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

Figures & data

Table 1.  Model inputs.

	Estimate	Range used in scenario analyses	Probabilistic distribution	Source
Starting population (December 31, 1994)
Dialysis patients without prior transplant	197,464	–	–	USRDS8
Dialysis patients with a failed transplant	3,029	–	–	USRDS8
Patients with a functioning graft	72,174	–	–	USRDS8
Total population of ESRD (December 31, 1994)	272,667	–	–	USRDS8
Estimates of effectiveness
Relative risk of all cause mortality for patients on no ESA relative to ESA	1.00	0.81, 2.5	Log-normal	Tonelli et al. meta-analysis12,37
Relative risk of mortality for patients following a graft failure relative to patients on dialysis without a transplant	1.78	–	Log-normal	Rao et al.13
Likelihood of transplantation events for patients on no ESA relative to ESA	0.75	0.5, 1.0	Beta	Assumption
Annual incidence of iron overload requiring iron chelation therapy	10.4%	5.2, 20.8%	Beta	Hakim et al.25
Additional parameters
Health state preferences (utilities)
No ESA	0.55	–, 0.62*	Beta	CESG^†4
<11 g/dL	0.62^†	–		Finkelstein et al.15
11–12 g/dL	0.64^†	–		Finkelstein et al.15
Functioning renal transplant	0.77	–		Laupacis et al.17
Acute graft failure	0.62	0.50*, –		Laupacis et al.17
Mean number of hospital days per year
8–9 g/dL 9–10 g/dL 10–11 g/dL 11–12 g/dL	Assumed equal number of days in both arms regardless of Hb level.	8.07 days 6.15 days 4.69 days 3.57 days	Uniform	Collins et al.18 Xia et al.19
Cost per hospital day (SD)^‡	$1,469	–	Gamma	Lee et al.37
	($1,102)
Cost per transfused unit of blood (SD)^‡	$369	–, 649	Gamma	Cantor et al.38
	($277)
Annual cost of iron chelation therapy	$17,087	–	Gamma	Payne et al.39
Cost of treating a hepatitis B infection^§	$13,437	–	–	Coyle et al.40
Cost of treating a hepatitis C infection^§	$33,044	–	–	Coyle et al.40
Cost of treating delayed hemolytic reactions^§	$2,161	–	–	Coyle et al.40

All cost estimates are in 2008 US$.

*Assumption.

^†Indirectly calculated from CESG. The base-case value is the weighted average of the utility for patients on dialysis under 65 (managed without ESAs) and the utility for patients on dialysis over 65 (also managed without ESAs).

^‡SDs for resource use items were assumed to be 75% of the mean estimate.

^§These resource use items were excluded from the base-case analysis. They were considered in secondary analyses.

Figure 1.  Model schematic.

Table 2.  Model inputs: modeled event rates.

Transition	Annual rate per 1000 patients (by year)										Source
	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004
Death in dialysis patients without a transplant	229.9	230.8	229.4	232.1	238.1	233.1	235.1	233.2	232.1	228.0	USRDS8
Death in patients with a functioning graft	33.9	33.9	33.9	33.9	34.3	34.5	35.6	33.9	34.5	33.1	USRDS8
Death in patients with a failed graft	409.2	410.8	408.3	413.1	423.8	414.9	418.5	415.1	413.1	405.8	Rao et al.13
Transplantation in dialysis patients	59.7	56.9	54.4	54.7	52.7	52.9	52.7	52.4	51.5	52.5	USRDS8
Acute graft failure in transplant patients	48.1	44.0	42.9	42.9	42.9	44.0	44.0	44.0	44.0	45.0	USRDS8

Figure 2.  Cost-effectiveness plane, showing the incremental costs and QALYs for ESAs vs. blood transfusions, each quadrant demonstrating the proportion of the probabilistic sensitivity analysis that would fall under the following categories: ESA therapy less costly and less effective (southwest quadrant), ESA therapy more expensive and less effective (southeast quadrant), ESA therapy more expensive and less effective (northwest quadrant), and ESA therapy more expensive and more effective (northeast quadrant).

Table 3.  Costs, effects, and cost effectiveness of ESAs as compared to blood transfusions*.

	ESA strategy	Transfusion strategy
Effects
QALYs	2,563,537	2,285,865
Costs
Dialysis and transplant related costs	$141,932,592,170	$143,621,469,112
Cost of ESA units	$13,533,098,255	N/A
Cost of transfusion units	N/A^†	$6,236,938,308
Costs of iron overload treatment		$5,364,875,327
Total	$155,465,690,425	$155,223,282,747
Incremental (ESA vs. transfusion)
QALYs		277,672
Costs		$242,407,678
Incremental QALYs per patient		0.59
Incremental costs per patient		$512.54
ICER (ESA vs. transfusion) per QALY		$873

*Retrospective analysis spanning the period between 1995 and 2004 (in 2008 US$).

^†Costs are from factual data already included in dialysis and transplant related costs.

Table 4.  Results of one-way sensitivity analyses.

Parameters	Low	Baseline	High	ICER (ESAs vs. transfusions)
				Low	High
Relative risk of all-cause mortality (transfusions vs. ESAs)	0.81	1.00	2.50	ESAs were both less costly and more effective in terms of QALYs gained (savings to Medicare: $226,756 per each additional QALY gained over 10 years)	$58,294 per QALY gained
Health state preferences (utilities)
No ESA	–	0.55	0.62	–	$2825 per QALY gained
Mean number of hospital days per year
8–9 g/dL 9–10 g/dL 10–11 g/dL 11–12 g/dL	–	Assumed equal number of days in both arms regardless of Hb level	8.07 6.15 4.69 3.57	$31,256 per QALY gained	ESAs were both less costly and more effective in terms of QALYs gained (savings to Medicare: $50,640 per each additional QALY gained over 10 years)
Annual incidence of iron overload requiring iron chelation therapy	5.2%	10.4%	20.8%	$10,905 per QALY gained	ESAs were both less costly and more effective in terms of QALYs gained (savings to Medicare: $16,962 per each additional QALY gained over 10 years)
Likelihood of transplantation events for patients on no ESA relative to ESA	0.50	0.75	1.00	ESAs were both less costly and more effective in terms of QALYs gained (savings to Medicare: $8249 per each additional QALY gained over 10 years)	$14,011 per QALY gained
Mean number of transfused units of blood per month	0.25	0.50	0.80	$12,104 per QALY gained	ESAs were both less costly and more effective in terms of QALYs gained (savings to Medicare: $12,604 per each additional QALY gained over 10 years)
Cost of red blood cell transfusion unit	–	$369	$648	–	ESAs were both less costly and more effective in terms of QALYs gained (savings to Medicare: $16,126 per each additional QALY gained over 10 years)

Figure 3.  Cost-effectiveness acceptability curve.

USRDS. 2008 Annual Data Report; 2008 Contract No.: Document Number

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