Skip to main content
SpringerLink
Log in

Cost Effectiveness of Epoetin-α to Augment Preoperative Autologous Blood Donation in Elective Cardiac Surgery

  • Original Research Article
  • Published:
PharmacoEconomics Aims and scope Submit manuscript

Abstract

Objective: The objective of this study was to assess the cost effectiveness of using epoetin-α (erythropoietin) to augment preoperative autologous donation (PAD) of blood prior to elective cardiac surgery.

Design and setting: We designed a decision-analytic model incorporating the risk of receiving allogeneic blood, the costs of blood products, the likelihood of developing transfusion-related diseases, the costs of transfusion-related diseases and their impact on life expectancy, and the effect of epoetin-α on the probability of transfusion.

Interventions: The efficacy of epoetin-α was derived from data from a meta-analysis of published randomised trials comparing the use of epoetin-α to augment PAD with the use of PAD alone. Estimates for the other parameters were obtained by a systematic review of the literature.

Main outcome measures and results: The use of epoetin-α reduced the proportion of patients receiving allogeneic transfusions by 60% (from 31.6 to 12.7%). However, this led to only a modest benefit of 0.000035 life years gained per patient and an incremental cost per life year gained of $Can44.6 million (1998 Canadian dollars). A detailed sensitivity analysis confirmed that the cost-effectiveness ratio was larger than that which is generally considered acceptable.

Conclusions: Our study indicates that the use of epoetin-α to reduce perioperative allogeneic transfusions in cardiac surgery is not cost effective.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Table I
Table II
Table III
Table IV

Similar content being viewed by others

References

  1. Schreiber GB, Busch MP, Kleinman, et al. The risk of transfusion- transmitted viral infections. N Engl J Med 1996; 334: 1685–90

    Article  PubMed  CAS  Google Scholar 

  2. Lackritz EM, Satten GA, Aberle-Grasse J, et al. Estimated risk of transfusion of the human immunodeficiency virus by screened blood in the United States. N Engl J Med 1995; 333: 1721–5

    Article  PubMed  CAS  Google Scholar 

  3. Turner ML, Ironside JW. New-variant Creutzfeldt-Jakob disease: the risk of transmission by blood transfusion. Blood Rev 1998; 12: 255–68

    Article  PubMed  CAS  Google Scholar 

  4. Blajchman MA. Transfusion associated immunomodulation and universal white cell reduction: are we putting the cart before the horse? Transfusion 1999; 39: 665–70

    Article  PubMed  CAS  Google Scholar 

  5. Chiavetta JA, Herst R, Freedman J, et al. A survey of red cell use in 45 hospitals in central Ontario, Canada. Transfusion 1996; 35: 699–706

    Article  Google Scholar 

  6. D’Ambra MN, Lynch KE, Boccagno MS, et al. The effect of perioperative administration of recombinant human erythropoietin (r-HuEPO) in CABG patients: a double blind, placebo- controlled study. Anesthesiology 1992; 77: 159

    Article  Google Scholar 

  7. Sowade O, Warnke H, Sowade B, et al. Avoidance of homologous blood transfusion and increase of oxygen availability by preoperative epoetin beta therapy in patients undergoing coronary artery bypass grafting (CABG) [abstract]. Blood 1996; 86: 352a

    Google Scholar 

  8. Laupacis A, Fergusson D. Erythropoietin to minimize perioperative blood transfusion: a systematic review of randomized trials. Transfus Med 1998; 8: 309–17

    Article  PubMed  CAS  Google Scholar 

  9. Hayashi J, Kumon K, Takanashi S, et al. Subcutaneous administration of recombinant human erythropoietin before cardiac surgery: a double-blind, multicenter trial in Japan. Transfusion 1994; 34: 142–6

    Article  PubMed  CAS  Google Scholar 

  10. Kulier AH, Gombotz H, Fuchs G, et al. Subcutaneous recombinant human erythropoietin and autologous blood donation before coronary artery bypass surgery. Anesth Analg 1993; 76: 102–6

    Article  PubMed  CAS  Google Scholar 

  11. Schmoeckel M, Nollert G, Mempel M, et al. Effects of recombinant human erythropoietin on autologous blood donation before open heart surgery. Thorac Cardiovasc Surg 1993; 41: 364–8

    Article  PubMed  CAS  Google Scholar 

  12. Walpoth BH, Spirig P, Galliker B, et al. Erythropoietin and autologous blood donation in cardiac surgery. In: The role of epoetin alfa in surgery. Forging the link in blood conservation [monograph]. Macclesfield: Adelphi Communications, 1995

  13. Watanabe Y, Fuse K, Naruse Y, et al. Subcutaneous use of erythropoietin in heart surgery. Ann Thorac Surg 1992; 54: 479–83

    Article  PubMed  CAS  Google Scholar 

  14. Fergusson D, VanWalraven C, Coyle D, et al. Economic evaluations of technologies to minimize perioperative transfusion: a systematic review of published studies. Transfus Med Rev 1999; 13: 106–17

    Article  PubMed  CAS  Google Scholar 

  15. Coyle D, Lee KM, Fergusson DA, et al. Economic analysis of erythropoietin use in orthopaedic surgery. Transfus Med 1999; 9: 21–30

    Article  PubMed  CAS  Google Scholar 

  16. Messmer K. Consensus statement: using epoetin alfa to decrease the risk of allogeneic blood transfusion in the surgical setting. Semin Hematol 1996; 33: 78–80

    PubMed  CAS  Google Scholar 

  17. Tretiak R, Laupacis A, Riviere M, et al. Cost of allogeneic and autologous blood transfusion in Canada. Can Med Assoc J 1996; 154: 1501–8

    CAS  Google Scholar 

  18. Canadian Coordinating Office of Health Technology Assessment (CCOHTA). Guidelines for the economic evaluation of pharmaceuticals: Ottawa (ON): CCOHTA, 1997

    Google Scholar 

  19. Statistics Canada. Life tables, Canada and provinces 1990–1992. (Catalogue 84–537Occasional).Ottawa (ON): Statistics Canada

  20. Gold M, Gafni A, Nelligan P, et al. Needle exchange programs: an economic evaluation of a local experience. Can Med Assoc J 1997; 157: 255–62

    CAS  Google Scholar 

  21. Huber TS, McGorray SP, Carlton LC, et al. Intraoperative autologous transfusion during elective infrarenal aortic reconstruction: a decision analysis model. J Vasc Surg 1997; 25: 984–94

    Article  PubMed  CAS  Google Scholar 

  22. Blood supply: transfusion-associated risks. Washington (DC): General Accounting Office, 1997

  23. Krever H. Interim report of the commission of inquiry on the blood system in Canada. Ottawa (ON): Ministry of Supply and Services Canada, 1995

    Google Scholar 

  24. Etchason J, Petz L, Keeler E, et al. The cost effectiveness of preoperative autologous blood donations. N Engl J Med 1995; 332: 719–24

    Article  PubMed  CAS  Google Scholar 

  25. Healy JC, Frankforter SA, Graves BK, et al. Preoperative autologous blood donation in total-hip arthroplasty. Arch Pathol Lab Med 1994; 118: 465–70

    PubMed  CAS  Google Scholar 

  26. Birkmeyer JD, Goodnough LT, AuBuchon JP et al. The cost-effectiveness of preoperative autologous blood donation for total hip and knee replacement. Transfusion 1993; 33: 544–51

    Article  PubMed  CAS  Google Scholar 

  27. Nelson KE, Donahue JG, Munoz A, et al. Transmission of retroviruses from seronegative donors by transfusion during cardiac surgery. Ann Intern Med 1992; 117: 554–9

    PubMed  CAS  Google Scholar 

  28. Murphy PJ, Connery C, Hicks GL, et al. Homologous blood transfusion as a risk factor for post-operative infection after coronary artery bypass graft operations. J Thorac Cardiovasc Surg 1992; 104: 1092–9

    PubMed  CAS  Google Scholar 

  29. Public service inter-agency guidelines for screening donors of blood, plasma, organs, tissues, and semen for evidence of hepatitis B and hepatitis C. MMWR Morbid Mortal Wkly Rep 1991; 40: 1–17

    Google Scholar 

  30. Donahue JD, Munoz A, Ness PM, et al. The declining risk of post-transfusion hepatitis C virus infection. N Engl J Med 1992; 327: 369–73

    Article  PubMed  CAS  Google Scholar 

  31. Linden JV, Kaplan HS. Transfusion errors: causes and effects. Transfus Med Rev 1994; 9: 169–83

    Article  Google Scholar 

  32. Gibis B. Leukodepletion: an investigation into the techniques used, their effectiveness and costs. Ottawa (ON): Canadian Coordinating Office of Health Technology Assessment (CCOHTA), 1997

    Google Scholar 

  33. Brettle RP, Atkinson FI, Wilcock J, et al. The cost of health care for HIV-positive patients. Int J STD AIDS 1997; 8: 50–3

    Article  PubMed  CAS  Google Scholar 

  34. Gable CB, Tierce JC, Simison D, et al. Cost of HIV+/AIDS at CD4+ counts disease stages based on treatment protocols. J Acquir Immune Defic Human Retrovirol 1996; 12: 413–20

    Article  CAS  Google Scholar 

  35. Petrou S, Dooley M, Whitaker L, et al. The economic costs of caring for people with HIV infection and AIDS in England and Wales. Pharmacoeconomics 1996; 9: 332–40

    Article  PubMed  CAS  Google Scholar 

  36. Brettle RP, Willock I, Cowan RM, et al. Inpatient health care utilization for patients with HIV and AIDS in Edinburgh city hospital. Int J STD AIDS 1994; 5: 194–201

    PubMed  CAS  Google Scholar 

  37. Fortgang IS, Moore RD. Hospital admission of HIV-infected patients from 1988 to 1992 in Maryland. J Acquir Immune Defic Syndr Human Retrovirol 1995; 8: 365–72

    Article  CAS  Google Scholar 

  38. Birkmeyer JD, AuBuchon JP, Littenberg B, et al. Cost-effectiveness of preoperative autologous donation in coronary artery bypass grafting. Ann Thorac Surg 1994; 57: 161–8

    Article  PubMed  CAS  Google Scholar 

  39. Hellinger FJ. The lifetime cost of treating a person with HIV. JAMA 1993; 270: 474–8

    Article  PubMed  CAS  Google Scholar 

  40. Andrulis DP, Weslowski VB, Hintz E, et al. Comparisons of hospital care for patients with AIDS and other HIV-related conditions. JAMA 1992; 267: 2482–6

    Article  PubMed  CAS  Google Scholar 

  41. Zowall H, Coupal L, Fraser RD, et al. Economic impact of HIV infection and coronary heart disease in immigrants to Canada. Can Med Assoc J 1992; 147: 1163–72

    CAS  Google Scholar 

  42. Andrews RM, Keyes MA, Fanning TR, et al. Lifetime medicaid service utilization and expenditures for AIDS in New York and California. J Acquir Immune Defic Syndr 1991; 4: 1046–58

    PubMed  CAS  Google Scholar 

  43. Roberts WA, Kirkley SA, Newby M. A cost comparison of allogeneic and preoperatively or intraoperatively donated autologous blood. Anesth Analg 1996; 83: 129–33

    PubMed  CAS  Google Scholar 

  44. Mah ET, Davis R, Seshadri P, et al. The role of autologous blood transfusion in joint replacement surgery. Anaesth Intensive Care 1995; 23: 472–7

    PubMed  CAS  Google Scholar 

  45. Monk TG, Goodnough LT, Birkmeyer JD, et al. Acute normovolemic hemodilution us a cost-effective alternative to preoperative autologous blood donation by patients undergoing radical retropubic prostatectomy. Transfusion 1995; 35: 559–65

    Article  PubMed  CAS  Google Scholar 

  46. Scott WJ, Rode R, Castlemain B, et al. Efficacy, complications, and cost of comprehensive blood conservation program for cardiac operations. J Thorac Cardiovasc Surg 1992; 103: 1001–7

    PubMed  CAS  Google Scholar 

  47. Solomon MD, Rutledge ML, Kane LE, et al. Cost comparison of intraoperative autologous versus homologous transfusion. Transfusion 1988; 28: 379–82

    Article  PubMed  CAS  Google Scholar 

  48. Elawad A, Benoni G, Montgomery F, et al. Cost effectiveness of blood substitution in elective orthopaedic operations. Acta Orthop Scand 1991; 62: 435–9

    Article  PubMed  CAS  Google Scholar 

  49. Laupacis A, Feeny D, Detsky AS, et al. How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. Can Med Assoc J 1992; 46: 473–81

    Google Scholar 

  50. The Trial to Reduce Alloimmunization to Platelets Study Group. Leukocyte reduction and ultraviolet B irradiation of platelets to prevent alloimmunization and refractoriness to platelet transfusions. N Engl J Med 1997; 337: 1861–9

    Article  Google Scholar 

  51. Bowden RA, Sayers M, Newton B, et al. Cytomegalovirus immune globlin and seronegative blood products to prevent primary cytomegalovirus infection after marrow transplantation. N Engl J Med 1986; 314: 1006–10

    Article  PubMed  CAS  Google Scholar 

  52. Laupacis A, Fergusson D. Drugs to minimize peri-operative blood loss in cardiac surgery: meta analyses using peri-operative blood transfusion as the outcome. Anesth Analag 1997; 85: 1258–67

    CAS  Google Scholar 

  53. Bryson GL, Laupacis A, Wells G, et al. Does acute normovolemic hemodilution reduce perioperative allogeneic transfusion? A meta analysis. Anesth Analg 1998: 86: 9–15

    PubMed  CAS  Google Scholar 

  54. Forgie M, Wells P, Laupacis A, et al. Pre-operative autologous donation decreases allogeneic transfusion but increases exposure to all red cell transfusion: results of a meta analysis. Arch Intern Med 1998; 158: 610–6

    Article  PubMed  CAS  Google Scholar 

  55. Rubens FD, Fergusson D, Wells PS, et al. Plateletpheresis in cardiac surgery: a meta analysis of the effect on transfusion requirements. J Cardiovasc Thorac Surg 1998; 116: 641–7

    Article  CAS  Google Scholar 

  56. Huet C, Salmi LR, Fergusson D, et al. A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopedic surgery. Anesth Analg 1999; 89: 861–9

    Article  PubMed  CAS  Google Scholar 

  57. Munoz JJ, Birkmeyer NJ, Birkmeyer JD, et al. Is epsilon-aminocaproic acid as effective as aprotinin in reducing bleeding with cardiac surgery? A meta-analysis. Circulation 1999; 99: 81–9

    Article  PubMed  CAS  Google Scholar 

  58. Levi M, Cromheecke ME, de Jonge E, et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999; 354: 1940–7

    Article  PubMed  CAS  Google Scholar 

  59. Bennett-Guerrero E, Spillane WF, White WD, et al. Epsilon-aminocaproic acid administration and stroke following coronary artery bypass graft surgery. Ann Thorac Surg 1999; 67: 1283–7

    Article  PubMed  CAS  Google Scholar 

  60. Alderman EL, Levy JH, Rich JB, et al. Analyses of coronary graft patency after aprotinin use: results from the International Multicenter Aprotinin Graft Patency Experience (IMAGE) trial. J Thorac Cardiovasc Surg 1998; 116: 716–30

    Article  PubMed  CAS  Google Scholar 

  61. Westaby S, Katsumata T. Aprotinin and vein graft occlusion: the controversy continues. J Thorac Cardiovasc Surg 1998; 116: 731–3

    Article  PubMed  CAS  Google Scholar 

  62. McAlister FA, Clark HD, Wells PS, et al. Peri-operative allogeneic blood transfusions do not cause adverse sequelae in oncologic patients: a meta-analysis of unconfounded studies. Br J Surg 1998; 85: 171–8

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgements

Funding for this study was provided by the Canadian Coordinating Office of Health Technology Assessment (CCOHTA). We would like to acknowledge the following for providing reviews of the preliminary draft to CCOHTA: Dr D. Anderson, Dr S. Grover, Dr M. Krahn, Dr G. Paiement, Dr B. O’Brien and Dr N. Otten. We are also grateful to Dr J. Dupuis, S. Grimes and Dr B. Gibis for their assistance in providing data for this report.

Author information

Authors and Affiliations

  1. Clinical Epidemiology Unit, Loeb Health Research Institute, Ottawa Hospital, 1053 Carling Avenue, Ottawa, K1Y 4E9, Canada

    Douglas Coyle, Dean A. Fergusson & Andreas Laupacis

  2. Departments of Medicine and Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada

    Douglas Coyle & Andreas Laupacis

  3. Health Priorities Research Group, University of California — Irvine, Irvine, California, USA

    Karen M. Lee

Authors
  1. Douglas Coyle
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Karen M. Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dean A. Fergusson
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Andreas Laupacis
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Douglas Coyle.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Coyle, D., Lee, K.M., Fergusson, D.A. et al. Cost Effectiveness of Epoetin-α to Augment Preoperative Autologous Blood Donation in Elective Cardiac Surgery. Pharmacoeconomics 18, 161–171 (2000). https://doi.org/10.2165/00019053-200018020-00006

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00019053-200018020-00006

Keywords

Search

Navigation