Wang Li, Baser Onur, Wells Phil, Peacock W Frank, Coleman Craig I, Fermann Gregory J, Schein Jeff, Crivera Concetta
STATinMED Research, Plano, Texas.
Center for Innovation & Outcomes Research, Department of Surgery, Columbia University and STATinMED Research, New York, New York.
Clin Ther. 2017 Jul;39(7):1426-1436.e2. doi: 10.1016/j.clinthera.2017.06.002. Epub 2017 Jun 23.
Due to limited evidence on the impact of rivaroxaban in clinical practice, we compared the effectiveness of rivaroxaban versus standard of care (SOC) among patients in the Veterans Health Administration.
Adult patients with continuous enrollment in a health plan with medical and pharmacy benefits for ≥12 months before and ≥3 months after an inpatient diagnosis of pulmonary embolism (PE) between October 1, 2011, and June 30, 2015, and a prescription claim for an anticoagulant during the index hospitalization, were included. SOC drugs were low-molecular-weight heparin, unfractionated heparin, and warfarin. Propensity score matching was used in comparing PE-related outcomes (recurrent venous thromboembolism, major bleeding, and death), hospital-acquired complications (HACs), health care resource utilization, and costs among patients receiving SOC versus rivaroxaban. We defined net clinical benefit as 1 minus the combined rate of PE-related outcomes and HACs.
Among 6746 patients with PE, 208 received rivaroxaban, 4641 received SOC and 1897 received other anticoagulants. Most (95%) were male; 22% were black. After 1:3 propensity score matching, there were 203 rivaroxaban and 609 SOC patients. During the 90-day follow-up, rivaroxaban users had similar rates of PE-related outcomes, but fewer had experienced at least 1 HAC (10.3% vs 15.9%; P = 0.0506), resulting in better net clinical benefit (82.8% vs 71.1%; P = 0.001). Rivaroxaban users had fewer outpatient visits per patient (17.0 vs 19.9; P = 0.0005), a similar rehospitalization rate (0.2 vs 0.3; P = 0.084), lesser inpatient costs (US $3501 vs $6189; P < 0.0001), lesser inpatient costs and lesser total costs ($10,545 vs $14,192; P = 0.0002). When the sample was limited to patients with low-risk PE, we found similar patterns.
Patients with PE prescribed rivaroxaban had similar PE-related outcomes, but fewer HACs and lesser total costs, than did patients on SOC.
由于利伐沙班在临床实践中的影响证据有限，我们比较了退伍军人健康管理局中利伐沙班与标准治疗（SOC）的有效性。
纳入2011年10月1日至2015年6月30日期间，在住院诊断为肺栓塞（PE）之前连续参加健康计划且拥有医疗和药房福利≥12个月，以及之后≥3个月，且在索引住院期间有抗凝剂处方索赔的成年患者。SOC药物为低分子量肝素、普通肝素和华法林。在比较接受SOC与利伐沙班治疗的患者的PE相关结局（复发性静脉血栓栓塞、大出血和死亡）、医院获得性并发症（HACs）、医疗资源利用和成本时，使用倾向评分匹配。我们将净临床获益定义为1减去PE相关结局和HACs的合并发生率。
在6746例PE患者中，208例接受利伐沙班治疗，4641例接受SOC治疗，1897例接受其他抗凝剂治疗。大多数（95%）为男性；22%为黑人。经过1:3倾向评分匹配后，有203例利伐沙班治疗患者和609例SOC治疗患者。在90天的随访期间，利伐沙班使用者的PE相关结局发生率相似，但经历至少1次HAC的患者较少（10.3%对15.9%；P = 0.0506），从而产生了更好的净临床获益（82.8%对71.1%；P = 0.001）。利伐沙班使用者每位患者的门诊就诊次数较少（17.0次对19.9次；P = 0.0005），再住院率相似（0.2对0.3；P = 0.084），住院费用较低（3501美元对6189美元；P < 0.0001），住院费用和总费用较低（10545美元对14192美元；P = 0.0002）。当样本仅限于低风险PE患者时，我们发现了类似的模式。
与接受SOC治疗的患者相比，接受利伐沙班治疗的PE患者的PE相关结局相似，但HACs较少，总费用较低。
