Powe N R, Griffiths R I, Bass E B
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
J Am Soc Nephrol. 1993 Apr;3(10):1660-71. doi: 10.1681/ASN.V3101660.
The purpose of this study was to estimate the net cost effect to Medicare of the increasing use of recombinant human erythropoietin (EPO) instead of red blood cell transfusions or androgens in the management of anemia for the approximately 100,000 hemodialysis patients in the U.S. End-Stage Renal Disease (ESRD) program. A computerized decision model that takes into account the effectiveness and possible side effects of transfusions, androgens, and EPO and predicts 1- and 5-yr direct medical costs to Medicare associated with each therapy was constructed. Probability estimates for clinical events were derived from the literature. Costs were assigned by use of the amounts Medicare pays providers of ESRD care for: (1) use of EPO, transfusions, and androgens; and (2) health care services related to the treatment of anemia (including complications of treatment and possible reductions in morbidity). For every 10,000 hemodialysis patients treated with EPO, net Medicare expenditures will be much greater than if only transfusions are used by $42,530,000 at 1 yr (6% of ESRD program costs) and by $118,050,000 at 5 yr and also much greater than if androgens are used (by $42,700,000 at 1 yr and $118,370,000 at 5 yr). The increase in cost was highly sensitive to the dose of EPO; moderately sensitive to changes in estimated anemia response rates for EPO, frequency of EPO-induced vascular access clotting, and reduction in cardiovascular or overall morbidity; and slightly sensitive to transfusion rates, estimated anemia response rates for androgens, frequency of EPO-induced seizure or hypertensive complications (stroke, myocardial infarction), frequency of transfusion-related viral infection, and frequency of androgen-induced virilization. Considering both effectiveness and side effects of alternative treatments for the anemia of ESRD, it was projected that the increasing use of EPO will markedly increase the cost to Medicare of ESRD medical care.
本研究的目的是估计在美国终末期肾病（ESRD）项目中，约100,000名血液透析患者在贫血管理中增加使用重组人促红细胞生成素（EPO）而非红细胞输血或雄激素对医疗保险产生的净成本影响。构建了一个计算机化决策模型，该模型考虑了输血、雄激素和EPO的有效性及可能的副作用，并预测了与每种治疗相关的医疗保险1年和5年直接医疗成本。临床事件的概率估计来自文献。成本通过医疗保险支付ESRD护理提供者的金额来确定：（1）EPO、输血和雄激素的使用；（2）与贫血治疗相关的医疗服务（包括治疗并发症和发病率可能的降低）。对于每10,000名接受EPO治疗的血液透析患者，医疗保险的净支出将比仅使用输血时在1年时多42530000美元（占ESRD项目成本的6%），在5年时多118050000美元，也比使用雄激素时多（1年时多42700000美元，5年时多118370000美元）。成本增加对EPO剂量高度敏感；对EPO估计贫血反应率的变化、EPO诱导的血管通路凝血频率以及心血管或总体发病率的降低中度敏感；对输血率、雄激素估计贫血反应率、EPO诱导的癫痫或高血压并发症（中风、心肌梗死）频率、输血相关病毒感染频率以及雄激素诱导的男性化频率轻度敏感。考虑到ESRD贫血替代治疗的有效性和副作用，预计EPO使用的增加将显著增加ESRD医疗护理对医疗保险的成本。
