Cost-effectiveness of a Telemedicine-based Coagulation Service versus Routine Medical Care for the Management of Patients Receiving Vitamin K-antagonists - Results from the thrombEVAL Study

Objectives: To evaluate the cost-efficiency of a telemedicine-based coagulation services (CS) in comparison to regular medical care (RMC) for the management of patients receiving oral anticoagulation (OAC) therapy with vitamin K-antagonists

Methods: The thrombEVAL study (NCT01809015) is a prospective multi-center cohort study investigating the impact of the health care model on the quality of OAC therapy. Average costs of adverse events and for therapy management were calculated for patients treated in RMC and CS. Costs of hospitalization were derived via diagnosis-related groups which comprise diagnoses (ICD-10) and operation and procedure codes (OPS), which resulted in OAC-related (i.e. bleeding or thromboembolic events) and non-OAC-specific costs. Management costs comprised testing frequency and personnel. Hospital expenses for causes of admission based on ICD principal diagnoses were assessed for both cohorts. In order to avoid bias, first 2 months of follow-up were blanked for the cost-effectiveness analysis since study enrolment for the RMC cohort was performed during hospitalization.

Results: In total, 705 patients were managed by CS (median age: 73.0 yrs [inter quartile range (IQR) 63.0/80.0]; 52% male) and 1,490 patients received RMC (median age: 73.0 yrs; IQR: 65.0/79.0; 64% male) with 465 and 1,184 patient-years (py), respectively. Overall, reasons for hospital admission did not statistically differ between groups; the most frequent reasons for hospital admission were atrial fibrillation/flutter (12% for both cohorts) and heart failure (11.7% for RMC; 10.1% for CS). The number of hospital stays was significantly lower in the CS cohort compared to RMC; with the most pronounced difference in OAC-related admissions (Δ-80%). Total management costs per py in RMC were lower by 228 EUR compared to CS, whereas hospitalization costs per py were 2,578 EUR higher. Overall, the cost saving was 2,351 EUR/py favoring the CS group. In propensity analyses accounting for different clinical profile of both groups confirmed the robustness of results (net cost-saving in the CS: 2,039 EUR/py). Mean costs of hospitalizations for the four most common diagnoses were lower in the CS cohort.

Conclusions: The lower frequency of adverse events in anticoagulated patients managed by the telemedicine-based CS compared to RMC translated into a substantial cost-saving. Elevated costs for the specialized management were out-balanced by lower absolute and relative secondary costs.

Table 1 Breakdown of management and hospitalization costs stratified by treatment group

		Regular medical care (n = 1,490)	Coagulation Service (n = 705)
	Staff and technology costs per test [EUR]	4.77	13.67
	Number of tests per year	21.49	24.03
	Total management costs per patient-year	101.00	328.56
OAC related hospital costs [EUR]	Number of admissions per 100 patient-years	13.3	2.8
	Cost per admission [EUR]	5,063 (4308-5945)	5,689 (2901-8933)
OAC unrelated hospital costs [EUR]	Number of admissions per 100 patient-years	55.4	20.6
	Cost per admission [EUR]	4,945 (4505-5445)	3,409 (2840-4163)
	Total hospital costs per patient-year [EUR]	3,261 (2,857-3,689)	683 (504-874)
	TOTAL COSTS PER PATIENT-YEAR [EUR]	3,362.00	1,011.56