Most Cost-Effective Hb Target in Anemic CKD Patients Identified

A hemoglobin level of 10.5 g/dL offers the optimal balance of cost and quality adjusted life years, researchers conclude.
A hemoglobin level of 10.5 g/dL offers the optimal balance of cost and quality adjusted life years, researchers conclude.

Among patients older than 30 years who have chronic kidney disease (CKD) stage 3–4, anemia treatment is most cost-effective when targeting a hemoglobin level of 10.5 g/dL, researchers concluded.

“This is an important step in informing and framing future guidelines around the treatment of anemia and in improving outcomes in persons with moderate to advanced CKD,” Benjamin O. Yarnoff, PhD, of RTI International, Research Triangle Park, North Carolina, and colleagues concluded in PLOS ONE. “It also serves as a model for testing the cost-effectiveness of other treatment interventions in people with CKD.”

Using the CKD Health Policy Model, Dr Yarnoff's team found that targeting a hemoglobin value of 10 g/dL resulted in an incremental cost-effectiveness ratio (ICER) of $32,111 compared with no treatment and an ICER of $32,475 compared with a target of 10 g/dL. They computed ICER as incremental cost divided by incremental quality adjusted life years (QALYs).

QALYs increased to 4.63 for a target of 10 g/dL and to 4.75 for a target of 10.5 g/dL or 11 g/dL. “Any treatment target above 11 g/dL increased medical costs and decreased QALYs,” the investigators wrote.

The investigators populated their model with a synthetic cohort of individuals older than 30 years with prevalent CKD stage 3–4 and anemia from the 1999–2010 National Health and Nutrition Examination Survey. The model incorporated the potential tradeoff between the benefits of higher hemoglobin targets and the adverse effects of higher doses of erythropoiesis-stimulating agents (ESAs) needed to achieve them.

The average lifetime costs increased from $94,056 in cases with no ESA treatment (only iron) to $140,925 for a treatment target of 13 g/dL, Dr. Yarnoff and his colleagues reported. ESA dose increased from 439 units for a target of 10 g/dL and to 27,145 units for a target of 13 g/dL. Life years increased to 6.84 at a target of 10 g/dL and to 6.99 at a target of 10.5 g/dL, but diminished incrementally at higher hemoglobin targets.

Increasing the target to 11 g/dL results in 0.39 additional life years compared with no ESA treatment, but 0.06 fewer life years than for a target of 10.5 g/dL, according to the investigators.

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