Background: Patients who are admitted through the emergency department with a primary diagnosis of bleeding represent a group with significant morbidity and mortality. Of those patients admitted with a primary bleeding diagnosis, those on anticoagulants represent the greatest risk for adverse outcomes and cost. Better identification of the types of patients who present with bleeding would identify a group that may benefit from the use of novel anticoagulants given the recent identification of agents that provide very rapid reversal in acute bleeding emergencies.
Methods: The aim of this study was to better characterize patients admitted with bleeding to a large tertiary academic medical center across important bleeding sites and correlate them with health outcome related metrics. In addition, for those patients on anticoagulants at the time of admission, reversal agent treatments were also determined across various bleeding sites. All patients admitted to a large academic medical center with a primary diagnosis of bleeding as determined by 274 bleeding related ICD-9 codes were identified from 1/1/14 to 12/31/14. Sites of bleeding were characterized as those related to trauma, GI, intracranial, other critical compartments and all other. Relevant healthcare outcomes identified included average LOS, in-hospital mortality, and facility costs. Patients were identified as using prior anticoagulants if an order within the EMR was found for the patient (placed inpatient or outpatient) at any point in the six months leading up to the index admission for a bleed. For these patients on anticoagulants, the type of reversal agent administered was identified.
Results: 626 patients with a primary diagnosis of bleeding were identified as a cohort for analysis using 274 bleeding related ICD-9 codes over the 1 year period of this study. Among the total 626 patients, 22% of patients (138 patients) using our methodology were on an anticoagulant (warfarin, LMWH, or Xa inhibitor) while the remaining 488 patients were not on anticoagulants. Of the patients on anticoagulants, 57% had GI bleeding, while 21% had intracranial, 4% in other critical compartments and 18% in other areas. In addition, in this anticoagulant treated subgroup, ICH patients had the highest mortality (14%) and cost ($20,125). Critical compartments and GI bleed patients had the longest LOS (5.9 and 6.2 days respectively). In the anticoagulant treated subgroup, GI bleed patients had the highest % of blood product use (58%) while PCCs were used only in ICH patients (11%).
Conclusions: Of patients on anticoagulants, ICH and GI bleeding represent a significant portion of all patients admitted with a primary bleeding diagnosis. In this subgroup, ICH patients had the highest mortality and cost and were most likely to get PCCs. Thus, patients with these characteristics are most likely to be impacted by the use of newer immediate reversal agents given the increasing use of novel oral anticoagulants in clinical practice which represents a significant opportunity to impact LOS, in-hospital mortality and overall cost.