Benefits and costs of recombinant human erythropoietin for end-stage renal failure: a review. Benefits and costs of erythropoietin

Collagen Hydrolysate Corrects Anemia in Chronic Kidney Disease via Anti-Inflammatory Renoprotection and HIF-2α-Dependent Erythropoietin and Hepcidin Regulation

Anemia is a common chronic kidney disease (CKD) complication contributing to increased morbidity and mortality. Collagen-based traditional Chinese nutraceuticals have long been used in antianemic therapies. This study aims to investigate the therapeutic effectiveness of porcine collagen hydrolysate (CH) and its underlying mechanism in the treatment of renal anemia by using adenine-induced CKD mice, RAW264.7 macrophages, and HepG2 hepatoma cells, with prolyl-hydroxyproline as a reference compound for collagen-derived hydroxyproline-containing di-/tripeptides. CH was found to alleviate renal filtering dysfunction, systemic and kidney inflammation, liver hepcidin overproduction and anemia and to increase erythropoietin production and hypoxia inducible factor (HIF)-2α stability in liver and kidney in CKD mice. Prolyl-hydroxyproline exerted direct anti-inflammatory effects on lipopolysaccharide-activated macrophages and elicited stimulating and inhibiting activities on erythropoietin expression and hepcidin overproduction, respectively, in HepG2 cells by HIF-2α activation. Overall, CH was effective in correcting renal anemia via anti-inflammatory renoprotection and HIF-2α-dependent erythropoietin and hepcidin regulation.

Darbepoetin Alfa Therapeutic Interchange Protocol for Anemia in Dialysis

BACKGROUND

Erythropoiesis-stimulating proteins, such as erythropoietin alfa and darbepoetin alfa, have positively impacted anemia management. These medications improve patient outcomes and quality of life. Their costs, however, remain a major barrier for health systems.

OBJECTIVE

To evaluate the development, implementation, and cost-effectiveness of an inpatient therapeutic interchange protocol for erythropoiesis-stimulating proteins at a large, tertiary care, university-affiliated health system.

METHODS

Virginia Commonwealth University Health System (VCUHS) developed and implemented a therapeutic interchange program to convert therapy for all inpatients undergoing dialysis from erythropoietin alfa to darbepoetin alfa for treatment of chronic kidney disease–related anemia. An evaluation of the economic impact of this program on drug expenditures over a fiscal quarter (2003) was conducted using historical comparator data (2002).

RESULTS

Preliminary evaluation of the program demonstrated cost-savings and reduced drug utilization of erythropoiesis-stimulating proteins in hospitalized dialysis patients. For the first quarter of 2003 compared with the first quarter of 2002, VCUHS realized a cost-savings of nearly $10 000, which was related to the program's aggressive screening procedure. When these data were normalized for equal numbers of patients in each group receiving one of the drugs, the actual cost-savings was over $2000. These cost-savings are largely due to reduced utilization of these expensive biotechnology products with implementation of a dosing protocol.

CONCLUSIONS

VCUHS has successfully developed and implemented a darbepoetin alfa therapeutic interchange protocol for hospitalized dialysis patients. This has translated into reduced use of erythropoiesis-stimulating proteins, resulting in cost-savings for the health system.

Pharmacoeconomic considerations in the health system management of anaemia in patients with chronic kidney disease and end stage renal disease

Anaemia is prevalent in patients with chronic kidney disease and end stage renal disease. If left untreated, it greatly affects patient survival, quality of life and functional status. Epoetin and darbepoetin are two biotechnology drugs that effectively stimulate the production of red blood cells. These drugs have been shown to significantly increase haemoglobin concentrations and improve quality of life. So far, there have been no head-to-head pharmacoeconomic studies that have compared epoetin to darbepoetin. Health system decision makers need to evaluate important considerations when comparing these agents. These considerations include drug acquisition costs, the patient population being treated, the location of drug administration (in-patient versus ambulatory) and federal government reimbursement. This review details these important pharmacoeconomic considerations.

Economic evaluation and end-stage renal disease: from basics to bedside

Economic evaluation is the comparative analysis of alternative health care interventions in terms of their relative costs (resource use) and effectiveness (health effects). High-quality studies of economic evaluation have been increasingly published in medical journals and read by clinicians, although publication of these studies in nephrology journals has been a more recent phenomenon. This article shows how the basic principles of economics can be applied to health care through the use of economic evaluation. Different types of economic evaluation are discussed, and pitfalls common to such studies are identified. A simple framework is introduced that can be used to interpret the results of economic evaluations. Using this framework, selected therapies for patients with end-stage renal disease (ESRD) are categorized to highlight therapies that are very efficient, encourage their use, and draw attention to therapies in current use that are less effective and more expensive (ie, less efficient) than alternative therapy. Using examples pertinent to care of the patient with ESRD, we show how economic evaluation can be used to link medical outcomes, quality of life, and costs in a common index for multiple therapies with disparate outcome measures. This article highlights the need for clinical studies and economic evaluations of therapies in ESRD for which the effects of the therapy on health outcomes and/or costs are unknown.

Fairness, public expenditure and the cost of new treatments in the UK

Current differences in standards for allocating resources in the UK for, on the one hand, drugs and surgery, and on the other, chronic community and social care and social security lead to significant inequality. Using a case study of hypothetical patients, it can be shown that adoption of new treatments, at high cost, to make marginal improvements in well-being would lead to much greater spending on some patients than on others with similar problems from different causes. Inequality occurs because society tolerates tighter constraints on community and social care and social security than on acute care and drug budgets for new treatments. Resolution of the inequality would involve establishing fairly the resources to increase the welfare of patients with different chronic diseases to some target level of welfare. However, this would make overt the current rationing of community and social services and demonstrate the low levels of welfare of many with chronic diseases. Governments concerned with lower taxation might prefer to avoid exposing such issues.

Health care technology as a policy issue

Health care technology has become an increasingly visible issue in many countries, primarily because of the rising costs of health care. In addition, many questions concerning quality of care are being raised. Health care technology assessment has been seen as an aid in addressing questions concerning technology, including benefits and costs. A number of industrialized countries have developed active programs of health care technology assessment during the past two decades. Eight countries at similar levels of socio-economic and health development--Australia, Canada, France, Germany, the Netherlands, Sweden, the United Kingdom and the United States--have been examined to gain insights into how they manage health care technology and what place technology assessment has in such management. In addition to seeking general information, specific cases--treatment for coronary artery disease, medical imaging, laparoscopic surgery, treatment of end-stage renal disease, neonatal intensive care, and breast cancer screening--were examined in each country.

Health care technology in The Netherlands

The Dutch health care system has been described as a 'patchwork quilt'. It is a complicated system that has evolved from a constant adding and changing of institutions, regulations and responsibilities. Every citizen of the Netherlands has an entitlement to health care. The government authorities in the Netherlands have focused on creating favourable conditions in which the already existing private sector could expand or improve services. Although health care is provided largely through private institutions and practitioners, the system is considered to have a high degree of regulation. Until the 1980s, the Dutch health care authorities had no clearly defined philosophy of controlling the development and use of health care technology. Since the mid-1980s, however, a number of initiatives have been taken, policy instruments for controlling technology have been used in a more coordinated manner, and health care technology assessment had developed rapidly. The immediate future will see increasingly explicit use of the benefit package to control introduction of new technologies, as well as a growing influence of technology assessment itself.