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      A Change from Subcutaneous to Intravenous Erythropoietin Increases the Cost of Anemia Therapy

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          Background: It seems that more erythropoietin (EPO) is required when given intravenously (IV) than when given subcutaneously (SC). Estimates of the magnitude of this difference vary widely, impeding development of economic models in this area. Concerns about pure red cell aplasia led our program to switch from SC to IV EPO, so we studied the impact of this change on the cost of anemia therapy. Methods: All in-center hemodialysis patients who had received EPO for at least 3 months prior to and following conversion to IV EPO were studied. Data was obtained retrospectively for 1 year prior to and prospectively for 1 year following conversion. The costs of anemia therapy (EPO, transfusions and iron) were calculated from the hospital’s perspective. Results: 158 patients were studied. One month after switching, the hemoglobin fell significantly, reaching a nadir at 3 months. This triggered more use of EPO, iron and transfusions. By month 7 hemoglobin levels had returned to initial levels, with a median rise in EPO dose of 1,250 units/week (p < 0.001). After the switch, the median rise in total anemia therapy costs was 13.1% (CAD 665/patient-year, p < 0.01). Conclusions: Conversion of EPO from SC to IV dosing increased the costs of anemia therapy at our center.

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          Cost analysis of ongoing care of patients with end-stage renal disease: the impact of dialysis modality and dialysis access.

          Care of patients with end-stage renal disease (ESRD) is important and resource intense. To enable ESRD programs to develop strategies for more cost-efficient care, an accurate estimate of the cost of caring for patients with ESRD is needed. The objective of our study is to develop an updated and accurate itemized description of costs and resources required to treat patients with ESRD on dialysis therapy and contrast differences in resources required for various dialysis modalities. One hundred sixty-six patients who had been on dialysis therapy for longer than 6 months and agreed to enrollment were followed up prospectively for 1 year. Detailed information on baseline patient characteristics, including comorbidity, was collected. Costs considered included those related to outpatient dialysis care, inpatient care, outpatient nondialysis care, and physician claims. We also estimated separately the cost of maintaining the dialysis access. Overall annual cost of care for in-center, satellite, and home/self-care hemodialysis and peritoneal dialysis were US $51,252 (95% confidence interval [CI], 47,680 to 54,824), $42,057 (95% CI, 39,523 to 44,592), $29,961 (95% CI, 21,252 to 38,670), and $26,959 (95% CI, 23,500 to 30,416), respectively (P < 0.001). After adjustment for the effect of other important predictors of cost, such as comorbidity, these differences persisted. Among patients treated with hemodialysis, the cost of vascular access-related care was lower by more than fivefold for patients who began the study period with a functioning native arteriovenous fistula compared with those treated with a permanent catheter or synthetic graft (P < 0.001). To maximize the efficiency with which care is provided to patients with ESRD, dialysis programs should encourage the use of home/self-care hemodialysis and peritoneal dialysis. Copyright 2002 by the National Kidney Foundation, Inc.
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            Meta-analysis of subcutaneous versus intravenous epoetin in maintenance treatment of anemia in hemodialysis patients.

            Clinical and pharmacokinetic studies have shown that target hemoglobin or hematocrit levels can be maintained using a reduced recombinant human erythropoietin (epoetin) dosage by switching from intravenous (IV) to subcutaneous (SC) administration. We conducted a meta-analysis of comparative studies of epoetin administered IV versus SC to assess the relative costs of these administration routes. Twenty-seven prospective clinical studies involving 916 patients were included in the analysis. The average difference between IV and SC doses of epoetin and average difference in drug costs between administration routes were determined. The average reduction in dose in patients treated with SC versus IV epoetin was 48 IU/kg/wk (P < 0.001), representing an average annual cost savings with SC administration of US $1,761 +/- $1,080 (SD) per patient. The difference between SC and IV doses was similar in both parallel- and crossover-design studies. A retrospective US survey showed a dose reduction of 26 IU/kg/wk (P < 0.001) with SC administration, translating to an annual savings of $946 per patient. This study indicates that the cost of epoetin is reduced substantially when administered SC in comparison to IV. Recommendations of current US and European guidelines, which encourage the use of SC administration, not only have a sound rationale in terms of efficacy and safety, but also have a sound economic basis. Copyright 2002 by the National Kidney Foundation, Inc.
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              Cost savings of home nocturnal versus conventional in-center hemodialysis.

              Home nocturnal hemodialysis (HNHD) can improve clinical and biochemical factors in people with renal failure, but its cost-effectiveness relative to conventional in-center hemodialysis (IHD) is uncertain. We hypothesized that HNHD would provide more dialysis treatments at a lower total cost than IHD. A prospective one-year descriptive costing study was performed at two centers in Toronto, Canada, involving patients enrolled from a HNHD program (N = 33), and a matched cohort from an IHD program (N = 23). All costs are expressed as mean weekly amount in Canadian year 2000 dollars. A projected mean annual cost (PMA) was calculated also. The mean number of treatments per week was much higher with HNHD (5.7 vs. 3.0, P = 0.004). Cost categories found to be less expensive for HNHD were staffing (weekly $210 vs. $423, P < 0.001, PMA $10,932 vs. $22,056) and overhead and support (weekly $80 vs. $238, P < 0.001, PMA $4179 vs. $12,393). There was a trend toward lower costs for hospital admissions and procedures (weekly $23 vs. $134, P = 0.355, PMA $1173 vs. $6997) and for medications ($172 vs. $231, P = 0.082, PMA $8989 vs. $12,029). Costs found to be more expensive for HNHD were the cost of direct hemodialysis materials (weekly $318 vs. $126, P < 0.001, PMA $16,587 vs. $6575) and capital costs (weekly $118 vs. $17, P < 0.001, PMA $6139 vs. $871), with a trend toward higher cost for laboratory tests (weekly $33 vs. $26, P = 0.094, PMA $1744 vs. $1364). Physician costs were the same at $128 per week (PMA $6650). The weekly mean total cost for health care delivery was 20% less for HNHD ($1082 vs. $1322, P = 0.006), with projected mean annual costs more than $10,000 lower ($56,394 vs. $68,935). HNHD provides about three times as many treatment hours at nearly a one-fifth lower cost, with savings evident even when only program and funding-specific costs are considered.

                Author and article information

                Nephron Clin Pract
                Nephron Clinical Practice
                S. Karger AG
                November 2007
                21 September 2007
                : 107
                : 3
                : c90-c96
                aHome Dialysis and bDiabetes Comprehensive Care Program, St. Michael’s Hospital, and cDepartment of Health Policy, Management, and Evaluation, University of Toronto, Institute for Clinical Evaluative Sciences, Sunnybrook and Women’s College Health Sciences Centre, Toronto, Ont., Canada
                108649 Nephron Clin Pract 2007;107:c90–c96
                © 2007 S. Karger AG, Basel

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                Page count
                Figures: 3, Tables: 2, References: 12, Pages: 1
                Original Paper


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