Association between rivaroxaban use and length of hospital stay, treatment costs and early outcomes in patients with pulmonary embolism: a systematic review of real-world studies

Abstract

Background: In the EINSTEIN-Pulmonary Embolism (PE) trial, subjects randomized to rivaroxaban versus enoxaparin bridging to vitamin K antagonist (VKA) therapy experienced a reduced index hospital length of stay (LOS). We sought to conduct a systematic review of real-world studies comparing LOS, costs and early outcomes among patients treated with rivaroxaban or parenterally bridged VKA in routine practice.

Methods: We searched Medline and Scopus from 1 January 2011 to 30 November 2016 to identify observational studies comparing acute PE patients anticoagulated with rivaroxaban or parenterally bridged VKA and reporting data on index hospital LOS, costs and/or early post-PE outcomes. Studies not using appropriate methods for minimizing confounding bias or not published in English were excluded.

Results: Five studies met inclusion criteria. Rivaroxaban use was associated with decreased index hospital LOS (range: 1.36–1.70 days) and treatment costs (range: $1818–$2688) during an index stay compared to parenterally bridged warfarin. No differences in early readmission for recurrent thrombosis were noted between anticoagulation strategies. Readmission for major bleeding was rare in both cohorts. Similar reductions in LOS (range: 0.23–4.3 days) and costs (range: $251–$7094) were observed with rivaroxaban in studies restricted to patients deemed low risk for early complications by clinical gestalt or by a clinical- or claims-based risk stratification tool.

Conclusions: Regardless of patient predicted risk of post-PE complications, real-world studies suggest that rivaroxaban is associated with a reduced hospital LOS and costs versus parenterally bridged warfarin, without increasing readmission.

Keywords:

• Rivaroxaban
• pulmonary embolism
• length of stay
• costs/readmission

Transparency

Declaration of funding

This analysis was sponsored by Janssen Scientific Affairs LLC. The authors maintained full control over the performance of the research and content of the manuscript.

Author contributions: Study concept and design: C.G.K., W.F.P., G.J.F., C.W.B., P.S.W., V.A., C.C., P.W., J.R.S., C.I.C. Acquisition of data: C.G.K., C.I.C. Analysis and interpretation of data: C.G.K., W.F.P., G.J.F., C.W.B., P.S.W., V.A., C.C., P.W., J.R.S., C.I.C. Drafting the manuscript: C.G.K., W.F.P., G.J.F., C.W.B., P.S.W., V.A., C.C., P.W., J.R.S., C.I.C. Critical revision of the manuscript for important intellectual content: C.G.K., W.F.P., G.J.F., C.W.B., P.S.W., V.A., C.C., P.W., J.R.S., C.I.C. Administrative, technical or material support: C.G.K., C.I.C. Study supervision: C.I.C. All authors read and approved the final manuscript. All authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICJME) and were fully responsible for all content and editorial decisions, and were involved in all stages of manuscript development.

Declaration of financial/other relationships

C.I.C. has disclosed that he has received grant funding and consultancy fees from Janssen Pharmaceuticals; Bayer AG and Boehringer-Ingelheim Pharmaceuticals Inc. V.A., C.C., J.R.S. and P.W. have disclosed that they are employees of Janssen Scientific Affairs LLC. W.F.P. has disclosed that he has received grant funding and consultancy fees from Janssen Pharmaceuticals and Portola. G.J.F. has disclosed that he has received grant funding from Pfizer and is on the advisory board and speaker’s bureau for Janssen Pharmaceuticals. C.W.B. has disclosed that he is a Roche Diagnostics Advisory Board member and received consulting fees from Janssen Pharmaceuticals; he also reports research support from Janssen Pharmaceuticals and Boehringer-Ingelheim. P.S.W. has disclosed that he has received grant funding from Bristol Myers Squib and Pfizer, is on the advisory board and has received speaker’s fees from Bayer Healthcare, has received consultancy fees from Janssen Pharmaceuticals, and served on a writing committee with Itreas. C.G.K. has disclosed that she has no significant relationships with or financial interests in any commercial companies related to this study or article.

CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.