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700 Clinical Outcomes after Hospitalization for Oral Anticoagulant-Related Bleeding

Program: Oral and Poster Abstracts
Type: Oral
Session: 905. Outcomes Research: Non-Malignant Conditions Excluding Hemoglobinopathies: Practice-Changing Outcomes Research for Patients with Thrombosis
Hematology Disease Topics & Pathways:
Adult, Research, Elderly, Epidemiology, Clinical Practice (Health Services and Quality), Clinical Research, Health outcomes research, Real-world evidence, Registries, Study Population, Human
Sunday, December 8, 2024: 5:15 PM

Nicholas L.J. Chornenki, MD, BSc1, Joshua O Cerasuolo2*, Aurélien Delluc, MD, PhD3*, Anne Holbrook, MD, MSc, PharmD4*, David Kirkwood2*, Michael Paterson2*, Rinku Sutradhar2* and Deborah Siegal, MD, MSc3

1Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
2Institute for Clinical Evaluative Sciences, Toronto, Canada
3Department of Medicine, University of Ottawa, Ottawa, ON, Canada
4McMaster University, Hamilton, ON, CAN

Background: Use of oral anticoagulant (OAC) therapy for the prevention and treatment of thromboembolism is limited by serious bleeding complications, the most common OAC-related adverse event resulting in emergency department (ED) visits, hospitalization, and death. There are limited data regarding patient outcomes after hospitalization for OAC-related bleeding. Our objectives were to describe the risk of death, recurrent bleeding, and thromboembolism [deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic stroke] after hospitalization for OAC-related bleeding, and to identify risk factors for these outcomes.

Methods: Using administrative healthcare data from Ontario, Canada, we conducted a population-based cohort study of adults aged >65 years who were discharged after incident hospitalization for bleeding with OAC dispensed in the preceding 100 days (April 1, 2012 – March 31, 2020). The primary outcome was mortality within 100 days after hospital discharge. Secondary outcomes were the cumulative incidence of all-cause mortality within 1 year, and hospital and ED admissions for bleeding and thromboembolism. We examined associations between baseline covariates and mortality using multivariable Cox regression models to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI), and Fine-Gray regression models to calculate adjusted sub-distribution HR and 95%CI for thrombosis, bleeding, and mortality.

Results :Among 16180 cohort members, 14414 (89%) survived the index hospitalization and were included. Index bleeds were gastrointestinal (GI; n=9450, 66%), intracranial (n=1750, 12 %), genitourinary (GU; n=1178, 8%) or other (n=2036, 14%). The mean age was 81 years and 47% were female. Atrial fibrillation was the main indication for OAC (n=9,351, 65%). Patients were frequently prescribed factor Xa inhibitors (51%) and warfarin (39%). Within 100 days of discharge, OACs were dispensed to 9420 patients (65%), 87% of whom were prescribed a factor Xa inhibitor.

Within 100 days of discharge, 28% of patients were re-hospitalized. The estimated cumulative incidence of mortality was 12% over 100 days and 24% over 1 year. Mortality was highest among individuals hospitalized for intracranial or GI bleeding over both 100 days (16% and 12%) and 1 year (26% and 24%). Using competing risk methods, the cumulative incidence of rebleeding was 11% (highest for index GI bleeding [11%]). The cumulative incidence of thromboembolism was 3% (highest for index GI bleeding [3%]). Baseline covariates associated with an increased risk of mortality were: cancer (HR 2.82; 95%CI 2.36-3.36), discharge to long-term care (ref: home, HR 2.06; 95%CI 1.82-2.34), Elixhauser comorbidity index ≥4 (HR 1.46; 95%CI 1.31-1.64), venous thromboembolism (ref: atrial fibrillation, HR 1.36; 95%CI 1.13-1.64), intracranial bleeding (ref: GU, HR 1.34; 95%CI 1.06-1.68), congestive heart failure (HR 1.35; 95%CI 1.22-1.50), dementia (HR 1.33; 95%CI 1.19-1.50), and increasing age (1-year older HR 1.05; 95%CI 1.04-1.06).

Conclusion: Patients who survived hospitalization for OAC-related bleeding experienced substantial mortality, one-quarter dying within 1 year of hospital discharge. This confirms that older adults who are hospitalized for bleeding have a poor prognosis irrespective of index bleed site. The presence of cancer, discharge to long-term care and higher comorbidity burden had the strongest associations with mortality within 100 days. Evidence-based strategies are needed to identify and address risk factors to prevent OAC-related bleeding and to improve outcomes after serious bleeding.

Disclosures: Siegal: Servier: Other: honoraria paid indirectly to research institute; Roche: Other: honoraria paid indirectly to research institute; BMS-Pfizer: Other: honoraria paid indirectly to research institute; Astra Zeneca: Other: honoraria paid indirectly to research institute.

*signifies non-member of ASH