Peri-Procedural Healthcare Costs of Thromboembolic and Bleeding Events in Patients on Direct Oral Anticoagulants Undergoing High-Risk Endoscopy

Background and study aims: Patients on direct oral anticoagulants (DOACs) undergoing high-risk endoscopy face competing risks of bleeding and thromboembolism during peri-procedural anticoagulant interruption. We quantified peri-procedural adverse event (AE) rates and incremental healthcare costs. Patients and methods: Retrospective cohort study using the TriNetX Linked Claims database (2015-2025), a US-wide multi-payer claims network. Adults on DOAC or warfarin therapy who underwent high-risk endoscopy were included (N=2,486 unique patients; N=1,933 with linked cost data). Peri-procedural bleeding and thromboembolic events were identified using principal-diagnosis codes in acute care encounters (emergency department or inpatient) within 90 days of the index procedure. Unadjusted and multivariable-adjusted incremental 90-day costs were compared between patients with and without each AE type using generalized linear models. Results: Among 2,486 anticoagulated patients (median age 65; 61.5% male; 81% with atrial fibrillation), bleeding occurred in 18.0% at 7 days and 22.9% at 90 days. Stroke/TIA occurred in 0.5% at 7 days and 1.7% at 90 days. Each thromboembolic event cost approximately 2.5 times more than each bleeding event. Stroke/TIA added $8,874 unadjusted (p<0.001) and $5,798 adjusted (cost ratio 1.56; 95% CI 1.11-2.20; p=0.011); bleeding added $3,471 unadjusted and $3,157 adjusted (cost ratio 1.33; 95% CI 1.18-1.50; p<0.001). Patients experiencing both bleeding and subsequent stroke/TIA had the highest costs (mean $23,716). Conclusions: Peri-procedural thromboembolic events cost the healthcare system 2.5-fold more per event than bleeding, underscoring the clinical and economic importance of periprocedural DOAC management and motivating randomized evidence on optimal DOAC resumption timing strategies.