Cost analytic model to determine the least costly inpatient erythropoiesis stimulating therapy regimen

Improvement in Appropriate Utilization of Recombinant Human Erythropoietin Pre- and Post-Implementation of a Required Order Form

BACKGROUND:

Erythropoietin stimulating agents (ESAs) are high-cost medications that have a significant impact on many pharmacy budgets. Recently, ESAs have received stronger safety warnings and reimbursement has been curtailed by third-party payers including the Centers for Medicare and Medicaid Services. For these reasons, many hospitals are developing strategies to optimize their use. A required order form with acceptable indications and dosing was implemented at an academic medical center in an attempt to improve dosing and appropriate utilization of ESAs.

OBJECTIVE:

To determine whether implementation of a required order form increased appropriate use and/or decreased total utilization of recombinant human erythropoietin (rHuEPO).

METHODS:

This was a retrospective cohort study of rHuEPO utilization for 4 months pre- and 6 months post-implementation (April 2008-January 2009).

RESULTS:

Implementation of a required order form for rHuEPO resulted in significantly fewer patients receiving inappropriate doses of rHuEPO (51.3% vs 19.2%, p < 0.001). The number of patients treated, adjusted to hospital census, was also reduced after implementation of the order form (0.003 vs 0.004 pts./average pt. days, p = 0.03). Annual spending for rHuEPO was reduced by 47% during 2008 despite an increased acquisition cost.

CONCLUSIONS:

Implementation of a required order form with evidence-based dosing recommendations can be an effective strategy to improve appropriate utilization of rHuEPO.

[Direct medical cost of erythropoiesis-stimulating agents in anaemia treatment of chronic renal failure patient: a literature review]

INTRODUCTION

Management of anaemia in chronic renal insufficiency (CRI) represents an important medico-economic challenge because of the great number of patients and the cost of the erythropoiesis-stimulating agent (ESA). The aim of this study was to identify determinants of the costs associated with these treatments in order to choose, with equal efficacy, the most efficient ASE.

METHOD

A bibliographic research was realised by Medline database interrogation.

RESULTS

Among the direct medical costs, five studies showed that acquisition of epoetine alfa (EA) compared to darbepoetin alfa (DA) was less expensive. Concerning the costs associated with the route of administration, the subcutaneous injection (SC) of epoetine allowed a gain in costs because of the decrease of doses compared to the intravenous (IV) route. The switch from EA in SC to DA in IV, for hemodialysis patients, was associated with a reduction of the number of injections and with a treatment's cost lower by DA than by EA. Costs related to the regimen of administration, notably those related to nursing, medical and pharmaceutical time, were negligible towards those associated to the acquisition of the ASE. Finally, the costs of the therapeutic follow-up and treatment of the adverse effects of the ASE were similar between the EA and the DA.

CONCLUSION

The costs associated with the prices of acquisition of the ASE, negotiated by the structure of care, represent the most important part of the direct medical costs.

Optimizing anemia management in hospitalized patients with end-stage renal disease

OBJECTIVE

To review available literature on the use of erythropoiesis-stimulating agents (ESAs) in patients with end-stage renal disease (ESRD) who require hospitalization and to provide recommendations for ESA use in this setting.

DATA SOURCES

Primary articles were identified by English-language MEDLINE search (1966-October 2008) using the MeSH headings: kidney failure (chronic), anemia, erythropoietin, darbepoetin, hospitalization, and hematinics. Relevant data presented at recent nephrology scientific meetings (2004-October 2008) were also identified.

STUDY SELECTION AND DATA EXTRACTION

Identified studies were reviewed and information regarding hospitalization, ESA use, and patient outcomes was evaluated.

DATA SYNTHESIS

Studies demonstrate that hospitalized patients with ESRD usually experience a decline in hemoglobin values. Contributing factors include infection, inflammation, and untreated iron deficiency. ESAs are used inconsistently during hospitalization, with less than 50% of hospitalized patients with ESRD receiving ESA therapy in some reports. Some controversy exists regarding optimal hemoglobin targets for ESA therapy in nonhospitalized patients with ESRD, and no targets are defined for hospitalized patients. Clinical trials examining in-hospital ESA use have primarily involved the intensive care population and excluded ESRD patients. Following the patient's hospitalization, lower hemoglobin values may persist for 6 months, despite increased ESA dosing. Variability exists in frequency of hemoglobin monitoring and ESA dose changes. To date, no clinical trials have evaluated different approaches to anemia management in hospitalized patients with ESRD, and there are no published guidelines in this area. Based on published observations and clinical experience, we offer recommendations for anemia management around the time of hospitalization in an attempt to define a more rational approach to ESA therapy in this population.

CONCLUSIONS

Trials are needed to define optimal ESA dosing strategies and hemoglobin targets in hospitalized patients with ESRD.