Effect of reimbursement changes on erythropoiesis-stimulating agent utilization and transfusions.

The near 30% increase in transfusion use to treat anemia following the 2007 Decision Memo to restrict the initiation and target for ESA use for chemotherapy-induced anemia to 10g/dL is of considerable concern. This increase was even more pronounced in persons greater than 65years of age. I recently asked one of my patients to bring in an EOB (explanation of benefits) following the reception of two units of packed red cells in the ambulatory oncology center at the hospital I admit to. The paid amount, including infusion costs, was US$5300. Although the limited blood supply and negative outcomes with transfusion are well known to most oncologists, few realize how expensive transfusions actually are.

The 2007 memo was based on negative cancer outcomes in eight clinical trials, all of which targeted supratherapeutic hemoglobin levels. Meta-analyses subsequent to this memo (Glaspy, Bohlius) showed no negative signal with ESA usage when used within guidelines targeting hemoglobin levels less than 12g/dL. In their excellent review, Hess et al. point out the significant changes in transfusion use for treatment of chemotherapy-induced anemia as a result of the ESA restrictions. The authors appropriately point out the number of new cancer patients is expected to double to more than two million persons before 2050. In this same time period, the >65 population is expected to increase to approximately 88million. Since more than half of all cancers occur in this population where anemia symptoms are more pronounced, the effect of the Decision Memo on transfusion use is likely to be formidable.

We are all familiar with the risks of transfusion. This excellent paper by Hess et al. reiterates our charge to keep the relative risks of the different treatment options for chemotherapy-induced anemia
in perspective.

– Michael Auerbach