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

Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium. bert.avau@cebap.org. 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. 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. Belgian Red Cross, Mechelen, Belgium.

PharmacoEconomics. 2021
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PICO Summary

Population

Elective surgery patients with anaemia (5 studies).

Intervention

Intravenous iron.

Comparison

Erythrocyte-stimulating agents (ESAs) and oral iron.

Outcome

The economic evaluation on intravenous iron only had an in-hospital time horizon. Cost effectiveness of preoperative iron remained uncertain. The three economic evaluations 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).
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.
Study details
Study Design : Systematic Review
Language : eng
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine