title: Historical clinical and economic consequences of anemia management in patients with end-stage renal disease on dialysis using erythropoietin stimulating agents versus routine blood transfusions: a retrospective cost-effectiveness analysis.
abstract: OBJECTIVE
  To determine whether Medicare's decision to cover routine administration of erythropoietin stimulating agents (ESAs) to treat anemia of end-stage renal disease (ESRD) has been a cost-effective policy relative to standard of care at the time.
  
  
  METHODS
  The authors used summary statistics from the actual cohort of ESRD patients receiving ESAs between 1995 and 2004 to create a simulated patient cohort, which was compared with a comparable simulated cohort assumed to rely solely on blood transfusions. Outcomes modeled from the Medicare perspective included estimated treatment costs, life-years gained, and quality-adjusted life-years (QALYs). Incremental cost-effectiveness ratio (ICER) was calculated relative to the hypothetical reference case of no ESA use in the transfusion cohort. Sensitivity of the results to model assumptions was tested using one-way and probabilistic sensitivity analyses.
  
  
  RESULTS
  Estimated total costs incurred by the ESRD population were $155.47B for the cohort receiving ESAs and $155.22B for the cohort receiving routine blood transfusions. Estimated QALYs were 2.56M and 2.29M, respectively, for the two groups. The ICER of ESAs compared to routine blood transfusions was estimated as $873 per QALY gained. The model was sensitive to a number of parameters according to one-way and probabilistic sensitivity analyses.
  
  
  CONCLUSIONS
  This model was counter-factual as the actual comparison group, whose anemia was managed via transfusion and iron supplements, rapidly disappeared following introduction of ESAs. In addition, a large number of model parameters were obtained from observational studies due to the lack of randomized trial evidence in the literature.
  
  
  CONCLUSIONS
  This study indicates that Medicare's coverage of ESAs appears to have been cost effective based on commonly accepted levels of willingness-to-pay. The ESRD population achieved substantial clinical benefit at a reasonable cost to society.
authors: London School of Economics & Political Science, London, UK. h.naci@lse.ac.uk
authors: Huseyin
authors: H
authors: Naci
authors: Gregory
authors: G
authors: de Lissovoy
authors: Christopher
authors: C
authors: Hollenbeak
authors: Brian
authors: B
authors: Custer
authors: Axel
authors: A
authors: Hofmann
authors: William
authors: W
authors: McClellan
authors: Matthew
authors: M
authors: Gitlin
mesh_terms: D000740:Anemia / Q000188:drug therapy* / Q000209:etiology; D001803:Blood Transfusion; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D004921:Erythropoietin / Q000191:economics* / Q000627:therapeutic use; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D019458:Insurance Coverage / Q000191:economics; D007676:Kidney Failure, Chronic / Q000150:complications*; D008390:Markov Chains; D006278:Medicare / Q000191:economics; D019057:Quality-Adjusted Life Years; D012189:Retrospective Studies; D014481:United States
chemical_list: D004921:Erythropoietin