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Published on: January 10, 2025
An economic evaluation of erythropoiesis-stimulating agents in CKD
Fiona M Clement1, Scott Klarenbach, Marcello Tonelli
1Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada. braden.manns@albertahealthservices.ca
Insights
Treating anemia in chronic kidney disease (CKD) patients with erythropoiesis-stimulating agents (ESAs) to high hemoglobin targets (>12 g/dL) increases costs and worsens outcomes. The most cost-effective target within 9-12 g/dL remains uncertain.
Area of Science:
- Nephrology
- Pharmacoeconomics
- Health Services Research
Background:
- Anemia is a common complication in chronic kidney disease (CKD).
- Erythropoiesis-stimulating agents (ESAs) are used to treat anemia in CKD patients.
- The optimal hemoglobin (Hb) target for ESA therapy in CKD remains debated.
Purpose of the Study:
- To evaluate the cost-effectiveness of different Hb level targets for ESA treatment in anemic CKD patients.
- To compare ESA treatment strategies (low, intermediate, high Hb targets) versus no ESA use.
- To analyze cost-effectiveness in dialysis-dependent and non-dialysis-dependent CKD subgroups.
Main Methods:
- Cost-utility analysis using decision analysis modeling.
- Perspective of a healthcare payer in a publicly funded healthcare system.
- Patient lifetime time horizon was considered.
Main Results:
- For dialysis patients, targeting a low Hb level (9-10.9 g/dL) with ESAs cost $96,270 per quality-adjusted life-year (QALY) gained compared to no ESA use.
- For non-dialysis patients, the cost per QALY for a low Hb target was $147,980 compared to no ESA use.
- Treating to a high Hb target (>12 g/dL) resulted in worse outcomes and higher costs than lower targets.
Conclusions:
- Targeting Hb levels >12 g/dL with ESAs is associated with worse clinical outcomes and higher costs compared to lower targets (9-12 g/dL).
- The most cost-effective Hb target within the 9-12 g/dL range is uncertain due to limited comparative data on clinical outcomes and quality of life.
- Higher Hb targets within the 9-12 g/dL range lead to increased costs.
Background:
The objective was to determine the cost-effectiveness of treating anemic patients with chronic kidney disease (CKD) with erythropoiesis-stimulating agents (ESAs) to a low (9-10.9 g/dL), intermediate (11-12 g/dL), or high (> 12 g/dL) hemoglobin level target compared with a strategy of managing anemia without ESAs.
Study Design:
Cost-utility analysis.
Setting & Participants:
Publicly funded health care system. Anemic patients with CKD, overall and stratified into dialysis-/non-dialysis-dependent subgroups.
Model, Perspective, & Timeframe:
Decision analysis, health care payer, patient's lifetime.
Main Outcome:
Cost per quality-adjusted life-year (QALY) gained.
Results:
For dialysis patients, compared with anemia management without ESAs, using ESAs to target a low hemoglobin level is associated with a cost per QALY of $96,270. Given a lack of direct trials comparing low and intermediate targets, significant uncertainty exists between these strategies. Treatment to a high hemoglobin target was always associated with worse clinical outcomes and higher costs compared with a low hemoglobin target. Results were similar in non-dialysis-dependent patients with CKD, with a cost per QALY for a low target compared with no ESA of $147,980.
Limitations:
Given limitations in the available randomized controlled trials, we were able to model only 4 treatment strategies, balancing the need to consider relevant targets with the requirement for accurate estimates of clinical effect. We assumed that the efficacy of the different strategies would continue over a patient's lifetime.
Conclusions:
Using ESAs to target a hemoglobin level > 12 g/dL is associated with worse clinical outcomes and significant additional cost compared with using ESAs to target lower hemoglobin levels (9-12 g/dL). Given a lack of studies comparing low (9-10.9 g/dL) and intermediate (11-12 g/dL) hemoglobin targets for clinical outcomes, including quality of life, the most cost-effective hemoglobin level target within the range of 9-12 g/dL is uncertain, although aiming for higher targets within this range will lead to higher costs.
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