choice of anticoagulation. RESULTS A total of 830 encounters (out of 922 enrolled participants) were recorded. Patients' mean (SD) age was 71.0 (10.4) years; 511 patients (61.6%) were men, 704 (86.0%) were White, 303 (40.9%) earned between $40 000 and $99 999 in annual income, and 657 (79.2%) were receiving anticoagulants. Clinicians' mean (SD) age was 44.8 (13.2) years; 75 clinicians (53.2%) were men, and 111 (76%) practiced as physicians, with approximately half (69 [48.9%]) specializing in either internal medicine or cardiology. Cost conversations occurred in 639 encounters (77.0%) and were more likely in the SDM arm (378 [90%] vs 261 [64%]; OR, 9.69; 95% CI, 5.77-16.29). In multivariable analysis, cost conversations were more likely to occur with female clinicians (66 [47%]; OR, 2.85; 95% CI, 1.21-6.71); consultants vs in-training clinicians (113 [75%]; OR, 4.0; 95% CI, 1.4-11.1); clinicians practicing family medicine (24 [16%]; OR, 12.12; 95% CI, 2.75-53.38]), internal medicine (35 [23%]; OR, 3.82; 95% CI, 1.25-11.70), or other clinicians (21 [14%]; OR, 4.90; 95% CI, 1.32-18.16) when compared with cardiologists; and for patients with an annual household income between $40 000 and $99 999 (249 [82.2%]; OR, 1.86; 95% CI, 1.05-3.29) compared with income below $40 000 or above $99 999. More patients who had cost conversations reported cost as a factor in their decision (244 [89.1%] vs 327 [69.0%]; OR 3.66; 95% CI, 2.43-5.50), but cost conversations were not associated with the choice of anticoagulation agent. CONCLUSIONS AND RELEVANCE Cost conversations were common, particularly for middle-income patients and with female and consultant-level primary care clinicians, as well as in encounters using an SDM tool; they were associated with patients' consideration of treatment cost burden but not final treatment choice. With increasing costs of care passed on to patients, these findings can inform efforts to promote cost conversations in practice. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02905032.
Collapse
Affiliation(s)
- Celia C. Kamath
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Rachel Giblon
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Marlene Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander I. Lee
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Megan E. Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Colorado School of Public Health, Anschutz Medical Campus, University of Colorado, Denver, Aurora
| | - Ian G. Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Angela L. Sivly
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Elizabeth A. Jackson
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Lois Park, Minnesota
| | - Haeshik Gorr
- Division of General Internal Medicine, Hennepin Health, Minneapolis, Minnesota
| | - Victor D. Torres Roldan
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Peter A. Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Juan P. Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
3
|
Zeballos-Palacios CL, Hargraves IG, Noseworthy PA, Branda ME, Kunneman M, Burnett B, Gionfriddo MR, McLeod CJ, Gorr H, Brito JP, Montori VM. Developing a Conversation Aid to Support Shared Decision Making: Reflections on Designing Anticoagulation Choice. Mayo Clin Proc 2019; 94:686-696. [PMID: 30642640 PMCID: PMC6450705 DOI: 10.1016/j.mayocp.2018.08.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/02/2018] [Accepted: 08/29/2018] [Indexed: 12/31/2022]
Abstract
Patient-centered care requires that treatments respond to the problematic situation of each patient in a manner that makes intellectual, emotional, and practical sense, an achievement that requires shared decision making (SDM). To implement SDM in practice, tools-sometimes called conversation aids or decision aids-are prepared by collating, curating, and presenting high-quality, comprehensive, and up-to-date evidence. Yet, the literature offers limited guidance for how to make evidence support SDM. Herein, we describe our approach and the challenges encountered during the development of Anticoagulation Choice, a conversation aid to help patients with atrial fibrillation and their clinicians jointly consider the risk of thromboembolic stroke and decide whether and how to respond to this risk with anticoagulation.
Collapse
Affiliation(s)
| | - Ian G. Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Peter A. Noseworthy
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Megan E. Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Louis Park, MN, USA
| | | | - Christopher J. McLeod
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Haeshik Gorr
- Department of Medicine, Hennepin Healthcare System, Minneapolis, MN, USA
| | - Juan Pablo Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
4
|
Tripathi MM, Egawa S, Wirth AG, Tshikudi DM, Van Cott EM, Nadkarni SK. Clinical evaluation of whole blood prothrombin time (PT) and international normalized ratio (INR) using a Laser Speckle Rheology sensor. Sci Rep 2017; 7:9169. [PMID: 28835607 PMCID: PMC5569083 DOI: 10.1038/s41598-017-08693-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 07/12/2017] [Indexed: 11/22/2022] Open
Abstract
Prothrombin time (PT) and the associated international normalized ratio (INR) are routinely tested to assess the risk of bleeding or thrombosis and to monitor response to anticoagulant therapy in patients. To measure PT/INR, conventional coagulation testing (CCT) is performed, which is time-consuming and requires the separation of cellular components from whole blood. Here, we report on a portable and battery-operated optical sensor that can rapidly quantify PT/INR within seconds by measuring alterations in the viscoelastic properties of a drop of whole blood following activation of coagulation with thromboplastin. In this study, PT/INR values were measured in 60 patients using the optical sensor and compared with the corresponding CCT values. Our results report a close correlation and high concordance between PT/INR measured using the two approaches. These findings confirm the accuracy of our optical sensing approach for rapid PT/INR testing in whole blood and highlight the potential for use at the point-of-care or for patient self-testing.
Collapse
Affiliation(s)
- Markandey M Tripathi
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Satoru Egawa
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Department of Precision Engineering, University of Tokyo, Tokyo, Japan
| | - Alexandra G Wirth
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Diane M Tshikudi
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Elizabeth M Van Cott
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Seemantini K Nadkarni
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| |
Collapse
|
5
|
Ahmed Z, Hassan S, Salzman GA. Novel Oral Anticoagulants for Venous Thromboembolism with Special Emphasis on Risk of Hemorrhagic Complications and Reversal Agents. CURRENT DRUG THERAPY 2016; 11:3-20. [PMID: 27594818 PMCID: PMC5003057 DOI: 10.2174/1574885511666160421145036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 03/08/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022]
Abstract
Warfarin was the only oral anticoagulant available for the treatment of venous thromboembolism for about half a century until the recent approval of novel oral agents dabigatran, rivoraxaban and apixaban. This presents new classes of medications less cumbersome to use. They do not require frequent laboratory monitoring or have nurmerous drug interactions. On the other hand it also poses a challenge to the physicians deciding which agent to use in specific patient populations, how to predict the bleeding risk compared to warfarin and between the different novel agents and how to manage bleeding with relatively recent discovery of few potential antidotes. This review summarizes the major trials that led to the approval of these agents and their exclusion criteria helping physicians understand which patient types might not benefit from these agents. It provides clinical pearls invaluable in everyday practice such as transitioning between traditional and novel anticoagulants, dose adjustments for high risk populations, drug interactions and cost analysis. Futhermore, the review provides direct comparisons with warfarin and indirect comparisons among the novel agents in terms of efficacy and bleeding risk narrating the numbers of patients with intracranial, gastrointestinal and fatal hemorrhages in each of the major trials. We hope that this review will help the physicians inform their patients about the benefits and risks of these agents and enable them to make an informed selection of the most appropriate anticoagulant.
Collapse
Affiliation(s)
- Zaheer Ahmed
- University of Missouri, Kansas City School of Medicine, Kansas City, MO,USA
| | - Seemeen Hassan
- University of Missouri, Kansas City School of Medicine, Kansas City, MO,USA
| | - Gary A Salzman
- University of Missouri, Kansas City School of Medicine, Kansas City, MO,USA
| |
Collapse
|
6
|
Abstract
OBJECTIVES To project the cost-effectiveness of population-based echo screening to prevent rheumatic heart disease (RHD) consequences. BACKGROUND RHD is a leading cause of cardiovascular mortality and morbidity during adolescence and young adulthood in low- and middle-per capita income settings. Echocardiography-based screening approaches can dramatically expand the number of children identified at risk of progressive RHD. Cost-effectiveness analysis can inform public health agencies and payers about the net economic benefit of such large-scale population-based screening. METHODS A Markov model was constructed comparing a no-screen to echo screen approach. The echo screen program was modeled as a 2-staged screen of a cohort of 11-year-old children with initial short screening performed by dedicated technicians and follow-up complete echo by cardiologists. Penicillin RHD prophylaxis was modeled to only reduce rheumatic fever recurrence-related exacerbation. Quality-adjusted life years (QALYs) and societal costs (in 2010 Australian dollars) associated with each approach were estimated. One-way, two-way and probabilistic sensitivity analyses were performed on RHD prevalence and transition probabilities; echocardiography test characteristics; and societal level costs including supplies, transportation, and labor. RESULTS The incremental costs and QALYs of the screen compared to no screen strategy were -$432 (95% CI = -$1357 to $575) and 0.007 (95% CI = -0.0101 to 0.0237), respectively. The joint probability that the screen was both less costly and more effective exceeded 80%. Sensitivity analyses suggested screen strategy dominance depends mostly on the probability of transitioning out of sub-clinical RHD. CONCLUSION Two-stage echo RHD screening and secondary prophylaxis may achieve modestly improved outcomes at lower cost compared to clinical detection and deserves closer attention from health policy stakeholders.
Collapse
Affiliation(s)
- Justin P Zachariah
- Department of Cardiology, Boston Children's Hospital , Boston, MA , USA and
| | | |
Collapse
|
7
|
Amin A. Oral anticoagulation to reduce risk of stroke in patients with atrial fibrillation: current and future therapies. Clin Interv Aging 2013; 8:75-84. [PMID: 23378750 PMCID: PMC3556861 DOI: 10.2147/cia.s37818] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Atrial fibrillation (AF) is associated with an increased incidence and severity of strokes. The burden of AF-related stroke is expected to increase in parallel with the aging of the population. Oral anticoagulation with warfarin has been the pharmacologic standard for stroke risk reduction in patients with AF. When used with close attention to dosing and monitoring, warfarin is effective prophylactic therapy against thromboembolic stroke. However, it is underused by physicians, in part because of the known risks of adverse events with warfarin. Consequently, many patients with AF live with an avoidably elevated risk of stroke. New options, ie, oral anticoagulants with novel mechanisms of action, have recently been approved to reduce the risk of stroke in AF, and others are in development. These newer agents may address some of the complexities of warfarin use while providing similar or better efficacy and safety.
Collapse
Affiliation(s)
- Alpesh Amin
- Hospitalist Program, University of California, Irvine, Orange, CA 92868, USA.
| |
Collapse
|