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298 Failure to Correct International Normalized Ratio Following Fresh Frozen Plasma Administration Among Patients With Anticoagulant-Related Major Bleeding in Clinical Practice
Research Forum Abstracts
298
Failure to Correct International Normalized Ratio Following Fresh Frozen Plasma Administration Among Patients With Anticoagulant-Related Major Bleeding in Clinical Practice
pain” order set utilized by physicians and nurses. Our objective was to assess the costeffectiveness of routine coagulation testing of patients with chest pain in the ED. Methods: We conducted a retrospective chart review on a non-consecutive sample of patients evaluated for chest pain in the ED between the dates of August 1, 2010 and October 31, 2010. Charts were reviewed to determine the number and results of coagulation studies ordered, the number of coagulation studies that were appropriately ordered, and the number of patients requiring a therapeutic intervention or change in clinical plan (withholding of antiplatelet/anticoagulant, delayed procedure, or treatment with FFP or vitamin K) based on an unexpected coagulopathy. We considered it appropriate to order coagulation studies on patients with cirrhosis, known/suspected coagulopathy, active bleeding, use of warfarin, or STEMI. We calculated the cost of the coagulation studies ordered on patients without the listed indications. Descriptive statistics were used for analysis. Results: 761 of the 1849 charts for patients evaluated for chest pain during the study period were reviewed. Thirteen patients were excluded due to age ⬍18, and an additional 8 patients left against medical advice before labs were drawn. Of the 740 patients included, 406 (55%) had coagulation studies ordered. Of that 406, 327 (81%) patients with coagulation studies ordered had no indications for testing. 315 patients of the 327 were tested with PT/INR ($19.00) and PTT ($33.50). 11 of the remaining 12 patients were tested with only a PT/INR, and 1 patient was tested with only PTT. One of the 327 patients (0.31%; 95%CI 0.05-1.7%) tested without indication had a clinically significant coagulopathy (INR ⬎1.5, PTT ⬎50 sec), but none (0%; 95%CI 0-1.2%) of the patients with coagulation testing performed without indication required a therapeutic intervention or change in clinical plan. The cost of coagulation testing in these 327 patients was $16,780. By our estimates, routine coagulation testing without indication for patients with chest pain in the York Hospital emergency department cost $165,000 annually. Conclusion: Coagulation testing on chest pain patients in the ED is not costeffective and should not be routinely performed.
300
Cost to Correct International Normalized Ratio Among Patients With Warfarin-Associated Major Bleeding in Clinical Practice
Menzin J, White L, Friedman M, Nichols C, Menzin J, Hoesche J, Jones C/Boston Health Economics, Inc., Waltham, MA; CSL Behring, King of Prussia, PA
Menzin J, Friedman M, Nichols C, Menzin J, Hoesche J, Jones C/Boston Health Economics, Inc., Waltham, MA; CSL Behring, King of Prussia, PA
Study Objective: To assess the frequency of international normalized ratio (INR) remaining uncorrected in patients administered fresh frozen plasma for anticoagulantrelated major bleeding. Methods: A retrospective database analysis was undertaken using electronic medical record data from a large integrated health system. Patients who received fresh frozen plasma between 01/01/2004 and 12/31/2010, and who met the following criteria were selected: major hemorrhage diagnosis the day before to the day after initial fresh frozen plasma administration; INRⱖ2 on the day before or the day of fresh frozen plasma and another INR result up to 1 day after fresh frozen plasma; and supply of warfarin within 90 days prior to hospitalization. INR correction (defined as INR ⱕ 1.3) was evaluated at the last available test up to 1 day following fresh frozen plasma start. Logistic regression analysis was performed to assess probability of remaining uncorrected. Results: 414 patients met selection criteria (mean age 75 years, 53% male, mean baseline Charlson score of 2.5). The majority of patients presented with a gastrointestinal bleed (58%), followed by intracranial hemorrhage (ICH) (38%) and other bleed types (4%). Mean 1st elevated INR was 3.7, and mean INR was 1.5 at the last test. Sixty-seven percent of patients remained uncorrected. Mean time to correction among those achieving correction was 20.6 hours from start of fresh frozen plasma administration. Patients who were older, those with a baseline Charlson score of 4 or greater, and those with non-ICH bleeds were more likely to remain uncorrected within 24 hours of fresh frozen plasma administration. Using an INR threshold of ⱕ 1.5, 39% of patients remained uncorrected. Conclusions: A substantial proportion of patients remain uncorrected following fresh frozen plasma administration, with estimates varying depending on the INR threshold used.
Study Objective: To assess differences in total inpatient costs among patients whose international normalized ratio (INR) remained uncorrected versus corrected following use of fresh frozen plasma in the management of warfarin-associated major bleeding. Methods: A retrospective database analysis was undertaken using electronic medical record data from a large integrated health system. Patients who received fresh frozen plasma between 01/01/2004 and 12/31/2010, and who met the following criteria were selected: major hemorrhage diagnosis the day before to the day after initial fresh frozen plasma administration; INR ⱖ 2 on the day before or the day of fresh frozen plasma and another INR result up to 1 day after fresh frozen plasma; and supply of warfarin within 90 days prior to hospitalization. INR correction (defined as INR ⱕ 1.3) was evaluated at the last available test up to 1 day following fresh frozen plasma start. Costs were evaluated for each patient’s inpatient stay, including those for procedures, medications, physician visits, and facility usage. Statistical differences in costs between patients whose INR remained uncorrected versus corrected were evaluated with the Wilcoxon Rank-Sum test with statistical significance defined as P⬍0.05. All costs were adjusted to 2009 USD using the medical care component of the consumer price index. Results: 414 patients met selection criteria (mean age 75 years, 53% male, mean baseline Charlson score of 2.5). The majority of patients presented with a gastrointestinal bleed (58%), followed by intracranial hemorrhage (38%) and other bleed types (4%). Thirty-three percent of patients were corrected at the last available test up to 1 day following receipt of fresh frozen plasma. Mean volume of fresh frozen plasma, packed red blood cells, platelets, vitamin K, and albumin received were not significantly different among patients whose INR was corrected versus uncorrected. Total inpatient costs (mean⫹SD) were not significantly different among patients whose INR was corrected at 24 hours following receipt of fresh frozen plasma versus patients who remained uncorrected ($18,941 ⫾ $20,806 vs. $21,521 ⫾ $20,767; P⫽0.09). Similarly, total costs were not significantly different by INR correction when stratified by quartiles of hospital length of stay or presenting bleed type. Using an alternative definition of INR correction at ⱕ 1.5, total costs were also not significantly different (P⫽0.10).
299
Cost-Effectiveness of Routine Coagulation Testing in the Evaluation of Chest Pain in the Emergency Department
Kochert E, Goldhahn L, Hughes I, Gee K, Stahlman B/York Hospital, York, PA
Study Objectives: Approximately 5% of all United States emergency department (ED) visits are for chest pain. At York Hospital coagulation tests are part of the “chest
S278 Annals of Emergency Medicine
Volume , . : October
298
Failure to Correct International Normalized Ratio Following Fresh Frozen Plasma Administration Among Patients With Anticoagulant-Related Major Bleeding in Clinical Practice
pain” order set utilized by physicians and nurses. Our objective was to assess the costeffectiveness of routine coagulation testing of patients with chest pain in the ED. Methods: We conducted a retrospective chart review on a non-consecutive sample of patients evaluated for chest pain in the ED between the dates of August 1, 2010 and October 31, 2010. Charts were reviewed to determine the number and results of coagulation studies ordered, the number of coagulation studies that were appropriately ordered, and the number of patients requiring a therapeutic intervention or change in clinical plan (withholding of antiplatelet/anticoagulant, delayed procedure, or treatment with FFP or vitamin K) based on an unexpected coagulopathy. We considered it appropriate to order coagulation studies on patients with cirrhosis, known/suspected coagulopathy, active bleeding, use of warfarin, or STEMI. We calculated the cost of the coagulation studies ordered on patients without the listed indications. Descriptive statistics were used for analysis. Results: 761 of the 1849 charts for patients evaluated for chest pain during the study period were reviewed. Thirteen patients were excluded due to age ⬍18, and an additional 8 patients left against medical advice before labs were drawn. Of the 740 patients included, 406 (55%) had coagulation studies ordered. Of that 406, 327 (81%) patients with coagulation studies ordered had no indications for testing. 315 patients of the 327 were tested with PT/INR ($19.00) and PTT ($33.50). 11 of the remaining 12 patients were tested with only a PT/INR, and 1 patient was tested with only PTT. One of the 327 patients (0.31%; 95%CI 0.05-1.7%) tested without indication had a clinically significant coagulopathy (INR ⬎1.5, PTT ⬎50 sec), but none (0%; 95%CI 0-1.2%) of the patients with coagulation testing performed without indication required a therapeutic intervention or change in clinical plan. The cost of coagulation testing in these 327 patients was $16,780. By our estimates, routine coagulation testing without indication for patients with chest pain in the York Hospital emergency department cost $165,000 annually. Conclusion: Coagulation testing on chest pain patients in the ED is not costeffective and should not be routinely performed.
300
Cost to Correct International Normalized Ratio Among Patients With Warfarin-Associated Major Bleeding in Clinical Practice
Menzin J, White L, Friedman M, Nichols C, Menzin J, Hoesche J, Jones C/Boston Health Economics, Inc., Waltham, MA; CSL Behring, King of Prussia, PA
Menzin J, Friedman M, Nichols C, Menzin J, Hoesche J, Jones C/Boston Health Economics, Inc., Waltham, MA; CSL Behring, King of Prussia, PA
Study Objective: To assess the frequency of international normalized ratio (INR) remaining uncorrected in patients administered fresh frozen plasma for anticoagulantrelated major bleeding. Methods: A retrospective database analysis was undertaken using electronic medical record data from a large integrated health system. Patients who received fresh frozen plasma between 01/01/2004 and 12/31/2010, and who met the following criteria were selected: major hemorrhage diagnosis the day before to the day after initial fresh frozen plasma administration; INRⱖ2 on the day before or the day of fresh frozen plasma and another INR result up to 1 day after fresh frozen plasma; and supply of warfarin within 90 days prior to hospitalization. INR correction (defined as INR ⱕ 1.3) was evaluated at the last available test up to 1 day following fresh frozen plasma start. Logistic regression analysis was performed to assess probability of remaining uncorrected. Results: 414 patients met selection criteria (mean age 75 years, 53% male, mean baseline Charlson score of 2.5). The majority of patients presented with a gastrointestinal bleed (58%), followed by intracranial hemorrhage (ICH) (38%) and other bleed types (4%). Mean 1st elevated INR was 3.7, and mean INR was 1.5 at the last test. Sixty-seven percent of patients remained uncorrected. Mean time to correction among those achieving correction was 20.6 hours from start of fresh frozen plasma administration. Patients who were older, those with a baseline Charlson score of 4 or greater, and those with non-ICH bleeds were more likely to remain uncorrected within 24 hours of fresh frozen plasma administration. Using an INR threshold of ⱕ 1.5, 39% of patients remained uncorrected. Conclusions: A substantial proportion of patients remain uncorrected following fresh frozen plasma administration, with estimates varying depending on the INR threshold used.
Study Objective: To assess differences in total inpatient costs among patients whose international normalized ratio (INR) remained uncorrected versus corrected following use of fresh frozen plasma in the management of warfarin-associated major bleeding. Methods: A retrospective database analysis was undertaken using electronic medical record data from a large integrated health system. Patients who received fresh frozen plasma between 01/01/2004 and 12/31/2010, and who met the following criteria were selected: major hemorrhage diagnosis the day before to the day after initial fresh frozen plasma administration; INR ⱖ 2 on the day before or the day of fresh frozen plasma and another INR result up to 1 day after fresh frozen plasma; and supply of warfarin within 90 days prior to hospitalization. INR correction (defined as INR ⱕ 1.3) was evaluated at the last available test up to 1 day following fresh frozen plasma start. Costs were evaluated for each patient’s inpatient stay, including those for procedures, medications, physician visits, and facility usage. Statistical differences in costs between patients whose INR remained uncorrected versus corrected were evaluated with the Wilcoxon Rank-Sum test with statistical significance defined as P⬍0.05. All costs were adjusted to 2009 USD using the medical care component of the consumer price index. Results: 414 patients met selection criteria (mean age 75 years, 53% male, mean baseline Charlson score of 2.5). The majority of patients presented with a gastrointestinal bleed (58%), followed by intracranial hemorrhage (38%) and other bleed types (4%). Thirty-three percent of patients were corrected at the last available test up to 1 day following receipt of fresh frozen plasma. Mean volume of fresh frozen plasma, packed red blood cells, platelets, vitamin K, and albumin received were not significantly different among patients whose INR was corrected versus uncorrected. Total inpatient costs (mean⫹SD) were not significantly different among patients whose INR was corrected at 24 hours following receipt of fresh frozen plasma versus patients who remained uncorrected ($18,941 ⫾ $20,806 vs. $21,521 ⫾ $20,767; P⫽0.09). Similarly, total costs were not significantly different by INR correction when stratified by quartiles of hospital length of stay or presenting bleed type. Using an alternative definition of INR correction at ⱕ 1.5, total costs were also not significantly different (P⫽0.10).
299
Cost-Effectiveness of Routine Coagulation Testing in the Evaluation of Chest Pain in the Emergency Department
Kochert E, Goldhahn L, Hughes I, Gee K, Stahlman B/York Hospital, York, PA
Study Objectives: Approximately 5% of all United States emergency department (ED) visits are for chest pain. At York Hospital coagulation tests are part of the “chest
S278 Annals of Emergency Medicine
Volume , . : October