{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"institution":[{"name":"medRxiv"}],"indexed":{"date-parts":[[2026,8,5]],"date-time":"2026-08-05T11:43:40Z","timestamp":1785930220447,"version":"3.56.0"},"posted":{"date-parts":[[2026,8,3]]},"group-title":"Gastroenterology","reference-count":34,"publisher":"openRxiv","license":[{"start":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T00:00:00Z","timestamp":1785715200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/www.medrxiv.org\/about\/FAQ#license"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"accepted":{"date-parts":[[2026,8,3]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                <jats:sec>\n                  <jats:title>Background and study aims<\/jats:title>\n                  <jats:p>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.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Patients and methods<\/jats:title>\n                  <jats:p>Retrospective cohort study using the TriNetX Linked Claims database (2015\u20132025), 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.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>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&lt;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&lt;0.001). Patients experiencing both bleeding and subsequent stroke\/TIA had the highest costs (mean $23,716).<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>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.<\/jats:p>\n                <\/jats:sec>","DOI":"10.64898\/2026.07.31.26359377","type":"posted-content","created":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T17:35:16Z","timestamp":1785778516000},"source":"Crossref","is-referenced-by-count":0,"title":["Peri-Procedural Healthcare Costs of Thromboembolic and Bleeding Events in Patients on Direct Oral Anticoagulants Undergoing High-Risk Endoscopy"],"prefix":"10.64898","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0306-8364","authenticated-orcid":false,"given":"Zachary L.","family":"Smith","sequence":"first","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA"},{"name":"Wisconsin Institute for Research in Endoscopy, Medical College of Wisconsin, Milwaukee, WI, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nauzer","family":"Forbes","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, University of Calgary Cumming School of Medicine, Calgary, AB, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"B. Joseph","family":"Elmunzer","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology & Center for Digestive Health & Surgery, Atrium Health-Wake Forest University School of Medicine, Charlotte, NC, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Denise M.","family":"Scholtens","sequence":"additional","affiliation":[{"name":"Department of Preventive Medicine, Division of Biostatistics and Informatics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian T","family":"Ruff","sequence":"additional","affiliation":[{"name":"Division of Cardiovascular Medicine, Brigham and Women\u2019s Hospital, Harvard Medical School, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"54368","reference":[{"key":"2026080503450908000_2026.07.31.26359377v1.1","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjmed.2015.05.044"},{"key":"2026080503450908000_2026.07.31.26359377v1.2","first-page":"339","article-title":"Trends in utilization, reimbursement, and price for DOACs and warfarin in the US Medicaid population from 2000 to 2020","volume":"55","year":"2023","journal-title":"J Thromb Thrombolysis"},{"key":"2026080503450908000_2026.07.31.26359377v1.3","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-020-5058-1"},{"key":"2026080503450908000_2026.07.31.26359377v1.4","doi-asserted-by":"crossref","first-page":"4916","DOI":"10.1007\/s12325-025-03287-4","article-title":"Bleeding-Related Hospitalizations Among Direct Oral Anticoagulant Users and Nonusers in Medicare Fee-For-Service: Variation in Prevalence, Burden, and Characteristics","volume":"42","year":"2025","journal-title":"Adv Ther"},{"key":"2026080503450908000_2026.07.31.26359377v1.5","doi-asserted-by":"crossref","first-page":"778","DOI":"10.1055\/a-2568-7473","article-title":"Curriculum for training in peroral endoscopic myotomy (POEM) in Europe (Part I): European Society of Gastrointestinal Endoscopy (ESGE) Position Statement","volume":"57","year":"2025","journal-title":"Endoscopy"},{"key":"2026080503450908000_2026.07.31.26359377v1.6","doi-asserted-by":"crossref","first-page":"361","DOI":"10.1055\/a-2031-0874","article-title":"Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review","volume":"55","year":"2023","journal-title":"Endoscopy"},{"key":"2026080503450908000_2026.07.31.26359377v1.7","doi-asserted-by":"publisher","DOI":"10.1136\/gutjnl-2018-316385"},{"key":"2026080503450908000_2026.07.31.26359377v1.8","doi-asserted-by":"publisher","DOI":"10.1016\/j.cgh.2020.11.037"},{"key":"2026080503450908000_2026.07.31.26359377v1.9","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1007\/s10120-020-01105-0","article-title":"Influence of anticoagulants on the risk of delayed bleeding after gastric endoscopic submucosal dissection: a multicenter retrospective study","volume":"24","year":"2021","journal-title":"Gastric Cancer"},{"key":"2026080503450908000_2026.07.31.26359377v1.10","doi-asserted-by":"publisher","DOI":"10.3748\/wjg.v24.i14.1540"},{"key":"2026080503450908000_2026.07.31.26359377v1.11","doi-asserted-by":"publisher","DOI":"10.14309\/ajg.0000000000001627"},{"key":"2026080503450908000_2026.07.31.26359377v1.12","doi-asserted-by":"crossref","first-page":"332","DOI":"10.1007\/s12664-022-01324-6","article-title":"Position statement from the Indian Society of Gastroenterology, Cardiological Society of India, Indian Academy of Neurology and Vascular Society of India on gastrointestinal bleeding and endoscopic procedures in patients on antiplatelet and\/or anticoagulant therapy","volume":"42","year":"2023","journal-title":"Indian J Gastroenterol"},{"key":"2026080503450908000_2026.07.31.26359377v1.13","doi-asserted-by":"crossref","first-page":"141","DOI":"10.5946\/ce.2024.002","article-title":"International Digestive Endoscopy Network consensus on the management of antithrombotic agents in patients undergoing gastrointestinal endoscopy","volume":"57","year":"2024","journal-title":"Clinical Endoscopy"},{"key":"2026080503450908000_2026.07.31.26359377v1.14","doi-asserted-by":"crossref","first-page":"433","DOI":"10.1111\/den.13184","article-title":"Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment: 2017 Appendix on Anticoagulants Including Direct Oral Anticoagulants","volume":"30","year":"2018","journal-title":"Digestive Endoscopy"},{"key":"2026080503450908000_2026.07.31.26359377v1.15","doi-asserted-by":"publisher","DOI":"10.1136\/gutjnl-2021-325184"},{"key":"2026080503450908000_2026.07.31.26359377v1.16","doi-asserted-by":"crossref","unstructured":"Masuda S , Koizumi K , Nishino T , et al. 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