Lack of Cost-Effectiveness of Preoperative Erythropoiesis-Stimulating Agents and/or Iron Therapy in Anaemic, Elective Surgery Patients: A Systematic Review and Updated Analysis.

Bert Avau, Hans Van Remoortel, Jorien Laermans, Geertruida Bekkering, Dean Fergusson, Jørgen Georgsen, Paola Maria Manzini, Yves Ozier, Emmy De Buck, Veerle Compernolle, Philippe Vandekerckhove

Journal: PharmacoEconomics 2021;39(10):1123-1139

PMID: 34235646

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Abstract

OBJECTIVES

For anaemic elective surgery patients, current clinical practice guidelines weakly recommend the routine use of iron, but not erythrocyte-stimulating agents (ESAs), except for short-acting ESAs in major orthopaedic surgery. This recommendation is, however, not based on any cost-effectiveness studies. The aim of this research was to (1) systematically review the literature regarding cost effectiveness of preoperative iron and/or ESAs in anaemic, elective surgery patients and (2) update existing economic evaluations (EEs) with recent data.

METHODS

Eight databases and registries were searched for EEs and randomized controlled trials (RCTs) reporting cost-effectiveness data on November 11, 2020. Data were extracted, narratively synthesized and critically appraised using the Philips reporting checklist. Pre-existing full EEs were updated with effectiveness data from a recent systematic review and current cost data. Incremental cost-effectiveness ratios were expressed as cost per (quality-adjusted) life-year [(QA)LY] gained.

RESULTS

Only five studies (4 EEs and 1 RCT) were included, one on intravenous iron and four on ESAs + oral iron. The EE on intravenous iron only had an in-hospital time horizon. Therefore, cost effectiveness of preoperative iron remains uncertain. The three EEs on ESAs had a lifetime time horizon, but reported cost per (QA)LY gained of 20-65 million (GBP or CAD). Updating these analyses with current data confirmed ESAs to have a cost per (QA)LY gained of 3.5-120 million (GBP or CAD).

CONCLUSIONS

Cost effectiveness of preoperative iron is unproven, whereas routine preoperative ESA therapy cannot be considered cost effective in elective surgery, based on the limited available data. Future guidelines should reflect these findings.

Address: Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium. [email protected].; Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium.; Center for Evidence-Based Medicine, Leuven, Belgium.; Cochrane Belgium, Leuven, Belgium.; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.; Department of Medicine, University of Ottawa, Ottawa, Canada.; Canadian Blood Services, Ottawa, Canada.; South Danish Transfusion Service, Odense University Hospital, Odense, Denmark.; SC Banca del Sangue Servizio di Immunoematologia, University Hospital Città della Salute e della Scienza di Torino, Torino, Italy.; University Hospital of Brest, Brest, France.; Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium.; Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium.; Blood Services, Belgian Red Cross, Mechelen, Belgium.; Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.; Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium.; Belgian Red Cross, Mechelen, Belgium.

DOI: 10.1007/s40273-021-01044-3