Economic consequences of severe bleeding in patients with acute coronary syndrome in the USA

Abstract

Previous studies have demonstrated increased costs associated with bleeding in clinical trials, but none have yet examined the association of bleeding with costs/charges in a real-world setting. This study examines the association between health care charges and severe bleeding events among patients with acute coronary syndrome (ACS) in a real-world US setting. This retrospective study of ACS patients enrolled in a regional, 570,000-member commercial health plan evaluated resource utilization for patients with and without severe bleeding using medical encounter data in health care administrative records. Inclusion criteria were continuous health plan enrollment in the 6 months before initial ACS-related hospitalization, age of at least 18 years, and an inpatient ACS claim between January 1995 and May 2007. Severe bleeding events were defined as having an in-hospital record for: (a) bleeding plus blood transfusion, (b) intracranial hemorrhage, or (c) blood transfusion followed by death. Hospitalizations in which the patient had a nonsevere bleeding event, defined as having an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for bleeding without transfusion or death, were removed from analysis. Resource utilization was assessed using hospital charges. Multiple linear regression analyses controlling for key covariates were used to assess the association of severe bleeding during initial hospitalization with an ACS diagnosis/procedure with charges and length of stay (LOS). There were 11,266 ACS patients identified: 928 patients (8.2%) had severe bleeding during initial hospitalization. Severe bleeding events were associated with significantly higher hospital charges and increased LOS than hospitalizations without severe bleeding events. After adjusting for patient characteristics, in-hospital ACS-related procedures, and LOS, patients with severe bleeding incurred initial hospitalization charges that were $48,114 higher than those of patients without bleeding (P<0.001). In a real-world setting, hospitalizations with both severe bleeding and an ACS diagnosis or procedure are associated with significantly higher hospitalization charges and resource use compared with ACS-related hospitalizations without bleeding events. However, due to the limitations of retrospective analyses, no causal relationship can be determined as patient comorbidities represent a possible source of confounding.