Presentation Details
| Safety and cost-effectiveness analysis of anticoagulation therapy in adult patients undergoing extracorporeal membrane oxygenation Amanda Arenella1, Michael Calloway1, Joshua Oh2. 1Department of Health Economics and Outcomes Research, Grifols SSNA, Research Triangle Park, NC, USA.2University of North Carolina at Charlotte, College of Health and Human Services, Department of Public Health Sciences, Charlotte, NC, USA |
Abstract
Background: Unfractionated heparin (UFH) is currently the gold standard of treatment for anticoagulation in patients undergoing extracorporeal membrane oxygenation (ECMO). Recent Extracorporeal Life Support Organization (ELSO) guidelines also recommend the use of direct thrombin inhibitors (DTIs), bivalirudin and argatroban, in patients with diagnosed heparin-induced thrombocytopenia (HIT) undergoing extracorporeal membrane oxygenation (ECMO). However, DTIs are becoming increasingly utilized as alternative anticoagulants for patients with and without HIT requiring ECMO support. Antithrombin III (AT3) is a plasma-derived agent that can be used in adjunct with UFH to supplement low AT3 levels in response to heparin resistance in this patient population. Objectives: The purpose of this study is to investigate safety and cost outcome differences between AT3 supplementation and direct thrombin inhibitor treatment for anticoagulation in patients undergoing ECMO. Methods: A retrospective review of adult patients undergoing ECMO using the Premier Perspective® Hospital dataset (2018-2021) was conducted. Patients receiving coronary artery bypass graft (CABG) surgery were excluded due to the difference in treatment decisions for anticoagulation. It is suspected that severity of illness plays a role in treatment patterns when a patient is receiving both CABG and ECMO, which would bias outcomes in the study. Patients were stratified into AT3 only and DTI only treatment groups. Prior to the comparisons, and to make the comparisons more robust, the two groups were balanced amongst patient demographics, hospital characteristics, and comorbidities using propensity score matching (PSM). Examples of these characteristics include age, gender, and race of the patients as well as urban versus rural hospital type, hospital bed number, and teaching hospital status. Charlson Comorbidity Index was also used to measure and match baseline clinical status. The use of PSM adjusts for any differences in significant health issues. Logistic regression, quantile regression, and negative binomial regression were utilized to assess clinical outcomes. Results: 2,625 patients undergoing ECMO met study requirements. After propensity score matching, 357 patients in each treatment arm were included in the analysis. Higher rates of thrombosis were found in the DTI group compared to AT3 (OR: 1.97; 95% CI: 1.35-2.88). No difference was seen between bleed events (OR: 0.98; 95% CI: 0.68-1.40). There was a significantly longer median length of stay found in the DTI group compared to the AT group (DTI: 30 days; AT: 22 days; p <0.0001). However, median patient cost did not significantly differ (DTI: $233,245; AT3: $211,478; p = 0.116). Conclusions: Anticoagulation with DTIs in patients undergoing extracorporeal membrane oxygenation showed a statistically significantly higher rate of thrombosis and a longer median length of stay compared to treatment with AT3. No difference in cost and bleed events were identified. Further studies are needed to validate the clinical and economic differences between these two therapies for anticoagulation in ECMO.
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No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the author.