Ian Jenkins, MD, assistant professor in the division of hospital medicine at the University of California at San Diego, says the windfall of time saved might not hit hospitalists directly, at least at some centers.
“The education is being done by pharmacy here for warfarin, and nurses handle enoxaparin injection teaching,” he says. “So the workload that benefits may be that of our colleagues.”
Dr. Shah notes that the responsibility in patient counseling ultimately falls within hospitalists’ purview, so he predicts that any greater simplicity in that regard would help hospitalists.
Who Ends up Hospitalized?
The option of oral agents might help diminish the number of patients who have to stay in the hospital for enoxaparin injections that bridge them to warfarin, a topic at a recent roundtable discussion Dr. Shah attended.
“It was shocking to me that I have many colleagues throughout the country who have patients who are in the hospital simply to get parenteral injections because they can’t take them themselves at home and have no loved ones or friends to help them,” he says.
Dr. Merli agrees that the new agents might affect hospitalists’ patient census. Many patients, he says, will be discharged straight from the ED.
“The DVT patients probably won’t get [admitted]. You’re going to put them on rivaroxaban and send them home,” he says. “You’re not going to get [admitted] with a DVT anymore, unless it’s extensive. And if it’s an extensive DVT, you’re not going to get rivaroxaban. You’re going to get enoxaparin or you’re going to get thrombolytics therapy followed by IV heparin followed by enoxaparin. So I don’t see rivaroxaban jumping into the marketplace and being a boon to hospitalists immediately.”
If patients skip hospitalization and are discharged straight from the ED, Dr. Deitelzweig says, “there will be patients who will backfill those spots.”
“I think most of the people will come in as observation status, if not inpatient,” he says, although simpler DVT patients will be likelier candidates for discharge from the ER. He predicts that stays might be shorter, though.
But Dr. Merli says hospitalists shouldn’t expect a big effect on length of stay.
“I don’t think you’re going to reduce dramatically length of stay because you have an oral pill,” he says.
QI Initiatives
What might be a boon, though, are opportunities for quality-improvement (QI) initiatives related to the new therapies, Dr. Jenkins says. “Many of these projects that are being done with anticoagulants … do focus on warfarin safety; it’s a frequent part of readmission and patient harm,” he says. “Having it much simpler to treat and educate these patients is actually going to be a boon, I think, for hospitalists working on quality-improvement projects, and for people who do that education, whether that is a hospitalist or a pharmacist or some other member of the staff.”
There are downsides, though, he notes. One is cost. Another is reversibility. Warfarin can be easily reversed in the event of a bleed, but that’s not the case with rivaroxaban and dabigatran. And none of the new therapies are suitable for patients with renal failure.
“Right now, we’re stuck with IV heparin and Coumadin in the hospital, and rivaroxaban won’t change this,” he says. “Rivaroxaban patients one might help with PCC; but with dabigatran, I don’t think much will help besides time and dialysis, which is dangerous in unstable anticoagulated patients.”
Dr. Shah, though, says he’s aware of only two times that bleeding reversal protocols—based on anecdotal evidence, because no method has been scientifically proven—had to be invoked at Northwestern in the past year.