By implementing protocols that restrict the use of erythropoietin-stimulating agents (ESAs), hospitals can successfully cut costs while maintaining an equivalent level of patient care, according to two recent studies.
At St. John Hospital and Medical Center in Detroit, a policy that delayed ESA administration to certain patients decreased ESA purchases by more than $16,000 per month. “We wanted to [determine whether] having [such] a program in place would still benefit patients and potentially reduce costs,” said Michelle Dehoorne-Smith, PharmD, the manager of pharmacy patient care services at St. John Hospital. A similar measure at Banner Health, in Phoenix, saved $19,000 during a two-month study period.
ESAs have come under scrutiny because of their high costs and potential for harm. “Over the past eight years, perhaps more, we’ve noted that ESAs are associated with a lot of detrimental adverse effects,” said investigator Jeff Hurren, PharmD, a clinical specialist in drug information and policy at St. John Hospital. For example, a 2009 study of ESA use in patients with chronic kidney disease (CKD) or type 2 diabetes found that the likelihood of stroke was increased in patients who received darbepoetin (Aranesp, Amgen) (hazard ratio, 1.92; 95% confidence interval, 1.38-2.68) compared with placebo (N Engl J Med 361:2019-2032).
In 2011, the FDA released guidelines to help clinicians adopt more conservative ESA treatment for patients with CKD. The agency suggested that a patient with CKD who is not on dialysis should meet several criteria—a hemoglobin level of less than 10 g/dL and a high likelihood of red blood cell transfusion, with a risk for alloimmunization—before beginning ESA treatment. When administering ESA, the goal is to “provide the lowest dose possible that avoids transfusions,” Dr. Hurren said.
At St. John Hospital, modifications to the ESA policy included a switch from erythropoietin (Procrit, Janssen) to darbepoetin. Clinicians delayed ESA treatment until the seventh day after admission for some patient groups, although there was no delay for Jehovah’s Witnesses and other patients who could not receive transfusions. A retrospective study of 289 patients found that the new policy had no effect on transfusion rates or hemoglobin levels. The percentage of ESA doses administered on or after day 7 increased from 19% to 44% (P<0.001; Figure). This delay, Dr. Hurren said, helped ensure that the timing of administration did not result in double doses of ESA during care transitions.
Given that the most frequent administration of darbepoetin is once weekly for non-dialysis patients, waiting until day 7 “ensures you never double dose from the outpatient side,” said Robert Adamson, PharmD, the vice president of clinical pharmacy services at Barnabas Health, headquartered in Livingston, N.J. Oncology patients should receive darbepoetin once every three weeks, he added, and nephrology patients once every two weeks. Although waiting until day 7 “obviates the need for phone calls,” physicians risk giving patients such as these “more darbepoetin than they may need,” Dr. Adamson said. The approach that pharmacists use at Barnabas Health is to ascertain when patients had last received darbepoetin. “This is a little more precise,” he noted.
Clinical Decision Support
The Banner Health team implemented a clinical decision support system (CDSS) to restrict ESA orders for patients who had hemoglobin levels of greater than 11 g/dL. After the CDSS was in place, patients were significantly more likely to have iron studies (56% of patients after compared with 25% before; P<0.001), and administration of ESA decreased by 20%. Among patients with hemoglobin levels greater than 11 g/dL, ESA use dropped from 14% of patients to 0% (P<0.001).
Whichever approaches are used, to effectively enact a new ESA policy, it is critical to work with all medical staff to emphasize how the changes improve patient safety, Dr. Dehoorne-Smith said. If strategies are seen primarily as efforts at cost reduction, she noted, they likely will not be so successful.