Preoperative use of recombinant human erythropoietin in pediatric orthopedics: a decision model for long-term outcomes.
BACKGROUND
Spine surgery for scoliosis is associated with significant blood loss and may require blood transfusion. The risks inherent in blood transfusion have inspired interventions, including human recombinant erythropoietin (rHuEPO), which has emerged as a safe and effective adjunct in minimizing exposure to allogenic blood in children undergoing scoliosis surgery. However, there is little information in the literature on their economic impact on the health-care system.


OBJECTIVE
The purpose of this study was to evaluate the cost-effectiveness of rHuEPO in adolescent idiopathic scoliosis.


METHODS
We designed a decision analytic model capturing costs and potential long-term outcomes of transfusion-related complications to compare the cost-effectiveness of preoperative rHuEPO with a control group and a common alternative, preoperative autologous donation (PAD).


METHODS
This is a decision analytic model. Decision modeling relies on a summation of the probability of different clinical studies; no patients were specifically studied.


METHODS
The standard cost-effectiveness ratio (C/E) of $50,000 per quality-adjusted life year (QALY) was used as the threshold value for determining the cost-effectiveness of these two preoperative intervention strategies.


METHODS
From the model we calculated the probability that a patient would experience transfusion-related complications based on the mean number of allogenic units transferred as a result of scoliosis surgery. The standard C/E of $50,000 per QALY was used as the threshold value for determining the cost-effectiveness. Some aspects of the model were derived from retrospective data from the literature. Sensitivity analyses were also conducted to discover which variables, when changed within the accepted range, caused the final result of the model to change significantly.


RESULTS
Results indicated a cost per year-of-life-saved exceeding $1 million for the PAD arm and over $1.5 million for the rHuEPO arm. The low rates of transfusion in adolescent idiopathic scoliosis surgery and the relative safety of the blood supply create a scenario where even inexpensive interventions are not cost-effective. However, rHuEPO would become cost-effective if decreased transfusion rates or higher postoperative hematocrit resulted in decreased length of stay.


CONCLUSIONS
The use of rHuEPO preoperatively and the use of PAD are not cost-effective although both techniques remain clinically effective tools.
Vitale
Michael G
MG
Columbia University and New York Presbyterian Hospital, 600 W. 168th Street, 7th Floor, New York, NY 10032, USA. mgv1@columbia.edu
Roye
Benjamin D
BD
Ruchelsman
David E
DE
Roye
David P
DP
D000293:Adolescent; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D004921:Erythropoietin / Q000191:economics*; D005260:Female; D006801:Humans; D011300:Preoperative Care / Q000191:economics* / Q000379:methods; D019057:Quality-Adjusted Life Years; D011994:Recombinant Proteins; D012600:Scoliosis / Q000601:surgery*; D065227:Transfusion Reaction
D011994:Recombinant Proteins; D004921:Erythropoietin