Cite as: Otten N. Economic evaluation of erythropoietin use in surgery. Ottawa: Canadian Coordinating Office for Health Technology Assessment (CCOHTA); 1998.
- The use of allogeneic (donor) blood transfusion is associated with risks such as the transmission of infectious diseases including HIV and Hepatitis B and C.
- The perioperative use of blood in elective surgery (e.g. hip arthroplasty and open heart surgery) accounts for a substantial amount of all blood used.
- The drug erythropoietin (EPO) is one of several methods developed to reduce the need for allogeneic transfusions during elective surgery.
- EPO allows donors to donate more of their own blood than would be possible without EPO by stimulating the bone marrow to produce red blood cells.
- EPO given pre-operatively increases mean hemoglobin, which reduces the need for perioperative transfusions.
This overview is based on a study commissioned by CCOHTA: "Economic analysis of erthropoietin use in surgery". The cost-effectiveness of two strategies were evaluated:
- The use of EPO to augment pre-donation of autologous (patient's) blood (PAD) for both orthopedic (hip arthroplasty) and cardiac (CABG and valvular replacement) elective surgeries.
- The use of EPO alone in orthopedic patients. The EPO dose used was 300 units/kg administered subcutaneously twice weekly for three weeks for a total of 6 doses, supplemented with 300 mg of oral iron sulfate three times a day for three weeks prior to surgery.
- The use of EPO reduced the proportion of patients receiving allogeneic transfusion:
(a) no predonation (EPO alone): by 51% (from 48% to 24%) in orthopedic surgery, (b) EPO to augment PAD: by 37% (from 17% to 11%) in orthopedic and by 60% (from 32% to 13%) in cardiac surgery.
- The potential life years gained/individual, based on a reduction in the proportion of patients receiving allogeneic transfusion and life-time risks from each allogeneic unit of blood received were: (a) no predonation (EPO alone): 0.000029 life years in orthopedic surgery (b) EPO to augment PAD: 0.000007 life years in orthopedic and 0.000043 life years in cardiac surgery.
- The incremental cost per life year gained was:
(a) no predonation (EPO alone): 55 million in orthopedic surgery (b) EPO to augment PAD: $296 million for orthopedic and $35 million for cardiac surgery.
The incremental cost per life year gained was even higher when current surgical practices were evaluated. This was primarily due to a decreased baseline need for allogeneic blood.
- Only under the most extreme case scenario (the highest reported costs of blood products and illnesses related to transfusions, the highest reported risks of transfusion related illnesses, and extreme quality of life effects) did erythropoietin therapy result in a cost per life year gained less than $100,000 ($90,000 for EPO to augment PAD in cardiac surgery).
No other scenarios that were tested resulted in the cost per life year gained to be less than $100,000. Other scenarios ranged from assuming all patients without EPO received allogeneic transfusions to increasing the cost of HIV and Hepatitis B and C to $1 million each. Compensation to patients contracting blood borne diseases would have to be in excess of $800 million/person to reduce the cost per life year gained to less than $100,000.
- The high incremental cost per life year gained is primarily due to low probabilities of transfusion and the current low risk of contracting known infectious diseases from blood (AIDS: 2 cases/1,000,000 units transfused; Hepatitis C: 10 cases/1,000,000 units transfused; and Hepatitis B: 16 cases/1,000,000 units transfused.)
- The impact of adopting EPO for 10% of all cases for hip arthroplasties and coronary artery bypass surgeries in Canada would be $5.9 million annually. This would result in a potential benefit of 0.12 life years gained for the total population.
The calculation of life years gained does not incorporate any anxiety caused to patients over concerns about the risks of transfusions. Others may question the applicability of the results which are based on different practices in different institutions, procedures other than orthopedic and cardiac surgery, and age of patients (e.g. use of erythropoietin in pediatric surgical cases). However, the extensive sensitivity analysis demonstrated that the results remained robust no matter what extremes of cost or practice were incorporated into the analysis.
This analysis does not address other potential but unproven health benefits of EPO such as increasing the percentage of patients able to pre-donate by treating hemoglobin<100 g/l; decreasing the possibility of immunomodulation; or the impact on clinical outcomes during blood supply shortages.