Program-wide transition from heparin to bivalirudin anticoagulation in adult ecmo: a cost analysis

Introduction: Bivalirudin is becoming an increasingly popular alternative to heparin for extracorporeal membrane oxygenation (ECMO) anticoagulation due to its short half-life, organ-independent metabolism, thrombin inhibition without the need for a co-factor, and its ability to bind clot-bound and freely circulating thrombin. The objective of this study was to compare the cost implications of bivalirudin and heparin during adult ECMO support. Methods: A retrospective analysis of adults supported on ECMO who received heparin or bivalirudin for anticoagulation between January 2014 and January 2022 at Mayo Clinic was performed. In November 2017, the Mayo Clinic ECMO program transitioned from heparin to bivalirudin as the primary anticoagulant of choice, which separated the pre- and post-transition groups. Cost data were estimated using Wholesale Acquisition Costs and laboratory reimbursement schedules. Cost data were normalized to duration of ECMO support, compared between the pre- and post-transition groups, and were summarized in United States Dollar ($). Results: A total of 126 patients (123 heparin, 3 bivalirudin) in the pre-transition period and 275 patients (82 heparin, 193 bivalirudin) in the post-transition period were included. Antithrombin administration was more frequent in the pre-transition group (31% vs. 12%, p < 0.0001), as were number of coagulation assays per ECMO day (6.1 vs. 5.4, p = 0.0004). The post-transition group had significantly less costs from antithrombin assessments ($1.03 vs. $11.78, p < 0.0001) and antithrombin supplementation ($0 [IQR $0, $0] vs. $0 [IQR $0, $312.82], p < 0.0001) per day of ECMO support. The aggregate costs per patient were similar in the heparin ($333 vs. $248, p = 0.5690) and bivalirudin ($2723 vs $1720, p = 0.4659) groups pre- and post-transition, respectively. Survival at 28-days was greater in the post-transition group (75% vs. 64%, p = 0.0286). Conclusions: Antithrombin assessment and supplementation comprised a majority of anticoagulant-related costs in heparin-based ECMO patients, which was significantly reduced following transition to bivalirudin-based anticoagulation. When considering laboratory and drug costs in aggregate, there is a favorable association between bivalirudin and heparin anticoagulation in adult ECMO patients.