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Kwong WJ, Wang K, Wang P, Boccia R. Effect of Ferric Carboxymaltose Versus Low-Dose Intravenous Iron Therapy and Iron Sucrose on the Total Cost of Care in Patients with Iron Deficiency Anemia: A US Claims Database Analysis. Drugs Real World Outcomes 2024; 11:251-261. [PMID: 38502304 PMCID: PMC11176131 DOI: 10.1007/s40801-024-00418-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Iron deficiency is the most common cause of anemia. We compared the effect of ferric carboxymaltose (FCM), low-dose intravenous (IV) iron (LDI), and iron sucrose on total cost of care in patients with iron-deficiency anemia (IDA) from a US health plan perspective. METHODS We conducted a retrospective claims analysis using the IQVIA PharMetrics Plus database. Patients with index (first) claims of FCM and LDI and a medical claim associated with IDA between 1 January 2017 and 31 December 2019 were included. Monthly total healthcare and inpatient and outpatient costs after receiving index IV iron for patients in the treatment cohorts were compared using a generalized linear model with gamma distribution and log-link. RESULTS The overall study cohort included 37,655 FCM, 44,237 LDI, and 27,461 iron sucrose patients. Mean per-patient-per-month numbers of IV iron infusions for FCM, LDI, and iron sucrose were 0.20, 0.34, and 0.37, respectively. Compared with baseline, the FCM group had greater reductions in the number of hospital admissions and smaller increases in the number of outpatient visits in the 12 months post-IV iron therapy than LDI and iron sucrose, translating to significantly lower total healthcare cost (post-index adjusted cost ratio for total cost: 0.96 and 0.92, respectively; both P < 0.0001). CONCLUSIONS Higher drug acquisition cost of FCM relative to LDI and iron sucrose was offset by significantly lower inpatient and outpatient costs in the 12 months post-IV iron therapy. These results support the economic value of FCM for patients with IDA receiving IV iron therapy.
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Affiliation(s)
- Winghan Jacqueline Kwong
- Health Economics and Outcomes Research, Daiichi Sankyo, Inc., 211 Mt Airy Road, Basking Ridge, NJ, 07920, USA
| | - Kevin Wang
- Health Economics and Outcomes Research, Daiichi Sankyo, Inc., 211 Mt Airy Road, Basking Ridge, NJ, 07920, USA.
| | - Peng Wang
- Health Economics and Outcomes Research, Daiichi Sankyo, Inc., 211 Mt Airy Road, Basking Ridge, NJ, 07920, USA
| | - Ralph Boccia
- The Center for Cancer and Blood Disorders, Bethesda, MD, USA
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2
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Durand A, Routier B, Druesne L, Dubois-Laurent M, Roca F, Chenailler C. [The proper use of carboxymaltose iron and its economic impact in the geriatric wards of a French university hospital]. SOINS. GERONTOLOGIE 2023; 28:42-46. [PMID: 37481291 DOI: 10.1016/j.sger.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
The proper use and economic impact of carboxymaltose iron were evaluated for patients hospitalized in the geriatric wards of a French university hospital from November 2019 to April 2020. Martial supplementation was recommended for 75.7% of the 173 patients who received carboxymaltose iron: 43.4% had a real indication for carboxymaltose iron, while 14.4% could have received sucrose iron and 17.9% could have received per os iron. Compliance with the recommendations would have generated savings of 10,345.80 euros (32.1%).
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Affiliation(s)
- Amaury Durand
- Pharmacie à usage interne, CHU Rouen, 37 boulevard Gambetta, 76000 Rouen, France; Médecine interne gériatrique, CHU Rouen, 37 boulevard Gambetta, 76000 Rouen, France; Soins de Suite et de Réadaptation, CHU Rouen, 37 boulevard Gambetta, 76000 Rouen, France.
| | - Baptiste Routier
- Pharmacie à usage interne, CHU Rouen, 37 boulevard Gambetta, 76000 Rouen, France; Médecine interne gériatrique, CHU Rouen, 37 boulevard Gambetta, 76000 Rouen, France
| | - Laurent Druesne
- Médecine interne gériatrique, CHU Rouen, 37 boulevard Gambetta, 76000 Rouen, France
| | | | - Frédéric Roca
- Médecine interne gériatrique, CHU Rouen, 37 boulevard Gambetta, 76000 Rouen, France
| | - Catherine Chenailler
- Pharmacie à usage interne, CHU Rouen, 37 boulevard Gambetta, 76000 Rouen, France
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Lacquaniti A, Gargano R, Campo S, Casuscelli di Tocco T, Schifilliti S, Monardo P. The Switch from Ferric Gluconate to Ferric Carboxymaltose in Hemodialysis Patients Acts on Iron Metabolism, Erythropoietin, and Costs: A Retrospective Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1071. [PMID: 37374275 DOI: 10.3390/medicina59061071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/18/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Iron deficiency and anemia characterize patients on chronic hemodialysis (HD). Available intravenous iron agents, such as ferric gluconate (FG) and ferric carboxymaltose (FCM), vary in dosing regimens and safety profiles. The aim of the present study was to analyze the modification of the iron status, the correction of anemia, and the economic implications after the shift from FG to FCM therapy in chronic HD patients. We evaluated, during the study, the variations in iron metabolism, assessing ferritin and transferrin saturation, erythropoietin-stimulating agent (ESA) doses and the number of administrations, the effects on anemic status, and consequent costs. Materials and Methods: A retrospective study was performed with a follow-up period of 24 months, enrolling forty-two HD patients. The enrolment phase started in January 2015, when patients were treated with iv FG, and continued until December 2015, when FG was discontinued, and, after a wash-out period, the same patients were treated with FCM. Results: The iron switch reduced the administered dose of ESA by 1610.500 UI (31% of reduction; p < 0.001) during the entire study period and reduced the erythropoietin resistance index (ERI) (10.1 ± 0.4 vs. 14.8 ± 0.5; p < 0.0001). The FCM group had the highest percentage of patients who did not require ESA treatment during the study period. The FCM patients were characterized by higher levels of iron (p = 0.04), ferritin (p < 0.001), and TSAT levels (p < 0.001) compared to the FG patients. The annual cost during FG infusion was estimated at EUR 105,390.2, while one year of treatment with FCM had a total cost of EUR 84,180.7 (a difference of EUR 21,209.51 (20%), saving EUR 42.1 per patient/month (p < 0.0001). Conclusions: FCM was a more effective treatment option than FG, reducing ESA dose requirements, increasing Hb levels, and improving iron status. The reduced ESA doses and the decreased number of patients needing ESA were the main factors for reducing overall costs.
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Affiliation(s)
| | - Romana Gargano
- Department of Economics, University of Messina, 98100 Messina, Italy
| | - Susanna Campo
- Nephrology and Dialysis Unit, Papardo Hospital, 98158 Messina, Italy
| | | | - Silvia Schifilliti
- Faculty of Pharmacy, Clinical Pharmacy Fellowship, University of Messina Annunziata Campus, 98168 Messina, Italy
| | - Paolo Monardo
- Nephrology and Dialysis Unit, Papardo Hospital, 98158 Messina, Italy
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4
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Lanas A, Andrews JM, Lau J, Toruner M, Bromley SE, Gralnek IM. Management of iron-deficiency anemia following acute gastrointestinal hemorrhage: A narrative analysis and review. J Gastroenterol Hepatol 2023; 38:23-33. [PMID: 36266733 DOI: 10.1111/jgh.16033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/16/2022] [Accepted: 10/13/2022] [Indexed: 01/18/2023]
Abstract
Many patients experiencing acute gastrointestinal bleeding (GIB) require iron supplementation to treat subsequent iron deficiency (ID) or iron-deficiency anemia (IDA). Guidelines regarding management of these patients are lacking. We aimed to identify areas of unmet need in patients with ID/IDA following acute GIB in terms of patient management and physician guidance. We formed an international working group of gastroenterologists to conduct a narrative review based on PubMed and EMBASE database searches (from January 2000 to February 2021), integrated with observations from our own clinical experience. Published data on this subject are limited and disparate, and those relating to post-discharge outcomes, such as persistent anemia and re-hospitalization, are particularly lacking. Often, there is no post-discharge follow-up of these patients by a gastroenterologist. Acute GIB-related ID/IDA, however, is a prevalent condition both at the time of hospital admission and at hospital discharge and is likely underdiagnosed and undertreated. Despite limited data, there appears to be notable variation in the prescribing of intravenous (IV)/oral iron regimens. There is also some evidence suggesting that, compared with oral iron, IV iron may restore iron levels faster following acute GIB, have a better tolerability profile, and be more beneficial in terms of quality of life. Gaps in patient care exist in the management of acute GIB-related ID/IDA, yet further data from large population-based studies are needed to confirm this. We advocate the formulation of evidence-based guidance on the use of iron therapies in these patients, aiding a more standardized best-practice approach to patient care.
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Affiliation(s)
- Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico, University of Zaragoza, IIS Aragón, Zaragoza, Spain.,CIBERehd, Madrid, Spain
| | - Jane M Andrews
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Health Science, University of Adelaide, Adelaide, South Australia, Australia
| | - James Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Murat Toruner
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | | | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Rosati A, Conti P, Berto P, Molinaro S, Baldini F, Egan CG, Panichi V. Efficacy, Safety and Pharmacoeconomic Analysis of Intravenous Ferric Carboxymaltose in Anemic Hemodialysis Patients Unresponsive to Ferric Gluconate Treatment: A Multicenter Retrospective Study. J Clin Med 2022; 11:5284. [PMID: 36142929 PMCID: PMC9506237 DOI: 10.3390/jcm11185284] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/12/2022] [Accepted: 09/02/2022] [Indexed: 12/01/2022] Open
Abstract
Patients undergoing hemodialysis with iron deficiency anemia (IDA) receiving treatment with erythropoiesis-stimulating agents (ESAs) who were intolerant or non-responsive to intravenous (i.v.) ferric gluconate (FG) (hemoglobin; Hb values < 10.5 g/dL or increase in <1 g/dL) or % transferrin saturation; TSAT of <20%) in the previous 6 months were switched to i.v. ferric carboxymaltose (FCM). Changes in iron status parameters, economic and safety measures were also assessed. Seventy-seven hemodialysis patients aged 68 ± 15 years were included. Erythropoietin resistance index decreased from 24.2 ± 14.6 at pre-switch to 20.4 ± 14.6 after 6 months of FCM treatment and Hb levels ≥10.5 g/dL improved from 61% to 75.3% patients (p = 0.042). A 1 g/dL increase in Hb levels was also seen in 26% of patients as well as a 37.7% increase in patients achieving >20% increase in TSAT after FCM. Levels of Hb, TSAT and ferritin parameters increased during FCM treatment with a concomitant decrease in ESA. A mixed-model analysis, which also considered gender, confirmed these trends. Safety variables remained stable, no hypersensitivity reaction was recorded and only one patient reported an adverse event after FCM. FCM treatment was associated with a cost saving of 11.11 EUR/patient/month. These results confirm the efficacy, safety and cost-effectiveness of FCM in correcting IDA in hemodialysis patients.
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Affiliation(s)
- Alberto Rosati
- SOC Nefrologia e Dialisi, Ospedale San Giovanni di Dio, 50143 Firenze, Italy
| | - Paolo Conti
- Nephrology and Dialysis Unit, Nephrology Department, Arezzo Hospital, 52100 Arezzo, Italy
| | | | - Sabrina Molinaro
- National Research Council, Institute of Clinical Physiology (CNR-IFC), 56124 Pisa, Italy
| | - Federica Baldini
- National Research Council, Institute of Clinical Physiology (CNR-IFC), 56124 Pisa, Italy
| | | | - Vincenzo Panichi
- Nephrology and Dialysis Unit, Versilia Hospital, 55049 Lido Di Camaiore, Italy
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Bielesz B, Lorenz M, Monteforte R, Prikoszovich T, Gabriel M, Wolzt M, Gleiss A, Hörl WH, Sunder-Plassmann G. Comparison of Iron Dosing Strategies in Patients Undergoing Long-Term Hemodialysis: A Randomized Controlled Trial. Clin J Am Soc Nephrol 2021; 16:1512-1521. [PMID: 34470831 PMCID: PMC8499011 DOI: 10.2215/cjn.03850321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 08/07/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Whether iron supplementation in patients on hemodialysis could be delivered by less frequent but higher single doses compared with the currently more common higher-frequency schedules of lower single iron doses is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We carried out an open-label, randomized, controlled noninferiority trial over 40 weeks in patients on prevalent hemodialysis (n=142). We administered in total 2 g iron as 100 mg iron sucrose biweekly in a continuous (20 × 100 mg) fashion or 500 mg ferric carboxymaltose every 10 weeks in a periodic (4 × 500 mg) fashion. The primary end point was the change in hemoglobin at week 40 from baseline with a noninferiority margin of -0.8 g/dl. Secondary end points were changes in ferritin, transferrin, transferrin saturation, and erythropoiesis-stimulating agent use. RESULTS In total, 108 patients completed the study. At 40 weeks, hemoglobin changed by -0.27 g/dl (95% confidence interval, -0.64 to 0.09) in the iron sucrose arm and by -0.74 g/dl (95% confidence interval, -1.1 to -0.39) in the ferric carboxymaltose arm compared with baseline. Noninferiority was not established in the per-protocol population as hemoglobin changes compared with baseline differed by -0.47 g/dl (95% confidence interval, -0.95 to 0.01) in the ferric carboxymaltose arm compared with the iron sucrose arm. Proportional changes from baseline to week 40 differed by -31% (98.3% confidence interval, -52 to -0.1) for ferritin, by 1% (98.3% confidence interval, -7 to 10) for transferrin, and by -27% (98.3% confidence interval, -39 to -13) for transferrin saturation in the ferric carboxymaltose arm compared with the iron sucrose arm. Erythropoiesis-stimulating agent dosing did not differ between groups. The overall number of adverse events was similar; however, more infections were observed in the iron sucrose arm. CONCLUSIONS An equal cumulative dose of ferric carboxymaltose administered less frequently did not meet noninferiority for maintaining hemoglobin levels compared with iron sucrose administered more frequently. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Comparison Study of Two Iron Compounds for Treatment of Anemia in Hemodialysis Patients (COPEFER), NCT02198495.
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Affiliation(s)
- Bernhard Bielesz
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Rossella Monteforte
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | | | - Michael Wolzt
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Andreas Gleiss
- Center for Medical Statistics, Informatics, and Intelligent Systems, Institute of Clinical Biometrics, Medical University of Vienna, Vienna, Austria
| | - Walter H. Hörl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gere Sunder-Plassmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Beverina I, Aloni A, Gatti F, Varalli L, Brando B. Attitude changes in prescribing intravenous iron supplementation in different settings at a hospital consortium in Italy. Transfus Apher Sci 2021; 60:103139. [PMID: 33865715 DOI: 10.1016/j.transci.2021.103139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Iron deficiency anaemia is a public health problem. In case oral iron treatment is ineffective, poorly tolerated or contraindicated, the intravenous route becomes the first choice. The aim of the study was to evaluate the shift between ferrous gluconate (FG) and ferric carboxymaltose (FCM) usage at our hospitals over the years. We also performed a cost comparison between pre and post-FCM availability periods, taking into account the acquisition costs of both intravenous iron and red blood cell units (PRBC). STUDY DESIGN AND METHODS The amount and costs of FG and FCM released by hospital Pharmacy Services from 2010 to 2019 were analysed, along with the number of transfused PRBC units in the same timeframe. RESULTS Overall, the proportion of FCM usage rose from 8.6 % in 2014 to 71.9 % in 2019, as percentage of total intravenous iron released. After exclusion of haemodialysis, where FG is still widely used, the FCM use in the last four years raised from 12.9% to 92.5%. Despite the higher FCM cost, the mean yearly expenditure for intravenous iron plus PRBC units did not differ between pre- and post-FCM eras (2010-2013, € 2,396,876 € versus 2014-2019, € 2,307,875 - p = 0.234), as a result of a net decrease of PRBC usage, namely from 15,083 to 12,654 (-16.1 %), respectively. DISCUSSION Intravenous iron has a major role in treating iron deficiency anaemia in several settings. Third generation compounds are paving the way to more updated and safer treatments.
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Affiliation(s)
- Ivo Beverina
- Blood Transfusion Centre, Legnano General Hospital, ASST Ovest Milanese, Legnano, Italy.
| | - Alessandro Aloni
- Blood Transfusion Centre, Legnano General Hospital, ASST Ovest Milanese, Legnano, Italy
| | - Federico Gatti
- Pharmacy Service Unit, ASST Ovest Milanese, Legnano General Hospital, Legnano, Italy
| | - Luca Varalli
- Pharmacy Service Unit, ASST Ovest Milanese, Legnano General Hospital, Legnano, Italy
| | - Bruno Brando
- Blood Transfusion Centre, Legnano General Hospital, ASST Ovest Milanese, Legnano, Italy
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Efficacy and Safety of Intravenous Ferric Carboxymaltose in Patients with Postoperative Anemia Following Same-Day Bilateral Total Knee Arthroplasty: A Randomized Controlled Trial. J Clin Med 2021; 10:jcm10071457. [PMID: 33918110 PMCID: PMC8036569 DOI: 10.3390/jcm10071457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/25/2021] [Accepted: 03/28/2021] [Indexed: 01/28/2023] Open
Abstract
(1) Background: The purpose of this study was to evaluate the efficacy and safety of intravenous (IV) ferric carboxymaltose (FCM) to treat acute postoperative anemia following same-day bilateral total knee arthroplasty (TKA). (2) Methods: A total of 118 patients who underwent same-day bilateral TKA were randomly assigned to two groups: an FCM group (FCM infusion, 58 patients) and a Control group (placebo with normal saline, 60 patients). The primary endpoint was the number of responders with a Hb increase of two or more points by the second postoperative week. The secondary endpoints were Hb level, iron metabolism variables and blood transfusion rate at 2, 6 and 12 weeks after surgery. (3) Results: The FCM group had more Hb responders than the Control group (62.1% vs. 31.6%, p < 0.001). The Hb level was significantly higher in the FCM group during 12 weeks after surgery (all p < 0.05). Ferritin, iron and transferrin saturation levels were significantly higher in the FCM group from 2 to 12 weeks postoperatively (all p < 0.05). There was no difference in transfusion rate after surgery (p > 0.05). (4) Conclusion: In patients with postoperative anemia after same-day bilateral TKA, IV FCM infusion significantly improved Hb response two weeks after surgery without severe adverse events compared to placebo. In contrast, transfusion rate and various parameters of quality of life assessment up to 12 weeks did not vary between these groups. Level of evidence: Level I.
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Wong B, Redmond S, Blaine C, Nugent CA, Saiva L, Buckley J, O'Neill J. Study of patients with iron deficiency and HF in Ireland: prevalence and treatment budget impact. THE BRITISH JOURNAL OF CARDIOLOGY 2021; 28:10. [PMID: 35747488 PMCID: PMC8822530 DOI: 10.5837/bjc.2021.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This study aims to present the screening, prevalence and treatment of heart failure (HF) patients with iron deficiency in an Irish hospital and use an economic model to estimate the budget impact of treating eligible patients with intravenous ferric carboxymaltose (IV FCM). Retrospective data were collected on 151 HF patients over a one-year period from all newly referred HF patients to a secondary care hospital. This included 36 patients with preserved ejection fraction (HFpEF) and 115 with reduced ejection fraction (HPrEF). An existing budget impact model was adapted to incorporate Irish unit cost and resource use data to estimate the annual budget impact of treating patients with IV FCM. The total number of HFrEF patients who met criteria for iron replacement was 44 (38% of total HFrEF patients); of this, only nine (20%) were treated. The budget impact model estimates that treating all eligible patients with IV FCM in this single centre would save 40 bed-days and over €7,600/year. To improve the quality of life and reduce hospitalisation, further identification and treatment of iron deficient patients should be implemented. Expanding the use of IV iron nationally would be cost and bed saving.
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Affiliation(s)
- Bethany Wong
- Irish Clinical Academic Fellow in Cardiology Cardiology Department, Connolly Hospital, Dublin 15, Ireland
| | - Sandra Redmond
- Health Economic Specialist and Managing Director of Salutem Insights Salutem Insights, www.saluteminsights.com
| | - Ciara Blaine
- Cardiology Specialist Nurse Cardiology Department, Connolly Hospital, Dublin 15, Ireland
| | - Carol-Ann Nugent
- Cardiology Specialist Nurse Cardiology Department, Connolly Hospital, Dublin 15, Ireland
| | - Lavanya Saiva
- Cardiology Registrar Cardiology Department, Connolly Hospital, Dublin 15, Ireland
| | - John Buckley
- Cardiology Specialist Registrar Cardiology Department, Connolly Hospital, Dublin 15, Ireland
| | - Jim O'Neill
- Cardiology Consultant in Heart Failure Cardiology Department, Connolly Hospital, Dublin 15, Ireland
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