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 and Philippe Vandekerckhove
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Bert Avau: Belgian Red Cross
Hans Van Remoortel: Belgian Red Cross
Jorien Laermans: Belgian Red Cross
Geertruida Bekkering: Center for Evidence-Based Medicine
Dean Fergusson: Ottawa Hospital Research Institute
Jørgen Georgsen: Odense University Hospital
Paola Maria Manzini: University Hospital Città della Salute e della Scienza di Torino
Yves Ozier: University Hospital of Brest
Emmy De Buck: Belgian Red Cross
Veerle Compernolle: Belgian Red Cross
Philippe Vandekerckhove: KU Leuven

PharmacoEconomics, 2021, vol. 39, issue 10, No 3, 1123-1139

Abstract: 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.

Date: 2021
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DOI: 10.1007/s40273-021-01044-3

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