Skip to main content

Advertisement

SpringerLink
Log in

The cost-effectiveness of different management strategies for patients on chronic warfarin therapy

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

OBJECTIVE: To examine the cost-effectiveness of moving from usual care to more organized management strategies for patients on chronic warfarin therapy.

DESIGN: Using information available in the scientific literature, supplemented with data from a large health system and, when necessary, expert opinion, we constructed a 5-year Markov model to evaluate the health and economic outcomes associated with each of three different anticoagulation management approaches: usual care, anticoagulation clinic testing with a capillary monitor, and patient self-testing with a capillary monitor.

PATIENTS: Three hypothetical cohorts of patients beginning long-term warfarin therapy were used to generate model results.

MAIN RESULTS: Model results indicated that moving from usual care to anticoagulation clinic testing would result in a total of 1.7 thromboembolic events and 2.0 hemorrhagic events avoided per 100 patients over 5 years. Another 4.0 thromboembolic events and 0.8 hemorrhagic events would be avoided by moving to patient self-testing. When direct medical care costs and those incurred by patients and their caregivers in receiving care were considered, patient self-testing was the most cost-effective alternative, resulting in an overall cost saving.

CONCLUSIONS: Results illustrate the potential health and economic benefits of organized care management approaches and capillary monitors in the management of patients receiving warfarin therapy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Landefeld CS, Beyth RJ. Anticoagulant-related bleeding: clinical epidemiology, prediction, and prevention. Am J Med. 1993;95:315–28.

    Article  PubMed  CAS  Google Scholar 

  2. Matchar DB, Samsa GP, Cohen SJ. Should we just let the anticoagulation service do it? The conundrum of anticoagulation for atrial fibrillation. J Gen Intern Med. 1996;11:768–70.

    Article  PubMed  CAS  Google Scholar 

  3. Chiquette E, Amato MG, Bussey HI. Comparison of an anticoagulation clinic with routine medical care. Circulation. 1995;92:1–686. Abstract.

    Google Scholar 

  4. Cortelazzo S, Finazzi G, Viero P, Galli M, Remuzzi A, Parenzan L, et al. Thrombotic and hemorrhagic complications in patients with mechanical heart valve prosthesis attending an anticoagulation clinic. Thromb Haemost. 1993;69:316–20.

    PubMed  CAS  Google Scholar 

  5. White RH, McKittrick T, Takakuwa J, et al. Management and prognosis of life-threatening bleeding during warfarin therapy. Arch Intern Med. 1996;156:1197–1201.

    Article  PubMed  CAS  Google Scholar 

  6. Ansell JE, Patel N, Ostrovsky D, Nozzolillo E, Peterson AM, Fish L. Long-term patient self-management of oral anticoagulation. Arch Intern Med. 1995;155:2185–9.

    Article  PubMed  CAS  Google Scholar 

  7. Hasenkam JM, Knudsen L, Kimose HH, et al. Practicability of patient self-testing or oral anticoagulant therapy by the international normalized ratio (INR) using a portable whole blood monitor. A pilot investigation. Thromb Res. 1997;85:77–82.

    CAS  Google Scholar 

  8. Bernardo A, Halhuber C. Long-term experience with patient self-management of oral anticoagulation. Ann Hematol. 1996;72:A62. Abstract.

    Google Scholar 

  9. Anderson DR, Harrison L, Hirsh J. Evaluation of a portable prothrombin time monitor for home use by patients who require long-term oral anticoagulant therapy. Arch Intern Med. 1993;153:1441–7.

    Article  PubMed  CAS  Google Scholar 

  10. Fihn SD, McDonell MB, Martin DC, et al. Risk factors for complications of chronic anticoagulation: a multicenter study. Ann Intern Med. 1993;118:511–20.

    PubMed  CAS  Google Scholar 

  11. Fihn SD, Callahan CM, Martin DC, et al. The risk for and severity of bleeding complications in elderly patients treated with warfarin. Ann Intern Med. 1996;124:970–9.

    PubMed  CAS  Google Scholar 

  12. Gottlieb LK, Salem-Schatz S. Anticoagulation in atrial fibrillation. Does efficacy in clinical trials translate into effectiveness in practice? Arch Intern Med. 1994;154:1945–53.

    Article  PubMed  CAS  Google Scholar 

  13. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low dose warfarin on the risk of stroke in patients with non-rheumatic atrial fibrillation. N Engl J Med. 1990;323:1505–11.

    Article  Google Scholar 

  14. Connolly SJ, Laupacis A, Gent M, Roberts RS, Cairns JA, Joyner C. Canadian atrial fibrillation anticoagulation study. J Am Coll Cardiol. 1991;18:349–55.

    Article  PubMed  CAS  Google Scholar 

  15. European Atrial Fibrillation Trial Study Group. Secondary prevention in non-rheumatic atrial fibrillation after transient ischemic attack or minor stroke. Lancet. 1993;342:1255–62.

    Google Scholar 

  16. The European Atrial Fibrillation Trial Study Group. Optimal oral anticoagulant therapy in patients with non-rheumatic atrial fibrillation and recent cerebral ischemia. N Engl J Med. 1995;333:5–10.

    Article  Google Scholar 

  17. Ezekowitz MD, Bridgers SL, James KE, et al. Warfarin in the prevention of stroke associated with non-rheumatic atrial fibrillation. Veterans Affairs stroke prevention in nonrheumatic atrial fibrillation investigators. N Engl J Med. 1992;327:1406–12.

    Article  PubMed  CAS  Google Scholar 

  18. Petersen P, Godtfredsen J, Boysen G, Andersen ED, Andersen B. Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation. The Copenhagen AFASAK study. Lancet. 1989;175–8.

  19. Stroke Prevention in Atrial Fibrillation Investigators. Stroke prevention in atrial fibrillation study. Circulation. 1991;84:527–39.

    Google Scholar 

  20. Stroke Prevention in Atrial Fibrillation Investigators. Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: stroke prevention in atrial fibrillation II study. Lancet. 1994;343:687–91.

    Google Scholar 

  21. Palaretti G, Leal N, Cocchen S, et al. Bleeding complications of oral anticoagulant treatment: an inception-cohort, prospective collaborative study (ISCOAT). Lancet. 1996;348:423–8.

    Article  Google Scholar 

  22. van der Meer FJM, Rosendaal FR, Vandenbroucke JP, Briet E. Bleeding complications in oral anticoagulant therapy. An analysis of risk factors. Arch Intern Med. 1993;153:1557–62.

    Article  PubMed  Google Scholar 

  23. White RH, McCurdy SA, von Mardensdorff H, Woodruff DE Jr., Leftgoff L. Home prothrombin time monitoring after the initiation of warfarin therapy. Ann Intern Med. 1989;111:730–7.

    PubMed  CAS  Google Scholar 

  24. Wilkinson PR, Wolfe CDA, Warburton FG, et al. A long-term follow-up of stroke patients. Stroke. 1997;28:507–12.

    PubMed  CAS  Google Scholar 

  25. Bonita R, Solomon N, Broad JB. Prevalence of stroke and strokerelated disability. Estimates from the Auckland Stroke Studies. Stroke. 1997;28:1898–1902.

    PubMed  CAS  Google Scholar 

  26. Dorman PJ, Waddell F, Slattery J, Dennis M, Sandercock P. Is the EuroQol a valid measure of health-related quality of life after stroke? Stroke. 1997;28:1876–82.

    PubMed  CAS  Google Scholar 

  27. Tennant A, Geddes JML, Fear J, Hillman M, Chamberlain MA. Outcome following stroke. Disabil Rehabil. 1997;19:278–84.

    PubMed  CAS  Google Scholar 

  28. Dighe MS, Aparasu RR, Rappaport HM. Factors predicting survival, changes in activity limitations, and disability in a geriatric post-stroke population. Gerontologist. 1997;37:483–9.

    PubMed  CAS  Google Scholar 

  29. Naglie G, Detsky AS. Treatment of chronic nonvalvular atrial fibrillation in the elderly: a decision analysis. Med Decis Making. 1992;12:239–49.

    Article  PubMed  CAS  Google Scholar 

  30. Disch DL, Greenberg ML, Holzberger PT, Malenka DJ, Birkmeyer JD. Managing chronic atrial fibrillation: a Markov decision analysis comparing warfarin, quinidine, and low-dose amiodarone. Ann Intern Med. 1994;120:449–57.

    PubMed  CAS  Google Scholar 

  31. Tsevat J, Eckman MH, McNutt RA, Pauker SG. Warfarin for dilated cardiomyopathy: a bloody tough pill to swallow? Med Decis Making. 1989;9:162–9.

    Article  PubMed  CAS  Google Scholar 

  32. Seto TB, Taira DA, Tsevat J, Manning WJ. Cost-effectiveness of transesophageal echocardiographic-guided cardioversion: a decision analytic model for patients admitted to the hospital with atrial fibrillation. J Am Coll Cardiol. 1997;29:122–30.

    Article  PubMed  CAS  Google Scholar 

  33. Gage BF, Cardinalli AB, Albers GW, Owens DK. Cost-effectiveness of warfarin and aspirin for prophylaxis of stroke in patients with nonvalvular atrial fibrillation. JAMA. 1995;274:1839–45.

    Article  PubMed  CAS  Google Scholar 

  34. Sarent R, Wainwright E. Crystal Ball Version 4.0 User Manual. Broomfield, Colo: CG Press; 1996.

    Google Scholar 

  35. Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-effectiveness in Health and Medicine. New York, NY: Oxford University Press, Inc, 1996.

    Google Scholar 

  36. Ansell JE, Hamke AK, Holden A, Knapic N. Cost effectiveness of monitoring warfarin therapy using standard versus capillary prothrombin times. Am J Clin Pathol. 1989;91:587–9.

    PubMed  CAS  Google Scholar 

  37. US Bureau of the Census, Current Population Reports, Money Income in the United States: 1996 (With Separate Data on Valuation of Noncash Benefits). Washington, DC: US Government Printing Office; 1997:60–197, Table 7.

  38. Murphy DJ, Williamson PS, Nease DE Jr. Supportive family members of diabetic adults. Fam Pract Res J. 1994;14:323–31.

    PubMed  CAS  Google Scholar 

  39. Mitchell JB, Ballard DJ, Whisnant JP, Ammering CJ, Samsa GP, Matchar DB. What role do neurologists play in determining the costs and outcomes of stroke patients? Stroke. 1996;27:1937–43.

    PubMed  CAS  Google Scholar 

  40. Holloway RG, Witter DM, Lawton KB, Lipscomb J, Samsa G. Inpatient costs of specific cerebrovascular events at five academic medical centers. Neurology. 1996;46:860.

    Google Scholar 

  41. Health Insurance Association of America. Washington, DC: Source Book of Health Insurance Data, 1996. 854–60:1997.

Download references

Author information

Authors and Affiliations

  1. Henry Ford Health System, Center for Health Services Research, 1 Ford Place-3A, 48202, Detroit, MI

    Jennifer Elston Lafata PhD, Susan A. Martin MSPH, Scott Kaatz DO & Richard E. Ward MD, MBA

Authors
  1. Jennifer Elston Lafata PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Susan A. Martin MSPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Scott Kaatz DO
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Richard E. Ward MD, MBA
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jennifer Elston Lafata PhD.

Additional information

Financial support for this work was received from Boehringer Mannheim Corp.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lafata, J.E., Martin, S.A., Kaatz, S. et al. The cost-effectiveness of different management strategies for patients on chronic warfarin therapy. J GEN INTERN MED 15, 31–37 (2000). https://doi.org/10.1046/j.1525-1497.2000.01239.x

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1046/j.1525-1497.2000.01239.x

Key Words

Search

Navigation