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ANTICOAGULATION

Postdischarge Oral Versus Injectable Anticoagulation Following Major Orthopedic Surgery

Associate Director, Pulmonary and Critical Care, Washington Hospital Center; Associate Professor of Medicine, Georgetown University, Washington Hospital Center, Washington, DC

Edith A Nutescu, PharmD FCCP

Clinical Associate Professor, Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL

Eileen Farrelly, MPH

Associate Director, Xcenda, Palm Harbor, FL

Ruslan Horblyuk, MBA

Health Outcomes Scientist, Cardiovascular/Metabolic/Oncology, GlaxoSmithKline, Philadelphia, PA

Laura E Happe, PharmD

Associate Director, Xcenda

Meg Franklin, PhD

Assistant Director, Xcenda

Reprints: Dr. Happe, Xcenda, 4114 Woodlands Parkway, Ste. 500, Palm Harbor, FL 34685, fax 727/771-4144, laura.happe{at}xcenda.com

BACKGROUND: Multiple clinical studies have shown postdischarge anticoagulation to be beneficial following major orthopedic surgery (MOS); however, outpatient prophylaxis is not widely practiced.

OBJECTIVE: To quantify, from a third-party payer perspective, real-world clinical and economic outcomes for patients receiving injectable or oral anticoagulation as prophylaxis for venous thromboembolism (VTE) following discharge after MOS.

METHODS: A retrospective database analysis was conducted using outpatient medical and pharmacy data from the PharMetrics Patient-Centric Database (January 1, 2002, to March 31, 2006). Patients greater than 18 years of age with 9 months of continuous eligibility who received an anticoagulant in the outpatient setting following MOS were eligible. Patients were stratified into 2 cohorts: injectable (dalteparin, enoxaparin, fondaparinux) and oral (warfarin), and were matched 1:1 on demographic and clinical characteristics.

RESULTS: A total of 12,724 patients were included (injectable, 6362; oral, 6362). At 90 days, patients receiving oral anticoagulation were 20% more likely to experience a VTE than were those receiving an injectable agent (7.4% vs 6.3%; p = 0.02, OR 1.18; 95% CI 1.03 to 1.36). No significant differences in bleeding were observed (<0.4%). The average adjusted total 6-month costs were significantly (p < 0.001) higher for the oral versus injectable cohort ($18,039 vs $16,429). Medical costs in the oral cohort offset the higher pharmacy costs in the injectable cohort.

CONCLUSIONS: This study demonstrates that the risk of VTE extends to the outpatient setting following MOS, even with postdischarge anticoagulation. Injectable agents used in the outpatient setting may result in fewer clinical VTEs without increasing the risk for major bleeding. These findings support the data from controlled clinical studies and expand the evidence to the real-world setting. Despite higher pharmacy acquisition costs for injectable anticoagulants, injectable agents may offer significant per patient savings to third party payers.

Key Words: anticoagulation, major orthopedic surgery, prophylaxis, venous thromboembolism

Published Online, July 29, 2008. www.theannals.com, DOI 10.1345/aph.1L113