Burden-of-Illness Associated with Bleeding-Related Hospitalizations in Atrial Fibrillation Patients: Findings from the Nationwide Readmission Database

Abstract

Introduction A paucity of contemporary data examining bleeding-related hospitalization outcomes in atrial fibrillation (AF) patients exists.

Methods Adults in the Nationwide Readmissions Database (January 2016–November 2016) with AF and hospitalized for intracranial hemorrhage (ICH), gastrointestinal, genitourinary, or other bleeding were identified. Association between bleed types and outcomes were assessed using multivariable regression (gastrointestinal defined as referent) and reported as crude incidences and adjusted odds ratios (ORs) or mean differences with 95% confidence intervals (CIs).

Results In total, 196,878 index bleeding-related hospitalizations were identified in this AF cohort (CHA2DS2VASc score ≥2 in 95.1%), with 70.8% classified as gastrointestinal. The overall incidences of in-hospital mortality, need for post-discharge out-of-home care, and 30-day readmission were 4.9, 50.8, and 18.2%, respectively. Multivariable regression suggested traumatic and nontraumatic ICHs were associated with higher odds of in-hospital mortality (OR = 3.99, 95% CI = 3.79, 4.19; OR = 13.09, 95% CI = 12.24, 13.99) and need for post-discharge out-of-home care (OR = 2.92, 95% CI = 2.83, 3.01; OR = 2.74, 95% CI = 2.59, 2.90), and increases in mean index hospitalization length-of-stay (8.31 days, 95% CI = 8.03, 8.60, 6.27 days, 95% CI = 5.97, 6.57) versus gastrointestinal bleeding. Genitourinary and other bleeds were associated with lower mortality (OR = 0.37, 95% CI = 0.25, 0.55; OR = 0.59, 95% CI = 0.53, 0.64) and reduced length-of-stays (−2.84 days, 95% CI =  − 2.91, −2.76; −2.06 days, 95% CI =  − 2.11, −2.01) versus gastrointestinal bleeding. Genitourinary bleeds were also associated with a reduced need for post-discharge out-of-home care (OR = 0.86, 95% CI = 0.77, 0.97).

Conclusion The burden of bleeding-related hospitalizations was notably driven by relatively rare but severe and life-threatening ICH, and less morbid but more frequent gastrointestinal bleeding. There is need for continued research on bleeding risk factors and mitigation techniques to avoid bleeding-related patient hospitalizations.

Keywords

hemorrhage - bleeding - atrial fibrillation - outcomes - burden-of-illness

Publication History

Received: 16 March 2020

Accepted: 05 August 2020

Article published online:
11 September 2020

• References

• 1 Kirchhof P, Benussi S, Kotecha D. ESC Scientific Document Group. , et al; 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37 (38) 2893-2962
• 2 Jakobsen M, Kolodziejczyk C, Klausen Fredslund E, Poulsen PB, Dybro L, Paaske Johnsen S. Costs of major intracranial, gastrointestinal and other bleeding events in patients with atrial fibrillation—a nationwide cohort study. BMC Health Serv Res 2017; 17 (01) 398
• 3 Inohara T, Xian Y, Liang L. , et al. Association of intracerebral hemorrhage among patients taking non-vitamin K antagonist vs vitamin K antagonist oral anticoagulants with in-hospital mortality. JAMA 2018; 319 (05) 463-473
• 4 Deitelzweig S, Neuman WR, Lingohr-Smith M, Menges B, Lin J. Incremental economic burden associated with major bleeding among atrial fibrillation patients treated with factor Xa inhibitors. J Med Econ 2017; 20 (12) 1217-1223
• 5 Angamo MT, Chalmers L, Curtain CM, Bereznicki LR. Adverse-drug-reaction-related hospitalisations in developed and developing countries: a review of prevalence and contributing factors. Drug Saf 2016; 39 (09) 847-857
• 6 H CUP. Introduction to the HCUP Nationwide Readmissions Database (NRD). 2010–2016. Accessed November 15, 2019 at: https://www.hcup-us.ahrq.gov/db/nation/nrd/Introduction_NRD_2010-2016.jsp
• 7 Cunningham A, Stein CM, Chung CP, Daugherty JR, Smalley WE, Ray WA. An automated database case definition for serious bleeding related to oral anticoagulant use. Pharmacoepidemiol Drug Saf 2011; 20 (06) 560-566
• 8 Joos C, Lawrence K, Jones AE, Johnson SA, Witt DM. Accuracy of ICD-10 codes for identifying hospitalizations for acute anticoagulation therapy-related bleeding events. Thromb Res 2019; 181: 71-76
• 9 United States Census Bureau, American Fact Finder. Annual estimates of the resident population by sex, race, and Hispanic origin for the United States, States, and Counties: April 1, 2010 to July 1, 2016. 2017 . Accessed October 21, 2019 at: https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk
• 10 Benchimol EI, Smeeth L, Guttmann A. RECORD Working Committee. , et al; The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med 2015; 12 (10) e1001885
• 11 Siddique MS, Gregson BA, Fernandes HM. , et al. Comparative study of traumatic and spontaneous intracerebral hemorrhage. J Neurosurg 2002; 96 (01) 86-89
• 12 Shehab N, Ziemba R, Campbell KN. , et al. Assessment of ICD-10-CM code assignment validity for case finding of outpatient anticoagulant-related bleeding among Medicare beneficiaries. Pharmacoepidemiol Drug Saf 2019; 28 (07) 951-964
• 13 Steinberg BA, Gao H, Shrader P. GARFIELD-AF, ORBIT-AF Investigators. , et al; International trends in clinical characteristics and oral anticoagulation treatment for patients with atrial fibrillation: results from the GARFIELD-AF, ORBIT-AF I, and ORBIT-AF II registries. Am Heart J 2017; 194: 132-140
• 14 Hsu JC, Maddox TM, Kennedy KF. , et al. Oral anticoagulant therapy prescriptions in patients with atrial fibrillation across the spectrum of stroke risk: insights from the NCDR PINNACLE Registry. JAMA Cardiol 2016; 1 (01) 55-62
• 15 Gandhi SK, Salmon W, Kong SX, Zhao SZ. Administrative databases and outcomes assessment: an overview of issues and potential utility. J Manag Care Spec Pharm 1999; 5: 215-222