Cost benefits of low dose subcutaneous erythropoietin in patients with anaemia of end stage renal disease

Associations of anemia persistency with medical expenditures in Medicare ESRD patients on dialysis

Most end-stage renal disease (ESRD) patients begin renal replacement therapy with hemoglobin levels below the recommended US National Kidney Foundation Dialysis Outcomes Quality Initiative Guidelines lower level of 110 g/L. Although most patients eventually reach this target, the time required varies substantially. This study aimed to determine whether length of time with below-target hemoglobin levels after dialysis initiation is associated with medical costs, and if so, whether intermediate factors underlie the associations. US patients initiating dialysis in 2002 were studied using the Centers for Medicare and Medicaid Services ESRD database. Anemia persistence (time in months with hemoglobin below 110 g/L) was determined in a six-month entry period, and outcomes were assessed in the subsequent six-month follow-up period. The structural equation modeling technique was used to evaluate associations between persistent anemia and medical costs and to determine intermediate factors for these associations. The study included 28,985 patients. Mean per-patient-per-month medical cost was $6267 (standard deviation $5713) in the six-month follow-up period. Each additional month with hemoglobin below 110 g/L was associated with an 8.9% increment in medical cost. The increased cost was associated with increased erythropoietin use and blood transfusions, and increased rates of hospitalization and vascular access procedures in the follow-up period.

Cost-effectiveness analysis of treatment with epoietin-alpha for patients with anaemia due to renal failure: the case of Sweden

OBJECTIVE

Anaemia is a common complication of renal failure. It can be treated with erythropoietin (EPO) administration, red blood cell transfusion (RBCT), or a combination of both. EPO has been registered for the treatment of renal anaemia in Sweden since the beginning of the 1990s, and is the primary treatment regimen for anaemia related to renal failure. The objective of this study was to carry out a cost-effectiveness analysis from a provider perspective of a treatment strategy comprising EPO and complementary RBCT compared to the traditional treatment of RBCT alone for patients with anaemia associated with renal failure in Sweden.

MATERIAL AND METHODS

Incremental costs and quality-adjusted life-years (QALYs) associated with EPO (epoietin-alpha) treatment compared to the traditional therapy of RBCT were estimated. The QALY gains were estimated using a modified version of a Markov model, which is used by the UK National Institute of Clinical Excellence in their evaluations of EPO treatment in the UK. Swedish treatment practice (i.e. EPO doses and iron supplementation), patient characteristics and unit costs were used throughout the study.

RESULTS

The estimated cost per QALY gained from administration of EPO to renal patients falls within the range acceptable in Sweden for both haemodialysis and peritoneal dialysis patients.

CONCLUSIONS

EPO administration to renal patients is much more costly in Sweden than in the UK, primarily due to the higher dosage of EPO and iron supplementation used in Sweden. However, Swedish patients reach higher haemoglobin levels, and thereby achieve higher QALY gains, compared to patients in the UK.

Impact of epoetin alfa on clinical end points in patients with chronic renal failure: a meta-analysis

BACKGROUND

Numerous randomized, controlled trials have demonstrated that recombinant human erythropoietin (rHuEPO, epoetin alfa) significantly raises hemoglobin levels, reduces transfusion requirements, and improves quality of life in anemic patients with chronic renal failure. However, this accumulation of data has yet to be systematically examined. The objectives of this meta-analysis were to quantify the effects of epoetin alfa on clinical efficacy, quality of life, hospitalizations, and transfusions by collecting and analyzing the published body of evidence.

METHODS

Sixteen published studies fulfilled all inclusion criteria and were subjected to data extraction. Data specifically related to hemoglobin and/or hematocrit levels, quality-of-life measurements, number and length of hospitalizations, and number of blood transfusions were then pooled across studies using a random effects meta-analysis. Simple combined estimates of the preselected variables were calculated, and adjusted estimates were made using meta-regression.

RESULTS

Baseline hemoglobin levels (<8 g/dL) increased substantially (40% to 50%) after epoetin alfa administration to a nonanemic state (Hb >11 g/dL) for the pooled study group. Substantial improvements (10% to 70%) were observed for all measures of quality of life. In addition, patients who received epoetin alfa had substantial reductions in hospitalization rate, hospital length of stay, transfusion rate, and number of units transfused.

CONCLUSION

This meta-analysis strongly suggests that epoetin alfa therapy for patients with chronic renal failure provides important clinical and quality-of-life benefits while substantially reducing hospitalizations and transfusions.

Correction of anemia in patients with congestive heart failure increases resting energy expenditure

BACKGROUND & AIM

Congestive heart failure (CHF) and anemia were reported to affect resting energy expenditure (REE). The aim of this study was to evaluate the effect of the correction of anemia on REE in subjects with CHF.

PATIENTS AND METHODS

Nine anemic patients with compensated CHF and CRF were studied before and after correction of anemia. REE was studied by an open circuit indirect calorimeter, body composition by dual-energy-X-ray absorption and total body and extracellular water by multi-frequency bioelectrical impedence. Four anemic and 5 non-anemic CHF patients who did not receive any new treatment served as controls.

RESULTS

After the correction of their anemia patients tended to increase weight (P<0.06), but no significant changes were observed in body composition. Daily caloric intake increased significantly (P<0.02). Ejection fraction increased (P<0.05) and pulse rate decreased significantly (P<0.001). REE and REEPP were in the normal range before correction but increased significantly afterwards (1402+/-256 vs. 1496+/-206 kcal/d, and 101+/-9 vs. 109+/-8, P<0.023 and P<0.006, respectively).

CONCLUSION

Correction of anemia in patients with CHF increases their REE. This can be related either to improved tissue oxygenation and/or to increased caloric intake.

Consensus statement: anemia in HIV infection--current trends, treatment options, and practice strategies. Anemia in HIV Working Group

BACKGROUND

Despite important advances in antiretroviral therapy, anemia remains a problem in many HIV-infected patients. Although the incidence of anemia in these patients has decreased, its prevalence appears to have stabilized or decreased only slightly. Anemia has a deleterious effect on both functional capacity and quality of life, and has been associated with shortened survival.

OBJECTIVE

The Anemia in HIV Working Group, an expert panel of physicians and researchers involved in the care of HIV-infected patients, met to determine the impact of anemia in this patient population; to develop practice strategies for the clinician treating HIV-infected patients with anemia; and to identify future research directions.

METHODS

The proposed practice strategies are based on results of the available clinical trials (as identified through a MEDLINE search), a review of the literature, and the clinical experience and expert opinion of the panel. The present report is based on meetings held in February and June of 1998; as further experience with various treatment options accumulates and the impact of highly active antiretroviral therapy becomes clearer, the panel will reconvene to develop evidence-based guidelines.

RESULTS

The working group considers HIV-associated anemia to be an important contributor to the morbidity and mortality of this infection. Recent reports indicate that recovery from anemia is associated with improved quality of life and survival.

CONCLUSIONS

As HIV-infected persons live longer, maintaining quality of life becomes an increasingly important goal of treatment. When planning treatment strategies, clinicians should consider the quality-of-life decrement caused by anemia. Transfusions should be used when rapid recovery is required, and underlying conditions causing anemia should be treated, if possible. Recombinant human erythropoietin (rHuEPO) therapy is appropriate in certain HIV-infected persons and should be considered to maintain hemoglobin concentrations. The target hemoglobin level is 12 g/dL for men and 11 g/dL for women. Weekly rHuEPO dosing is suggested, initiated at 40,000 U, as has been established in patients with cancer.

Hematocrit levels and associated Medicare expenditures

Clinical studies and the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines suggest that a target hematocrit of 33% to less than 36% is appropriate for patient benefit. Previous studies have shown an association of lower risks for death and hospitalization when hematocrits were 33% to less than 36%. In this study, we assessed the relationship between hematocrit value and associated Medicare expenditures, analyzing incident Medicare hemodialysis patients from January 1, 1991, through June 30, 1995. All patients survived at least 90 days to normalize eligibility and an additional 6-month entry period to assess comorbidity and hematocrit values. All patients were followed up from July 1, 1991, through December 31, 1996. We assessed the association between hematocrit values in the 6-month entry period and the Medicare-allowable Part A and Part B per-member-per-month (PMPM) expenditures in the follow-up period, controlling for other variables, including patient demographic characteristics, comorbid conditions, and severity of disease. We found that hematocrits of 33% to less than 36% and 36% and higher were associated with lower Medicare-allowable payments in the follow-up period. Compared with reference patients with hematocrits of 30% to less than 33%, the Medicare-allowable PMPM expenditures were significantly greater for patients with hematocrits less than 27% and 27% to less than 30% (12. 7% and 5.3%, respectively), and the Medicare-allowable PMPMs were significantly less for patients with hematocrits of 33% to less than 36% and 36% and higher (6.0% and 8.2%, respectively). Although these findings suggest that the treatment of anemia may be associated with significant savings in total patient Medicare expenditures, caution should be considered because these findings are associations and should not be deemed as showing causality.

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.

Subcutaneous r-HuEPO therapy in CAPD patients: dose determination and clinical experience

We present our results on the efficacy and safety of low dose r-HuEPO given subcutaneously in the treatment of anaemia in CAPD. We have studied 10 stable patients (5 males, 5 females) on CAPD. In our study subcutaneous r-HuEPO was administered twice a week for 6 months. Mean initial dose of r-HuEPO was 67.3+/-21.7 U/kg/week, and maintenance dose was 35.8+/-12.1 U/kg/week. The target Hb concentration was 10-12 g/dl. All patients responded to r-HuEPO. During treatment significant increases of haemoglobin concentration (p<0.05), haematocrit (p<0.05), red cell count (p<0.05) and reticulocyte count (p<0.05) were observed. We found no significant changes in total white cell or platelet counts. Long-term r-HuEPO treatment did not influence significantly plasma levels of electrolytes (Na, K, Ca), urea and creatinine. We found no significant changes in ultrafiltration volumes. In the present study the mean systolic and diastolic blood pressures did not change. Liver function tests were normal at the beginning and at the end of the study. r-HuEPO treatment was associated with a decrease of ferritin (455+/-90 vs. 224+/-83 microg/l. Oral or intravenous iron substitution became necessary in 6 patients. Side effects in our study were minimal; one patient had myalgia after the first seven doses but this disappeared as treatment was continued. Two patients reported pain (mild) at the injection site. In the present study, the correction of anaemia was accompanied by a substantial improvement in the quality of life, mainly in capacity for work, household and social activities.

A review of quality of life in chronic renal failure

The quality of life of patients with end-stage renal disease (ESRD) has become an area of intensive investigation because of the high costs of renal-replacement therapy (dialysis or renal transplantation) and the rising prevalence of renal failure. Studies comparing quality of life of patients using different forms of renal-replacement therapy are flawed by deficiencies in study design, such as lack of randomisation. Nevertheless, in both retrospective and prospective studies, transplantation has been shown to offer the highest levels of functional ability, employment and subjective quality of life. After case-mix adjustment, there is little difference between peritoneal dialysis and haemodialysis in terms of quality-of-life (QOL) outcomes. Vocational rehabilitation is an important aim of therapy; for patients below retirement age, pre-dialysis education and counselling are important in maintaining employment. The elderly comprise the fastest-growing group of dialysis recipients; multiple comorbidities add to functional impairment in these patients. Subjective quality of life remains surprisingly high in many elderly patients, despite poor objective quality of life. The quality of life of patients with diabetes mellitus and ESRD is lower than that of nondiabetic patients with ESRD. For selected patients with insulin-dependent diabetes mellitus, combined renal and pancreatic transplantation offers the advantage of freedom from insulin injections. Unfortunately, available evidence suggests only small improvements in quality of life with combined transplantation versus kidney-only transplantation, probably because many patients have developed multiple diabetic complications by the time of transplantation. Epoetin alfa (erythropoietin) has been shown to improve quality of life in a number of trials. The optimal target haematocrit is a subject of controversy, but on current evidence, a target of 34 to 37% is reasonable. The degree of improvement in quality of life must be balanced against the additional costs of achieving a higher haematocrit. Further study is necessary to clarify the optimal target haematocrit for epoetin alfa therapy, as well as the possible effects of nutritional support, growth hormone in paediatric patients, and combined renal and pancreatic transplantation in improving quality of life.

Biotechnology: a special case for health technology assessment?

Many substances produced naturally in a wide range of living organisms have been identified to be of benefit in the treatment of human disease. Current health biotechnologies recreate DNA-recombinant cellular processes in laboratory settings to produce 'natural' therapeutics: these are potentially a step forward from traditional pharmacology which has developed synthetic analogues or sought to extract products from donor material. However, with increasing financial pressures, decision makers require evidence that the benefits of biotechnologies justify their costs. The challenges experienced when evaluating the cost-effectiveness of biotechnologies are explored with reference to three examples: HA-1A human monoclonal antibody, erythropoietin and DNase. Difficulties in economic evaluation are similar to those experienced with conventional pharmaceuticals: use of short-term clinical endpoints rather than meaningful health outcomes, the artificial nature of clinical trial protocols, and uncertainty about the applicability of economic data. However, early clinical and economic assessments are required by decision-makers, particularly where biotechnology products fill major gaps in therapy. The financial structure of biotechnology companies may limit movement towards adequate clinical and economic research for health technology assessment. Governments should negotiate with the industry to promote more relevant studies, and develop policies for the managed introduction of products as evidence on effectiveness and cost expands. New technologies often present additional costs requiring reallocation of existing resources. Careful resource planning is required so that cost-effective innovation are not denied to patients.

The generalisability of pharmacoeconomic studies

Authors of pharmacoeconomic analyses understandably want their findings to apply as broadly as possible. Also, decision-makers may have to interpret the results of analyses conducted in healthcare settings other than their own. The validity of transferring or generalising results from one setting to another raises important issues for health-economic evaluation. Pharmacoeconomic analyses attempt to model the costs and benefits of alternative treatments in normal clinical practice. Usually, no single clinical study directly provides all the required information, and a variety of data sources is generally included in each analysis. Different data sources present different problems in terms of their relevance to decision-makers. At one extreme, an analysis based purely on trial outcomes and resource use may be precise, but not reflect normal practice; at the other extreme, an analysis using practice data may appear relevant, but be exposed to biases and confounding. Reviews of published studies suggest that general standards have been inadequate in the past. Reapplying such analyses in different localities may simply replicate inadequate findings. The 'perfect' should not become the enemy of the merely 'good'. Models can be helpful in decision-making, provided that they accurately communicate uncertainties in modelling and data. Even so, there will be limits to the generalisability of pharmacoeconomic models, since the required analysis differs between jurisdictions, and because of variations in normal clinical practice. The transferability of research findings re-opens the issue of credibility in pharmacoeconomics. Methodological standardisation, reporting standards and researcher independence are recognised as important factors for enhancing credibility. Where possible, pharmacoeconomic analyses should reflect the findings of systematic reviews of health outcomes to avoid the risk of biased selection of the evidence. In addition, the application of findings to individual healthcare settings must be considered, since cost effectiveness may vary markedly by setting and perspective.

Neocytolysis: physiological down-regulator of red-cell mass

It is usually considered that red-cell mass is controlled by erythropoietin-driven bone marrow red-cell production, and no physiological mechanisms can shorten survival of circulating red cells. In adapting to acute plethora in microgravity, astronauts' red-cell mass falls too rapidly to be explained by diminished red-cell production. Ferrokinetics show no early decline in erythropolesis, but red cells radiolabelled 12 days before launch survive normally. Selective destruction of the youngest circulating red cells-a process we call neocytolysis-is the only plausible explanation. A fall in erythropoietin below a threshold is likely to initiate neocytolysis, probably by influencing surface-adhesion molecules. Recognition of neocytolysis will require re-examination of the pathophysiology and treatment of several blood disorders, including the anaemia of renal disease.

Cost comparison of recombinant human erythropoietin and blood transfusion in cancer chemotherapy-induced anemia

OBJECTIVE

To compare the cost of recombinant human erythropoietin (rHuEPO) with that of blood transfusion in the treatment of chemotherapy-induced anemia from a healthcare system perspective.

DESIGN

A decision analytic model. Baseline estimates were obtained from a review of clinical trials data and economic evaluation studies.

SUBJECTS

Secondary data analyses of patients with advanced malignancies, excluding hematologic malignancies and metastasized solid tumors.

INTERVENTIONS

Patients received either leukocyte-depleted packed red blood cells (PRBCs) or rHuEPO 150 units/kg s.c. three times per week for 6 months (24 wk). After 6 weeks, if rHuEPO recipients did not display a response, they received rHuEPO 300 units/kg s.c. three times weekly for the duration of therapy. If rHuEPO recipients still exhibited no response, they were given blood transfusions.

MEASUREMENTS AND MAIN RESULTS

For a treatment period of 24 weeks, approximately 64% of rHuEPO recipients responded at an average expected cost of $12971 per patient. One hundred percent of transfusion recipients responded at a cost of $481; this resulted in a cost savings of $8490. Variation of response rates for rHuEPO or PRBCs did not appreciably lower costs. Lower rHuEPO dosages and higher numbers of transfused units of PRBCs yielded approximately equivalent costs; however, these strategies may not be clinically prudent.

CONCLUSIONS

From a healthcare system cost and outcome perspective, blood transfusion is the preferred strategy for chemotherapy-induced anemia. However, rHuEPO may be considered an effective blood-sparing alternative for patients with non-stem cell disorders. Future cost-effectiveness analyses are needed to assess more completely both the clinical and quality-of-life benefits rHuEPO may contribute to individual patients' lives and to society overall.

Financial effect of clinical decisions: case study of a dialysis center

The purpose of this study was to specify the financial effect of clinical decisions in a dialysis center. A consecutive sample of 14,343 outpatient hemodialysis treatments (OHD), 16,111 continuous ambulatory peritoneal dialysis (CAPD), and 4,513 chronic cycler-assisted peritoneal dialysis (CCPD) days of treatment was analyzed. An activity-based cost calculation method was applied to the analysis of alternative treatments (service bundles). The weekly cost of OHD was higher ($338 versus $241/$242), and the contribution margin (reimbursement minus total cost) of CAPD/CCPD was much greater ($.48 versus $148/$147 per patient week). Clinical decision-making had an influence on less than 6.8% of OHD and 45.4%/46.6% of CAPD/CCPD related expenses. In comparison to activity-based cost calculation, conventional methods overestimated the overhead expense of CAPD by 3-48%. This study documented that most cost control opportunities reside in the usual process of care and less can be influenced by a direct interference with the patient-physician contacts. Paying for 1 week of renal replacement (capitation) could simplify the process of reimbursement and cost tracking.

Evidence-based recommendations for the clinical use of recombinant human erythropoietin

In an era of increasing scrutiny regarding use of health care resources, it is critical that physicians have rational, evidence-based guidelines for treatment decisions. This review of more than 200 published papers constitutes a comprehensive approach to evaluating the current evidence regarding the clinical use of recombinant human erythropoietin therapy in renal failure patients. After this review, specific recommendations are provided regarding who should receive r-HuEPO; what the target hemoglobin should be; the best route of administration of r-HuEPO; how iron status should be evaluated and managed; and monitoring and follow-up of patients taking r-HuEPO. Throughout the article, areas for important future research are also identified.

Health-related quality of life in endstage renal failure

The objective of this study was to describe the health-related quality of life (HRQOL) of patients on different forms of treatment for endstage renal failure in such a way that the data could be used in a cost-utility analysis of renal failure treatment in Britain. Twenty-four British renal units participated in this study. 997 adult dialysis and transplant patients were randomly selected from these units using the European Dialysis and Transplant (EDTA) Registry Database. The Health Measurement Questionnaire was completed by 705 of the 900 patients who were alive at the time of the survey (response rate of 78%). The HRQOL data were linked with comorbidity data and with clinical data from the EDTA Registry. Compared to the general population, patients with endstage renal failure experienced a lower quality of life. Many factors contributed to this, but uncertainty about the future and lack of energy emerged as key components. Transplant recipients reported better HRQOL than dialysis patients, they reported fewer problems with physical mobility, self-care, social and personal relationships and usual activities. They also experienced significantly less distress, while dialysis patients reported problems with depression, anxiety, pain and uncertainty about the future. These differences remained after controlling for age and comorbidity.

Quantitative reticulocyte analysis may be of benefit in monitoring erythropoietin treatment in dialysis patients

Reticulocyte responses to low-dose erythropoietin (EPO) were monitored using automated flow cytometric analysis. Sixteen adult dialysis patients were treated with 1,000 U of recombinant human EPO (rHuEPO), subcutaneously, thrice weekly (mean dose 15.7, SD 3.7 U/kg). The reticulocyte count (baseline 31.1, SD 19.1 x 10(9)/L) increased in 14 patients in the first week, with a peak response occurring at Week 2 (mean 57.3, SD 26.5 x 10(9)/L, p < 0.01). There was a wide spectrum of response, the maximal absolute increment ranging from 6.8-69.7 x 10(9)/L (maximal percentage increase 19-863%). Overall there was no relationship between the early increment in reticulocyte count and hemoglobin (Hb) response over the ensuing 4 months. Nine patients became transfusion independent (mean Hb increasing from 6.9, SD 0.8-9.2, SD 1.2 g/dl). Two patients had poor reticulocyte increments and no significant change in Hb. The remaining 5 patients responded partially with a brisk reticulocyte response and a marked reduction in transfusion dependency, but without a sustained increase in Hb. On investigation, all had gastrointestinal bleeding (melena in 1, commencing after initiation of treatment, positive fecal occult bloods in 4), whereas none of the other patients showed evidence of blood loss. It is notable that the erythron was sensitive to this modest dose of rHuEPO in the majority of patients as evidenced by the reticulocyte response. The results provide useful information in the management of patients on rHuEPO. A small or inapparent reticulocyte response suggests a confounding factor; a poor Hb response in the presence of active reticulocyte synthesis points to occult blood loss or hemolysis.

A decision analysis comparing three dosage regimens of subcutaneous epoetin in continuous ambulatory peritoneal dialysis

Epoetin (recombinant human erythropoietin; EPO) therapy adds a significant cost to the management of end-stage renal disease, the majority of the extra expense being attributable to its acquisition cost. In a Japanese multicentre, randomised, prospective study, a significant dose-dependent response was documented with epoetin given subcutaneously (SC) once a week or once every 2 weeks to patients receiving continuous ambulatory peritoneal dialysis. Three different dosages were studied over 5 months in patients with a haematocrit (Hct) of 0.28 or less, namely 6000U (107 U/kg), 9000U (167 U/kg) and 12,000U (211 U/kg). Epoetin was given weekly for the first 2 months until the target Hct value of 0.33 was reached. The rates of response were 81, 85 and 100% with the 6000U, 9000U and 12,000U regimens, respectively. Subsequently, responders were maintained at the target Hct for an additional 3 months, with the administration frequency eventually being reduced to fortnightly or 4-weekly. Patients in the epoetin 6000U and 9000U groups who did not respond after 2 months' treatment underwent induction and maintenance with the 12,000U regimen. During the maintenance phase, patients receiving the epoetin 6000U and 9000U dosages required weekly (54 and 64%, respectively) or fortnightly (46 and 36%, respectively) injections. Patients receiving the 12,000U regimen were found to require weekly (9%), fortnightly (73%) or 4-weekly (18%) injections. Using these data, we performed a decision analysis that quantitatively incorporated the probability of attaining and maintaining target Hct levels in all patients (i.e. the effectiveness of epoetin), and direct costs as a function of both cumulative doses and injections required in all 3 strategies over 5 months. Decision analysis indicated that the most cost-effective SC epoetin strategy in patients undergoing peritoneal dialysis is epoetin 6000U weekly for 2 months, followed by maintaining the target Hct with weekly or 2-weekly epoetin 6000U for the next 3 months. Nonresponders should restart epoetin therapy using the 12,000U strategy. The 9000U and 12,000U strategies were associated with similar costs, because the economic advantages associated with the lower administration frequency of the 9000U regimen compared with the 6000U regimen were offset by its higher cumulative acquisition cost. In other words, decision analysis indicated that the most cost-effective strategy was to use the lowest effective dose, reserving the highest dosage for patients who do not respond after 2 months. The superiority of this strategy was confirmed by a sensitivity analysis performed on the cost of drug administration, which was varied from zero to $US60 per dose.(ABSTRACT TRUNCATED AT 400 WORDS)

Early adoption of cyclosporine and recombinant human erythropoietin: clinical, economic, and policy issues with emergence of high-cost drugs

The discovery of new drugs and their introduction into US markets will become an intense area of focus should health care reform result in Medicare insurance coverage for prescription drugs. Particular attention will be focused on high-cost drugs. Two high-cost drugs, cyclosporine and recombinant human erythropoietin (rHuEPO), introduced into the clinical management of patients with kidney disease during the past decade, provide some experience concerning the forces affecting the use of expensive drugs in a cost-conscious health care system. The decision to prescribe a drug will depend on provider's judgements of the drug's clinical benefits and costs compared with those of other possible therapies. It may also depend on payment policy. Both cyclosporine and rHuEPO were adopted rapidly and extensively by providers of end-stage renal disease care following US Food and Drug Administration approval, despite their high costs. Both drugs were remarkably effective, relatively safe, and able to be administered without great difficulty compared with the therapies they have replaced. There was no additional payment to hospitals for the initial use of cyclosporine, which was introduced in 1983 at the time when Medicare's prospective payment was established, since choice of immunosuppressive agent did not affect the fixed, per-admission payment determined by the diagnosis-related group for kidney transplantation. Medicare coverage for continuing outpatient use of cyclosporine was not initially provided, in contrast to rHuEPO, which was introduced in 1989 with Medicare outpatient coverage and payment of 80% of the allowed charge. Despite their high costs and different methods of insurance payment both drugs achieved a rather quick and high penetration rate into their respective populations.(ABSTRACT TRUNCATED AT 250 WORDS)

Low-dosage epoetin in maintenance haemodialysis: costs and quality-of-life improvement

Decisions about epoetin (recombinant human erythropoetin) dosage and target haematocrit in dialysis patients have been determined largely by the high acquisition cost of epoetin, but are made with incomplete knowledge about which target haematocrit gives the optimum clinical benefit. Haematopoietic response to epoetin may be determined by pharmacodynamic factors such as rate and frequency of administration, as well as by individual patient characteristics such as ethnicity. Resistance to epoetin may be due to iron or vitamin deficiency, natural or exogenous inhibitors of erythropoiesis and bone marrow fibrosis. The high acquisition cost of epoetin must be considered along with a number of other factors that can influence the true cost of epoetin treatment. Hidden costs of epoetin treatment include administration costs, changes in other treatments, extra laboratory tests and adverse events. Administration costs and extra laboratory surveillance add little to overall cost. Depletion of iron stores, hypertension, increased blood coagulability and reduced dialyser efficiency resulting from epoetin treatment may all add a small additional component to the true cost. Severe complications with significant cost implications are rare. Amongst the various components of true cost, only the acquisition cost can definitely be reduced by low dosage treatment. Balanced against the true and potential costs of epoetin are a number of benefits which can result in potential savings. The need for blood transfusion is all but abolished, avoiding the cost of transfusion and its complications. Sensitisation against histocompatibility antigens is reduced by avoiding transfusion, and so the waiting time for cadaveric transplantation may be reduced. Rates of hospitalisation for all causes, especially those associated with anaemia, may be reduced by epoetin treatment. By improving well-being, epoetin may allow patients to be transferred to minimal-care units or home where dialysis can be performed much more cheaply. Amongst the various potential benefits of epoetin, the one with the greatest potential to save money for society is improved productivity. To date, productivity improvements with epoetin have been demonstrated only in small studies. If the acquisition costs of epoetin are reduced by low dosage therapy, these potential benefits can cover a large proportion of the total cost of epoetin. Epoetin undoubtedly improves quality of life and activity, but it is not clear which level of haematocrit gives optimum improvement.(ABSTRACT TRUNCATED AT 400 WORDS)

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

Recombinant human erythropoietin is an efficacious therapy in treatment of the anemia of end-stage renal failure. However, the scale of impact on quality of life and medical care resources remains uncertain. By reviewing the literature we evaluate cost-effectiveness of recombinant human erythropoietin and show how previous studies may have implicitly overestimated cost-effectiveness.

Epoetin: a pharmacoeconomic review of its use in chronic renal failure and its effects on quality of life

Epoetin (recombinant human erythropoietin) is an effective treatment for the anaemia of patients with chronic renal failure. It is well tolerated, and the risk of adverse effects that are caused by too rapid a correction of anaemia, for example hypertension, can be reduced in most cases by lower starting dosage regimens. Epoetin improves the quality of life of anaemic patients with end-stage renal disease (ESRD), and significant improvements in most parameters of the Kidney Disease Questionnaire, the Sickness Impact Profile and the Nottingham Health Profile have been reported by patients. However, acquisition costs of epoetin are high, thereby adding a considerable cost to ESRD therapy despite a reduction in blood transfusion requirements. Notwithstanding, although cost-effectiveness studies have indicated that epoetin is associated with higher costs of therapy, cost-benefit analysis indicates that these costs can be reduced markedly with low-dose regimens and may be completely recovered if patients regain employment.