The cost effectiveness of erythropoietin-stimulating agents for treating anemia in patients on dialysis: a systematic review

Health related quality of life utility weights for economic evaluation through different stages of chronic kidney disease: a systematic literature review

BACKGROUND

A Task Force from the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) provides recommendations on how to systematically identify and appraise health state utility (HSU) weights for cost-effectiveness analyses. We applied these recommendations to conduct a systematic review (SR) to identify HSU weights for different stages of chronic kidney disease (CKD), renal replacement therapy (RRT) and complications.

METHODS

MEDLINE® and Embase were searched for interventional and non-interventional studies reporting HSU weights for patients with CKD stages 1-5 or RRT. As per ISPOR Task Force Guidance, study quality criteria, applicability for Health Technology Assessment (HTA) and generalisability to a broad CKD population were used to grade studies as either 1 (recommended), 2 (to be considered if there are no data from grade 1 studies) or 3 (not recommended).

RESULTS

A total of 17 grade 1 studies were included in this SR with 51 to 1767 participants, conducted in the UK, USA, Canada, China, Spain, and multiple-countries. Health related quality of life (HRQL) instruments used in the studies included were EQ-5D-3L (10 studies), SF-6D (4 studies), HUI2/HUI3 (1 study), and combinations (2 studies). Although absolute values for HSU weights varied among instruments, HSU weights decreased with CKD severity in a consistent manner across all instruments.

CONCLUSIONS

This SR identified HSU weights for a range of CKD states and showed that HRQL decreases with CKD progression. Data were available to inform cost-effectiveness analysis in CKD in a number of geographies using instruments acceptable by HTA agencies.

A quick scoping review of efficacy, safety, economic, and health-related quality-of-life outcomes of short- and long-acting erythropoiesis-stimulating agents in the treatment of chemotherapy-induced anemia and chronic kidney disease anemia

Erythropoiesis-stimulating agents (ESAs) are man-made forms of erythropoietin used in the treatment of anemia. This quick-scoping review of systematic literature reviews (SLRs) was conducted to define the clinical, economic, and health-related quality of life (HRQoL) outcomes for short-acting and long-acting ESAs in patients with chronic kidney disease-induced anemia (CKD-IA) and patients with chemotherapy-induced anemia (CIA). Embase, Medline, and the Cochrane Database of Systematic Reviews were searched from their establishment until October 2017. SLRs related to the use of short-acting and long-acting ESAs in the treatment of CIA and CKD-IA were included. Forty-eight studies met the inclusion criteria. The evidence suggests little difference in efficacy, HRQoL, and safety outcomes among ESA types. Cost-effectiveness and market price are likely to become determining factors driving the choice of agent. Comparative studies and costing models accounting for the utilization of biosimilars are needed to establish which ESAs are more cost-effective.

Reduction in new-onset diabetes mellitus after renal transplant with erythropoietin-stimulating agents: a retrospective cohort study

BACKGROUND

Studies have shown that erythropoietin-stimulating agents (ESAs) protect mice against the development of diabetes through direct effects on pancreatic ß cells. However, the effect of ESAs on the incidence of diabetes in humans has not been well studied. It is unknown whether exposure to ESAs is associated with a reduced incidence of new-onset diabetes after transplant (NODAT).

OBJECTIVE

The objective of this study is to examine the relationship between ESA exposure post-renal transplant and the development of NODAT.

DESIGN

We performed a single center, retrospective cohort analysis.

PATIENTS

We compared patients who received a first live or deceased donor renal allograft, with any exposure to an ESA vs. those without such exposure and who developed NODAT and who did not. Patients with a prior history of diabetes mellitus or multi-organ transplant, including a second renal transplant were excluded.

MEASUREMENTS AND METHODS

NODAT was defined based on the 2008 Canadian Diabetes Association criteria. Multivariate logistic regression analysis was performed to determine factors independently associated with NODAT.

RESULTS

One hundred thirty-two (29 %) patients were exposed to an ESA, four of which developed NODAT compared to 128 who did not develop NODAT (p < 0.0001). Of those not exposed to an ESA, 15 % (48/319) developed NODAT. By Fisher's exact test, exposure to an ESA at any time post-transplant reduced the risk of developing NODAT; odds ratio (OR) = 0.08, 95 % confidence interval (CI) (0.018-0.352), p = 0.0008. Older age; OR = 1.41, 95 % CI (1.036-1.933), p < 0.02, higher random blood sugar at discharge; OR = 1.30, 95 % CI (1.077-1.57), p < 0.006 and deceased donor; OR 2.18 CI (1.009-4.729), p = 0.04 were associated with an increased risk of NODAT.

LIMITATIONS

The limitations of this study include its retrospective nature, single center, and homogenous population; thus, generalizability of the results must be approached with caution.

CONCLUSION

ESA exposure may be associated with a reduced incidence of NODAT in the post-renal transplant population. The role of ESA in preventing NODAT requires further investigation.

The cost-utility of treating anemia with continuous erythropoietin receptor activator or Epoetin versus routine blood transfusions among chronic hemodialysis patients

OBJECTIVE

The purpose of this study was to determine the cost-utility of treating anemic dialysis patients with continuous erythropoietin receptor activator (CERA) once monthly or Epoetin Beta (EpoB) thrice weekly compared with a reference strategy of managing anemia with red blood cell transfusion (RBCT).

METHODS

Cost-utility analysis study design. Decision analysis model, National health care payer, over 1 year with the publicly funded health care system. Chronic hemodialysis patients with renal anemia were included. The outcome marker of this study was the incremental cost per quality-adjusted life-year (QALY) gained (incremental cost-utility ratio [ICUR]) of CERA or EpoB relative to RBCT.

RESULTS

The total cost per patient (in US$) was estimated at $2,176.37, $4,107.01, and $4,356.69 for RBCT, CERA, and EpoB, respectively. The cost-utility ratio was calculated at 4,423.52, 6,955.50, and 7,406.38 $/QALY for RBCT, CERA, and EpoB, with an ICUR of CERA and EpoB in relation to RBCT at 19,606.40 and 22,466.09 $/QALY, respectively. In sensitivity analysis, the model was most sensitive to hospitalization costs, hospital stay, and annual number of RBCT units. Also, assuming utility and survival improvement with erythropoiesis stimulating agents use resulted in a decrease in ICUR at 13,429 $/QALY for CERA and 15,331 $/QALY for EpoB. In probabilistic sensitivity analysis, the main results of our model were unchanged; CERA and EpoB were more costly and more effective than RBCT below a threshold of 19,500 $/QALY. CERA was the best option for a willingness to pay over 19,500 $/QALY.

LIMITATIONS

Some model parameters were obtained from observational data, the comparator RBCT is not the standard of care.

CONCLUSION

Our study suggests that managing anemia in dialysis patients with CERA or EpoB may result in better outcomes with higher overall costs. Considering different assumptions, we found substantial variability in the estimates of the cost-utility and incremental of using CERA or EpoB.