Rivaroxaban Associated With Decreased Hospitalization, Costs for Patients with Low-Risk PE

W. Frank Peacock, MD

When administered rivaroxaban (Xarelto, Janssen), patients that are at a low-risk for pulmonary embolism (PE) and are discharged early from the emergency department (ED) have similar outcomes compared to patients receiving the standard of care.

Additionally, those receiving rivaroxaban and early discharge had fewer total days hospitalized and lower costs over a 30-day period. All told, the total savings for the early discharged patients amounted to $2496 (95% CI, -$2999 to —$2151), and those patients spent 28.8 fewer hours at the hospital during their initial visit (95% CI, –42.55 to –15.12) and 26.4 fewer total hours hospitalized over the course of 90 days (95% CI = –46.97 to –3.34 hours).

"Every year, U.S. health care systems spend more than 2 billion dollars to manage patients with pulmonary emboli," said W. Frank Peacock, MD, FACEP, FACC, the associate chair and research director of Emergency Medicine at Baylor College of Medicine, in Houston, Texas, in a statement. "By avoiding hospitalizations that are not clinically necessary and transitioning patients with low-risk PE to out-patient treatment with XARELTO, we've seen significant cost savings, which could help alleviate the burden on health care systems."

Peacock, the principal investigator of the MERCURY-PE trial, led the team in randomizing 114 patients that were at low-risk for PE to either early discharge and rivaroxaban at 15 mg twice daily for 21 days (n = 51), or standard of care (n = 63) within 12 hours of diagnosis. The majority of the patients (98.2%; n = 112) received at least 1 dose of rivaroxaban. In total, 99 patients (86.8%) completed the trial.

Those in the standard of care group spent an average of 33.6 hours hospitalized for their initial visit compared to 4.8 hours for those in the early discharge group (P <.0001). In addition, the standard of care group spent a total of 43.2 hours hospitalized—for any reason&mdash;over the 90-day study period, compared to 19.2 hours in the early discharge group (P = .024).

As expected those granted early discharge on rivaroxaban spent less than those with the standard of care. The costs associated with the ED visits were $2638 less for those in the early discharge group (P <.001). The total costs over the course of the study were $1496 for those discharged early and $4234 for those receiving standard of care (P <.001).

The composite safety endpoint was similar in both groups, with a difference in proportions of 0.005 (95% CI = —0.18 to 0.19). Notably, there were no bleeding events, recurrences of venous thromboembolism (VTE), or deaths. No significant differences were observed in the bleeding-related hospitalizations or physician visits within 90 days from randomization, though, according to Janssen, this measure “should be interpreted with caution, as the study was significantly underpowered to detect any such differences.”

PE, along with deep vein thrombosis, is included as part of VTE, which occurs in roughly 900,000 adults in the United States annually. PE specifically occurs in more than 250,000 patients each year, and although protocols differ by hospital, the typical standard of care methods require admittance to the hospital, which in turn expectedly drives up costs and increases the risk of hospital-acquired infections.

"We're proud to have pioneered this groundbreaking research, which was the first prospective randomized trial to confirm the benefit of discharging patients with low-risk PE early from the hospital and completing treatment at home," said Paul Burton, MD, PhD, FACC, the vice president of Janssen Scientific Affairs, LLC, in a statement. "We expect that this XARELTO study will prompt physicians to reconsider how patients with low-risk PE are managed.”

The study, “Emergency Department Discharge of Pulmonary Embolus Patients,” was published in Academic Emergency Medicine.

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