Premier Perspective Comparative Hospital Database Research Articles

Digoxin Toxicity and Use of Digoxin Immune Fab: Insights From a National Hospital Database

ObjectivesThis study was developed to determine contemporary management of digoxin toxicity and clinical outcomes. BackgroundAlthough the use of digoxin in heart failure management has declined, toxicity remains a prevalent complication. MethodsThe Premier Perspective Comparative Hospital Database (Premier Inc., Charlotte, North Carolina) was used to retrospectively identify patients diagnosed with digoxin toxicity and/or who received digoxin immune fab (DIF) over a 5-year period (2007 to 2011). DIF was evaluated using treatment date, number of vials administered, and total cost. Clinical outcomes included length of stay (total hospitalization; days after DIF), cost of hospitalization, and in-hospital mortality. Exploratory multivariate analyses were conducted to determine predictors of DIF and effect on length of stay, adjusting for patient characteristics and selection bias. ResultsDigoxin toxicity diagnosis without DIF treatment accounted for 19,543 cases; 5,004 patients received DIF of whom 3086 had a diagnosis of toxicity. Most patients were >65 years old (88%). The predictors of DIF use were urgent/emergent admission, hyperkalemia, arrhythmia associated with digoxin toxicity, acute renal failure, or suicidal intent (odds ratios 1.7, 2.4, 3.6, 2.1, and 3.7, respectively; p < 0.0001 for all). The majority (78%) of DIF was administered on days 1 and 2 of the hospitalization; 10% received treatment after day 7. Digoxin was used after DIF administration in 14% of cases. Among patients who received DIF within 2 days of admission, there was no difference for in-hospital mortality or length of stay compared with patients not receiving DIF. ConclusionsDigoxin toxicity diagnoses are clustered in the elderly. One-fifth of cases receive treatment with DIF, most within 2 days of admission. Opportunities exist for improved diagnosis and post-DIF management. Prospective data may be required to assess the impact of DIF on length of stay.

Daily costs of hospitalization in non-valvular atrial fibrillation patients treated with anticoagulant therapy

Background:Atrial fibrillation (AF) is the most common cardiac rhythm disturbance in the US, with an estimated prevalence of 2.7–6.1 million persons in 2010.Objective:This study evaluates the progression of daily hospitalization costs among non-valvular atrial fibrillation (NVAF) patients treated with anticoagulant therapy.Methods:A claims analysis was conducted with Premier Perspective Comparative Hospital Database records from January 2009–March 2013. Patients of 18 years or older who were diagnosed with NVAF and used anticoagulant therapy were studied. Treatment patterns and mean daily costs of hospitalization per patient as well as total costs of hospitalization were reported. Comparisons of mean daily costs with those of the previous day were presented to identify statistical cost differences between hospitalization days.Results:A total of 375,560 patients were identified; 67,017 with AF as admitting/primary diagnosis, and 308,543 with AF as a secondary diagnosis. The mean age of the overall population, primary AF diagnosis cohort, and secondary AF diagnosis cohort was 73.8, 67.9, and 75.0 years, while their proportion of females was 46.3%, 45.6%, and 46.5%, respectively. The mean length of stay was 6.8 days, 3.7 days, and 7.5 days for the overall population, the primary AF diagnosis cohort, and the secondary AF diagnosis cohort, respectively. For all cohorts, mean daily costs stabilized on the third day (overall population: $2103; primary AF diagnosis cohort: $1505; secondary AF diagnosis cohort: $2208).Limitations:Claims data may have contained inaccuracies or omissions in coded procedures, diagnoses, or pharmacy claims.Conclusion:The study showed that daily hospitalization costs for NVAF patients stabilized on the third day of hospitalization and that any reduction or prolongation in hospital length of stay could have a significant impact on the cost burden associated with AF.

Daily Hospitalization Costs in Patients with Deep Vein Thrombosis or Pulmonary Embolism Treated with Anticoagulant Therapy

BackgroundVenous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), affects about 900,000 persons in the United States each year. ObjectivesTo quantify the progression of daily hospitalization costs among DVT and PE patients. Patients/MethodsA retrospective claims analysis was conducted from 01/01/2009 to 03/01/2013 using the Premier Perspective Comparative Hospital Database. Patients ≥18years of age with an admitting/primary diagnosis of DVT or PE and receiving anticoagulant therapy were identified. Treatment patterns, mean daily costs, and total hospitalization costs were reported for the DVT and PE populations. Comparisons of mean daily costs with those of the previous day were presented to identify statistical cost differences between hospitalization days. ResultsA total of 28,953 and 35,550 patients were identified with a diagnosis of DVT and PE, respectively. The daily costs were at their highest during the first three days for DVT patients at $2,321, $1,875, and $1,558, respectively. Similar results were found for PE patients with costs at their highest in the first three days, at $2,981, $2,034, and $1,564, respectively. Among the DVT and PE populations, mean daily costs were $1,594 and $1,735, respectively, and daily hospitalization costs became stable on the third day of the hospitalization (standardized differences <10%). ConclusionsDaily hospitalization costs of patients with an admitting/primary diagnosis of DVT or PE were high in the first days and became stable on the third day. It was further suggested that any change in the LOS could significantly affect hospitalization costs.

Hospital Length of Stay of Nonvalvular Atrial Fibrillation Patients who Were Administered Rivaroxaban versus Warfarin with and without Pretreatment Parenteral Anticoagulants Therapies

Background: Warfarin has been the only anticoagulant used for decades to prevent strokes and systemic embolisms in nonvalvular atrial fibrillation (NVAF) patients. Compared with rivaroxaban, warfarin has a narrow therapeutic range and many genetic and food–drug interactions that could potentially prolong hospital length of stay (LOS).Objective: To compare hospital LOS between NVAF patients who were administered rivaroxaban versus warfarin with and without pretreatment of parenteral anticoagulant agents in a population of rivaroxaban-treated patients.Methods: A retrospective matched-cohort analysis was conducted using the Premier Perspective Comparative Hospital Database from November 2010 to September 2012. Adult patients were included in the study if they had a hospitalization for NVAF. Rivaroxaban users were matched with up to 4 warfarin users based on propensity score analyses. Patients with and without pretreatment of parenteral anticoagulant agents were evaluated separately. Hospital LOS was compared between treatment groups using generalized estimating equations.Results: The matched cohorts' characteristics were well balanced. Among the matched rivaroxaban and warfarin users who were administered parenteral agents, the mean age of the cohorts was 70 years and 47% of patients were female, whereas in the sample of patients who were not administered parenteral agents, the mean age was 72 years and 50% of patients were female. In the sample of patients who were administered parenteral agents, rivaroxaban users had significantly shorter hospital LOS (LOS difference: 1.38 days, P < 0.001) compared with warfarin users among rivaroxaban-treated patients. No significant difference in LOS was found in the sample of patients who were not administered parenteral anticoagulant agents (P = 0.169).Conclusion: In the study sample of NVAF patients who were administered parenteral anticoagulant agents, rivaroxaban was associated with a significantly shorter hospital LOS compared with warfarin. The difference in LOS was not statistically significant in the sample of patients who were not administered parenteral anticoagulant agents.

Abstract 244: Anticoagulant Options and Inpatient Costs for Patients with Non-Valvular Atrial Fibrillation

Background: For decades, warfarin has been the primary oral anticoagulant prescribed for stroke prophylaxis in non-valvular atrial fibrillation (NVAF). With the recently introduced target specific oral anticoagulants (TSOAC), coagulation laboratory monitoring and the need to achieve and maintain the target international normalized ratio (INR) are no longer required. We hypothesized that use of a TSOAC may reduce hospitalization costs for patients with NVAF requiring stroke prophylaxis. Objective: To compare hospitalization costs between hospitalized NVAF patients using warfarin or rivaroxaban in a real-world setting. Methods: A retrospective claims analysis was conducted using the Premier Perspective Comparative Hospital Database from 11/2010 to 9/2012. Adult patients hospitalized for NVAF after November 2011 were included. The first hospitalization for NVAF was defined as the index hospitalization. Patients using rivaroxaban during hospitalization were matched with up to four warfarin users by propensity score analyses. Index hospitalization and all hospitalization (i.e., both index and readmissions occurring between November 2011 and September 2012) costs were compared between the cohorts using generalized estimating equations with gamma distribution, log link, and adjusting for the matched design. A sub-analysis was performed for patients who received their first oral anticoagulant treatment on day three or later of their hospital stay. Sensitivity analyses were also conducted on matched cohorts with a primary diagnosis of AF. Results: The characteristics of the matched cohorts (2,809 rivaroxaban and 11,085 warfarin users) were well balanced. The mean age of both cohorts was 71 years and 49% of patients were female. The average index hospitalization cost of the rivaroxaban cohort was $11,993 vs. $13,255 for the warfarin cohort, and the cost difference (CD; $1,284) was significant (P&lt;.001). Similarly, the corresponding all hospitalization cost were $13,900 vs. $16,697 for the rivaroxaban and warfarin cohorts, respectively, also significantly lower (CD= $2,798) for the rivaroxaban cohort (P&lt;.001). The subset of patients who first received oral anticoagulation on day three or after also incurred significantly lower costs with rivaroxaban compared to warfarin (index hospitalization: $15,703 vs. $20,042, CD= $4,350, P&lt;.001; all hospitalization: $18,499 vs. $24,897, CD= $6,388, P&lt;.001). In patients with a primary diagnosis of AF, the rivaroxaban cohort had significantly lower costs compared to the warfarin cohort (index hospitalization: $6,686 vs. $8,376, CD=$1,609; all hospitalization: $8,157 vs. $10,746, P&lt;.001, CD=$2,612, P&lt;.001). Conclusion: In propensity-matched cohorts of NVAF patients treated with warfarin or rivaroxaban, a TSOAC, our data demonstrated significant index and overall hospital cost reductions associated with the TSOAC strategy.

Is rivaroxaban associated with lower inpatient costs compared to warfarin among patients with non-valvular atrial fibrillation?

Background:Warfarin has been the mainstay treatment used by patients with a moderate-to-high risk of stroke due to non-valvular atrial fibrillation (NVAF). Unlike rivaroxaban, laboratory monitoring to allow the attainment of the prothrombin time international normalized ratio goal is required with warfarin, thereby potentially increasing a patient’s hospitalization costs.Objective:To compare hospitalization costs between hospitalized NVAF patients using rivaroxaban versus warfarin in a real-world setting.Methods:A retrospective claims analysis was conducted using the Premier Perspective Comparative Hospital Database from November 2010 to September 2012. The study included adult patients hospitalized for NVAF after November 2011. Patients using rivaroxaban during hospitalization were matched with up to four warfarin users by propensity score analyses. Hospitalization costs were compared between the matched cohorts using generalized estimating equations. A sub-analysis was performed for patients who were first administered their treatment on day three or later of their hospital stay. Sensitivity analyses were conducted on matched cohorts with a primary diagnosis of AF.Results:The matched cohorts’ (2809 rivaroxaban and 11,085 warfarin users) characteristics were well balanced. The mean age of cohorts was 71 years and 49% of patients were female. The average hospitalization cost of rivaroxaban users was $11,993 compared to $13,255 for warfarin users. The cost difference was significantly lower by $1284 (P < 0.001). Patients who were administered rivaroxaban treatment on day three or after incurred significantly lower hospitalization costs (cost difference: $4350; P < 0.001) compared to warfarin users. Rivaroxaban users with a primary diagnosis of AF also had significantly lower costs compared to warfarin users.Limitations:These included possible inaccuracies or omissions in diagnoses, completeness of baseline characteristics, and a study population that included patients newly initiated on and patients who continued anticoagulant therapy.Conclusion:Hospitalization costs for rivaroxaban were significantly lower than those for warfarin in NVAF patients treated with rivaroxaban.

Hospital length of stay: is rivaroxaban associated with shorter inpatient stay compared to warfarin among patients with non-valvular atrial fibrillation?

Background:Warfarin has been the mainstay treatment for prevention of stroke among patients with non-valvular atrial fibrillation (NVAF). Unlike rivaroxaban, warfarin requires laboratory monitoring to allow the attainment of the prothrombin time (PT) international normalized ratio (INR) goal, thereby potentially prolonging a patient’s hospital length of stay (LOS).Objective:To compare hospital LOS between hospitalized NVAF patients using rivaroxaban versus warfarin in a real-world setting.Methods:A retrospective claims analysis was conducted using the Premier Perspective Comparative Hospital Database from 11/2010 to 9/2012. Adult patients were included in the study if they had a hospitalization for NVAF. Patients using rivaroxaban during hospitalization were matched with up to four warfarin users by propensity score analyses. Patients who were first administered their oral anticoagulants on day 3 or later of their hospital stay were also evaluated. Comparison of hospital LOS was assessed using generalized estimating equations.Results:The characteristics of the matched cohorts were well balanced. Among the matched rivaroxaban and warfarin users (2809 and 11,085 patients, respectively), the mean age of the cohorts was 71 years and 49% of patients were female. The average (median) hospital LOS for rivaroxaban patients was 4.46 (3) days, compared to 5.27 (4) days for the warfarin cohort. The mean difference in hospital LOS of 0.81 days (19.44 hours) was found to be significant at P < 0.001. Patients who were administered rivaroxaban on day 3 of their hospital stay or later also had a significantly lower LOS compared to warfarin users.Limitations:These included inaccuracies or omissions in diagnoses, completeness of baseline characteristics, and a study population that included patients newly initiated on and patients who continued anticoagulant therapy.Conclusion:The study sample of NVAF patients receiving rivaroxaban was associated with a significantly shorter hospital length of stay compared to the sample of patients receiving warfarin.

Utilization and cost comparison of erythropoiesis-stimulating agents in inpatient and outpatient hospital settings

Objective:To compare utilization and associated costs of epoetin alfa (EPO) and darbepoetin alfa (DARB), two erythropoiesis-stimulating agents (ESAs), in patients with cancer undergoing chemotherapy and patients with chronic kidney disease (CKD) not on dialysis in inpatient and outpatient hospital settings.Methods:An analysis of medical claims recorded between January 2006 and December 2009 was conducted using the Premier Perspective Comparative Hospital database. Patients included were ≥18 years old with cancer and chemotherapy or with pre-dialysis CKD and with ≥1 claim for EPO or DARB during a hospital inpatient or outpatient treatment episode. Patients treated with both ESAs or who were receiving dialysis were excluded. Mean cumulative drug costs and dose ratios (units EPO: mcg DARB) were calculated using cumulative dose and April 2010 wholesale acquisition costs.Results:Cancer chemotherapy: 13,832 inpatient stays (EPO: 10,454; DARB: 3378) and 5590 outpatient treatment episodes (EPO: 2856; DARB: 2734) were identified. The inpatient and outpatient populations reported ESA dose ratios of 230:1 and 238:1 with DARB cost premiums of 42% (EPO: $948; DARB: $1348) and 38% (EPO: $3358; DARB: $4627), respectively. CKD: 148,746 hospital stays (EPO: 116,017; DARB: 32,729) and 11,012 outpatient treatment episodes (EPO: 6921; DARB 4091) were identified. The inpatient and outpatient populations reported ESA dose ratios of 251:1 and 257:1 with DARB cost premiums of 30% (EPO: $566; DARB: $738) and 27% (EPO: $2077; DARB: $2642), respectively.Limitations:The lack of randomization may have led to confounding by indication. In addition, statistical significance must be interpreted with caution in studies involving large samples.Conclusions:This study of 19,422 patients with cancer receiving chemotherapy and 159,758 patients with pre-dialysis CKD reported ESA dose ratios ranging from 230:1–257:1 (units EPO: mcg DARB) and associated cost premiums of 27–42% for DARB.

Methods to Identify and Compare Parenteral Nutrition Administered From Hospital‐Compounded and Premixed Multichamber Bags in a Retrospective Hospital Claims Database

Use of parenteral nutrition (PN) is indicated for patients who are unable to meet their needs enterally. PN may be administered via custom-compounded mix or commercially available ready-to-use multichamber bags (MCB), but little is known about potential differences in clinical outcomes between these delivery systems. This study was undertaken to assess the feasibility of comparing custom-compounded and MCB PN in a large hospital claims database. Hospital claims data from the Premier Perspective Comparative Hospital Database (PCD) reported from 2005 through 2007 were analyzed. The authors searched the data for patients who received any PN products, including compounded PN and MCB PN. Coding algorithms for identifying patient characteristics, risk factors, and outcomes of interest were explored. Using hospital billing claims, the authors identified patients in the database treated with premixed PN from multichamber bags ("MCB only," n = 4699) and patients treated with custom-compounded PN solution ("compounded PN," n = 64,315). Methods of identifying PN administration groups, patient characteristics and risk factors, outcomes of interest, and data limitations are described. Exploratory analysis suggests that comparisons of PN administered via compounding and MCB are possible using the Premier data. The ability to control for many identifiable risk factors allows data to be presented for the use of PN and related outcomes in both a clinically sensible and relevant manner, albeit with some limitations.

Impact of Drug Label Changes on Propofol Use in Pediatrics for Moderate Conscious Sedation

Background Drug product labeling is a critical component of communication regarding the appropriate use of medications. The information contained in a drug label is often complex, including contraindications and warnings that may be difficult to understand. In an attempt to further examine this issue, this article looks at one such difficult-to-understand label concerning anesthetic propofol and its use in the pediatric population. Objective The objective of this study was to describe the use of propofol for moderate conscious sedation (MCS) in pediatric patients (0–17 years) after drug warnings were disseminated. Methods This study was a retrospective, observational study from January 2001 to December 2007 that used data from the Premier Perspective Comparative Hospital database. This database includes approximately 425 hospitals with a broad range of hospital types and contains a weighting scheme that allows for the generation of national estimates in the United States. The main outcome measure was use of propofol during hospitalization. Results The study included 307,779 discharges in which MCS was used. Both the number of discharges for MCS and the percent of discharges using propofol increased from 2001 to 2007. After multivariable adjustment, there was more than a 3-fold increase in the odds of receiving propofol between 2001 and 2007 (odds ratio [OR] = 3.32; 95% CI, 2.96–3.72) for MCS. Conclusions The results of this study suggest that the label changes and a “Dear Doctor” letter did not affect propofol utilization. A more cohesive approach to the assessment of safety and the dissemination of label change information to practitioners is needed.

PCN35 DOSING PATTERN AND COST COMPARISON OF EPOETIN ALFA AND DARBEPOETIN ALFA IN CHRONIC KIDNEY DISEASE AND CHEMOTHERAPY-INDUCED ANEMIA INPATIENTS

To compare erythropoiesis-stimulating agent (ESA) dosing patterns and costs in inpatients with chronic kidney disease (CKD) not on dialysis or with chemotherapy-induced anemia (CIA). Electronic records from the Premier Perspective Comparative Hospital Database (2006Q1-2009Q4) were analyzed to identify inpatients ≥18 years old treated with epoetin alfa (EPO) or darbepoetin alfa (DARB). Patients receiving renal dialysis or treated with both ESAs were excluded. CKD patients had ≥1 claim for CKD, no claim for cancer, and did not receive chemotherapy. CIA patients had ≥1 claim for cancer, received chemotherapy, and had no claim for CKD. The mean cumulative ESA dose was used to calculate costs, based on April 2010 wholesale acquisition costs (EPO: $15.15/1,000 Units, DARB: $4.96/mcg). A total of 148,746 CKD (EPO: 116,017; DARB: 32,729) and 13,832 CIA (EPO: 10,454; DARB: 3,378) patients were identified. EPO patients were slightly younger than DARB patients in the CKD group (years: 71.0 vs. 71.2; P=.0199) and slightly older in the CIA group (years: 60.7 vs. 59.2; P<.0001). The proportion of females was higher in CKD (EPO 52.3% vs. DARB 51.3%; P=.0018) and similar in CIA (EPO 52.9% vs. DARB 53.8%; P= .3722). The mean length of stay (LOS) was slightly longer for EPO patients (days: CKD: 9.9 vs. 9.7, P=.0006; CIA: 13.4 vs. 12.6; P=.0028). The mean cumulative dose was EPO 37,333 Units and DARB 149 mcg for CKD patients, and EPO 62,605 Units and DARB 272 mcg for CIA patients, yielding dose ratios of 251:1 and 230:1 (Units EPO:mcg DARB), respectively. Corresponding ESA costs were higher for DARB than for EPO in both populations (CKD: $739 vs. $566; CIA: $1,349 vs. $948). This analysis reported dose ratios of 251:1 and 230:1 and a cost premium associated with DARB of 31% and 42% for CKD and CIA inpatients, respectively, despite longer LOS for EPO patients.

PCN32 COMPARISON OF EPOETIN ALFA AND DARBEPOETIN ALFA DOSING PATTERNS AND COSTS IN CHRONIC KIDNEY DISEASE AND CHEMOTHERAPY-INDUCED ANEMIA OUTPATIENTS

To compare erythropoiesis-stimulating agent (ESA) dosing patterns and costs in outpatients with chronic kidney disease (CKD) not on dialysis or with chemotherapy-induced anemia (CIA). Electronic records from the Premier Perspective Comparative Hospital Database (2006Q1-2009Q3) were analyzed to identify outpatients ≥18 years old treated with epoetin alfa (EPO) or darbepoetin alfa (DARB). Patients receiving renal dialysis or treated with both ESAs were excluded. CKD patients had ≥1 claim for CKD, no claim for cancer, and did not receive chemotherapy. CIA patients had ≥1 claim for cancer, received chemotherapy, and had no claim for CKD. The mean cumulative ESA dose was used to calculate costs, based on April 2010 wholesale acquisition costs (EPO: $15.15/1,000 Units, DARB: $4.96/mcg). A total of 11,012 CKD (EPO: 6,921; DARB: 4,091) and 5,590 CIA (EPO: 2,856; DARB: 2,734) outpatients were identified. EPO patients were slightly younger than DARB patients in the CKD group (years: 71.0 vs. 71.6; P=.0341) and of similar age in the CIA group (years: 62.2 vs. 62.7; P=.1316). The proportion of females was higher in CKD (EPO 62.2% vs. DARB 58.8%; P=.0003) and smaller in CIA (EPO 63.4% vs. DARB 67.0%; P=.0047). The mean treatment duration was slightly longer for EPO CKD patients (months: 3.6 vs. 3.4, P=.0004) and similar for CIA patients (months: 2.6 vs. 2.5; P=.1816). The mean cumulative dose was EPO 137,101 Units and DARB 533 mcg in CKD, and EPO 221,652 Units and DARB 933 mcg in CIA, yielding dose ratios of 257:1 and 238:1 (Units EPO:mcg DARB), respectively. Corresponding ESA costs were higher for DARB than for EPO in both populations (CKD: $2,644 vs. $2,077; CIA: $4,627 vs. $3,358). This analysis reported dose ratios of 257:1 and 238:1 in CKD and CIA outpatients, respectively. DARB price premiums of 27% for CKD and 38% for CIA patients were observed.

Comparison of epoetin alfa (EPO) and darbepoetin alfa (DARB) utilization in cancer chemotherapy patients treated in a hospital outpatient setting

e17524 Background: With recent changes in erythropoiesis-stimulating agent (ESA) labeling and coverage limitations by the Centers for Medicare and Medicaid Services, it is important to examine the evolution of EPO and DARB real-world utilization in cancer patients receiving chemotherapy in a hospital outpatient setting. Methods: Electronic outpatient records (2006–2007) from &gt;500 hospitals in the Premier Perspective Comparative Hospital Database were analyzed. Subjects were ≥18 years, had ≥1 cancer diagnosis, received chemo during newly initiated ESA therapy, and ≥2 doses during the treatment episode (classified by quarter of ESA initiation). Mean cumulative dose and dose ratio of EPO:DARB were calculated. 2% of patients with extreme doses were excluded. Results: 7,259 outpatient treatment episodes were identified (EPO 3,568;DARB 3,691). EPO patients were slightly younger (years; EPO 62.7;DARB 64.0, p&lt;.0001), had lower proportion of women (EPO 62.2%;DARB 65.4%, p=0.0044), and had slightly longer mean treatment duration (EPO 3.1 months; DARB 2.9 months, p=0.0009) compared to DARB patients. Mean cumulative dose (SD) per treatment episode was EPO 263,582 (210,167) Units and DARB 1,005 (678) mcg, corresponding to a dose ratio of 262:1 (Units EPO: mcg DARB). Over time, mean cumulative dose, mean treatment duration, and dose ratio reflected a downward trend for both groups ( Table ). Conclusions: This analysis reported a mean dose ratio of 262:1 (Units EPO: mcg DARB) in cancer chemotherapy patients from a hospital outpatient setting. Recent changes in ESA prescribing information and coverage appear to have decreased ESA utilization and the EPO: DARB dose ratio over time. [Table: see text] [Table: see text]

Comparison of Epoetin Alfa and Darbepoetin Alfa Dosing and Costs in an Inpatient Population with Myelodysplastic Syndromes

Background: Prevalent in the majority of patients at diagnosis, anemia associated with myelodysplastic syndromes (MDS) may increase in incidence and severity during the course of the disease. Red blood cell (RBC) transfusion support is often used to manage symptomatic anemia. Epoetin alfa (EPO) and darbepoetin alfa (DARB), two erythropoiesis-stimulating agents (ESAs), are frequently used as supportive care in the treatment of MDS-related anemia to reduce RBC transfusions. To date, limited information on dosing patterns and the associated costs of these agents for MDS patients in the hospital inpatient setting is available. This study examined cumulative ESA dosing and costs in MDS patients treated with ESAs in acute care hospitals.Methods: An analysis of electronic inpatient records from the Premier Perspective Comparative Hospital Database was conducted. The Premier database encompasses detailed inpatient services from patients admitted to more than 500 hospitals nationwide. A retrospective parallel-group design was used to compare two cohorts of MDS patients treated with EPO or DARB during their hospitalization. Study subjects were identified through hospitalization records between 4Q2006 and 1Q2008. Patients were ≥18 years of age, had an admitting diagnosis of MDS (ICD-9 codes: 238.72–238.75), and were treated with EPO or DARB during their hospital stay. Patients were excluded if they had cancer, received renal dialysis, or were treated with both ESAs. To minimize effect of outliers, 2% of patients, based on the upper and lower 1% patients with extreme doses in each group were excluded from the dosing analysis. Mean cumulative dose and July 2008 wholesale acquisition costs (EPO: $13.13/1,000 Units, DARB: $4.722/mcg) were used to calculate ESA costs.Results: A total of 3,312 inpatient stays were identified with a primary or secondary diagnosis of MDS (EPO: 2,719, DARB: 593). Mean age and gender distribution were comparable between groups (age: EPO 77.5 years, DARB 78.0 years; % women: EPO 49.4%, DARB 49.2%, p>.05 for both). Mean hospitalization length of stay was also similar for both groups (EPO: 8.8 days; DARB: 8.9 days; p>.05). The two groups were also comparable in terms of medical history at baseline, including hypertension, diabetes mellitus, cardiovascular disease, congestive heart failure, febrile neutropenia, chronic kidney disease, and sepsis. The mean cumulative dose per inpatient stay was 59,379 ± 66,002 Units for EPO and 230 ± 239 mcg for DARB, corresponding to a dose ratio of 258:1 (Units EPO: mcg DARB). Mean cumulative dose of EPO and DARB remained relatively stable over the period from 4Q2006 to 1Q2008. ESA treatment cost per inpatient stay was significantly lower in the EPO group, compared with DARB (EPO $780 vs. DARB $1,085; P<.0001). Sensitivity analysis including the 2% of outliers in each group corroborated the study findings.Conclusions: The current study, based on recent real-life clinical practice data from an inpatient setting, observed a dose ratio of 258:1 (Units EPO: mcg DARB) in patients with MDS. Based on the cumulative dose administered during hospitalization, EPO was associated with a cost savings of 28% compared to DARB. These results are similar to those observed in MDS patients in the outpatient setting and consistent with reported findings in the chronic kidney disease and oncology populations both in outpatient and inpatient settings.

Dose and cost comparison of erythropoietic agents in the inpatient hospital setting

The inpatient dosing patterns and treatment costs in cancer and predialysis chronic kidney disease (CKD) patients treated with erythropoietic agents from a hospital pharmacy perspective were studied. An analysis of electronic inpatient records from the Premier Perspective comparative hospital database was conducted. Study participants were identified through hospitalizations recorded between July 2002 and March 2005 from over 500 hospitals nationwide. Adult patients with an admitting diagnosis of cancer or predialysis CKD and treated with epoetin alfa or darbepoetin alfa during hospitalization were included. Patients who had received renal dialysis or both agents during a hospitalization were excluded. Wholesale acquisition costs from September 2006 were used to calculate drug costs. A total of 25,645 hospitalized patients with cancer (22,873 received epoetin alfa; 2,772 received darbepoetin alfa) and 66,822 hospitalized patients with CKD (60,079 received epoetin alfa; 6,743 received darbepoetin alfa) were identified. The mean cumulative dose per hospitalization resulted in dose ratios of 245:1 and 242:1 (units epoetin alfa:micrograms darbepoetin alfa) for cancer and CKD patients, respectively. On the basis of the cumulative dose per hospitalization, drug costs for darbepoetin alfa-treated patients were approximately 50% higher than drug costs for epoetin alfa-treated patients for both oncology and CKD patients. Epoetin alfa was associated with less cost compared with darbepoetin alfa for treating inpatients with cancer or CKD. Further research including the patients' clinical outcomes is necessary to determine the true pharmacoeconomic differences between the two agents.

Comparison of red blood cell transfusion rates of epoetin alfa and darbepoetin alfa in an inpatient oncology setting

16002 Background: Epoetin alfa (EPO) and darbepoetin alfa (DARB) are used to treat cancer-related anemia and to reduce the requirements for blood transfusions. To date, limited information on the relative effectiveness of these agents in the inpatient setting is available. This analysis evaluated red blood cell (RBC) transfusion rates in cancer patients receiving EPO or DARB during hospitalization. Methods: An analysis of electronic inpatient hospital records from the Premier Perspective Comparative Hospital Database was conducted to compare RBC transfusion rates in cancer patients receiving EPO or DARB therapy. Study subjects were identified through hospitalizations recorded between 07/2002 and 03/2005 from over 500 hospitals nationwide. Patients were required to be ≥18 years old, have a primary admitting diagnosis of cancer and be treated with EPO or DARB during hospitalization. Patients who had received renal dialysis were excluded. To minimize effects of outliers, 5% of patients with extreme doses in each group were excluded from the dosing analysis. In addition to descriptive statistics on transfusion requirements, a multivariate logistic model was employed to isolate the effect of an individual erythropoietic agent on the risk of RBC transfusion after controlling for patient demographics, comorbidities, admission characteristics, use of IV or oral iron and hospitalization severity markers. Results: Among the 24,814 EPO and 2,990 DARB study patients, mean age and gender distribution at admission were similar (age: EPO 65.3 years, DARB 64.5 years; %women: EPO 53%, DARB 55%). Mean cumulative dose per inpatient stay was EPO 61,656 ± 50,274 Units and DARB 259 ± 340 mcg. RBC transfusions occurred in 37.9% of EPO patients compared to 39.8% of DARB patients (p=0.0404). Transfused EPO patients received a mean of 2.24 units versus 2.20 units for DARB patients (p=0.2111). After adjusting for covariates, the multivariate model confirmed that DARB treatment was associated with a higher risk of transfusion compared to EPO (odds ratio: 1.2, 95% CI: 1.1–1.3, p=0.0007). Conclusions: This analysis of inpatients with cancer indicates DARB treatment is associated with a higher risk of receiving RBC transfusion compared to treatment with EPO. [Table: see text]