Bobade Rohit A, Helmers Richard A, Jaeger Thomas M, Odell Laura J, Haas Derek A, Kaplan Robert S
a Surgical Specialties Division , Mayo Clinic Health System , La Crosse , WI , USA.
b Critical Care Medicine , College of Medicine , Mayo Clinic, Eau Claire , WI , USA.
J Med Econ. 2019 May;22(5):471-477. doi: 10.1080/13696998.2019.1582058. Epub 2019 Mar 4.
To determine how overall cost of anticoagulation therapy for warfarin compares with that of Novel Oral Anticoagulants (NOACs). Also, to demonstrate a scientific, comprehensive, and an analytical approach to estimate direct costs involved in monitoring and management of anticoagulation therapy for outpatients in an academic primary care clinic setting, post-initiation of therapy.
A population-based cross-sectional study was conducted in conjunction with observations of patient care processes between August 2014 and January 2015. The study was conducted in an academic primary care outpatient setting at Mayo Clinic's warfarin anticoagulation clinic, Rochester, MN. The anticoagulation clinic serves patients 18 years of age or older in Warfarin therapy management, for any indication, after referral from the patient's primary care provider. The study included anticoagulation clinic enrollment data on a population of 5,526 patients. Time-Driven Activity-Based Costing (TDABC) technique was applied. Detailed process flow maps which showed process steps for all the anticoagulation program components and care continuum phases were created. Staff roles associated with each of the process steps were identified and displayed on the maps. Process times and costs were captured and analyzed. The main outcome was direct cost of monitoring and management of anticoagulation therapy, post-initiation of therapy.
The cost of warfarin management for patients who display unstable International Normalized Ratio (INR) is more than three times those who display stable INR over time. (Comparator to distinguish stability: Frequency of point-of-care visits needed by patients.) For complex anticoagulation patients, total cost of medication and monitoring for warfarin anticoagulation therapy is similar to that for NOACs.
Despite warfarin being significantly less expensive to purchase than NOACs, overall warfarin management incurs higher costs due to laboratory monitoring and provider time than NOACs. NOAC treatment, therefore, may not be more expensive than warfarin therapy management for complex anticoagulation patients.
确定华法林抗凝治疗的总体成本与新型口服抗凝剂（NOACs）相比如何。此外，展示一种科学、全面且分析性的方法，以估算学术初级保健诊所环境中门诊患者抗凝治疗启动后监测和管理所涉及的直接成本。
2014年8月至2015年1月期间，结合对患者护理过程的观察进行了一项基于人群的横断面研究。该研究在明尼苏达州罗切斯特市梅奥诊所的华法林抗凝门诊的学术初级保健门诊环境中进行。抗凝门诊为18岁及以上接受华法林治疗管理的患者提供服务，无论任何适应症，均由患者的初级保健提供者转诊而来。该研究纳入了5526名患者的抗凝门诊登记数据。应用了时间驱动作业成本法（TDABC）技术。创建了详细的流程地图，展示了所有抗凝项目组成部分和护理连续阶段的流程步骤。确定了与每个流程步骤相关的工作人员角色并显示在地图上。记录并分析了流程时间和成本。主要结果是治疗启动后抗凝治疗监测和管理的直接成本。
国际标准化比值（INR）不稳定的患者的华法林管理成本是随着时间推移INR稳定的患者的三倍多。（区分稳定性的比较标准：患者所需的即时护理就诊频率。）对于复杂抗凝患者，华法林抗凝治疗的药物和监测总成本与NOACs相似。
尽管华法林的购买成本远低于NOACs，但由于实验室监测和医生时间，华法林的总体管理成本高于NOACs。因此，对于复杂抗凝患者，NOAC治疗可能并不比华法林治疗管理更昂贵。
