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• W2953313251 abstract "To the Editor We recently read the meta-analysis by Cho et al1 on preoperative erythropoietin treatment and allogeneic red blood cell (RBC) transfusion in surgical patients. In their analysis, Cho et al1 demonstrated a reduction in allogeneic RBC transfusion with preoperative erythropoietin treatment; risk ratio for all surgeries was 0.59 (95% confidence interval [CI], 0.47–0.73) and for cardiac surgery 0.55 (0.37–0.81). This study is timely given the recent publication of an international consensus guideline on patient blood management. In this guideline, erythropoietin was given a “conditional” recommendation for use in anemic patients having major surgery.2 There are several important considerations before erythropoietin can be recommended for “routine use” in cardiac surgery. First, RBC transfusion is variable between cardiac surgery centers, even after adjusting for surgical risk.3 In 1 recent study of 10 Maryland hospitals, intraoperative RBC transfusion varied between 16% and 60%.3 Assuming that the risk ratio for RBC transfusion with erythropoietin treatment is relatively constant at 0.55, the number needed to treat (NNT) to prevent 1 RBC transfusion varies between 3 and 12. This is a fairly wide range and will lead to different cost–benefit analysis among centers. The second important consideration is reimbursement for therapy. In 1 detailed description of a preoperative anemia management program at Duke University, the authors describe significant financial gains by year 5 of their program, but these gains were contingent on receiving reimbursement for erythropoietin therapy at $3360 per patient.4 Preoperative erythropoietin use is off-label, and some commercial insurers will not pay for it. The Centers for Medicare and Medicaid Services (CMS) has previously refused to pay for off-label erythropoietin treatment in cancer patients, which brings into question whether they will pay for widespread use in surgical patients. In Maryland, hospital care is reimbursed under a total cost of care model and there is tremendous pressure to reduce hospital care costs because revenue is fixed. Without fee for service reimbursement for erythropoietin, the Duke anemia program would have lost approximately $200,000 at year 5, rather than gained $2.7 million.4 This highlights the difficult decision that hospital administrators are faced with because as Cho et al1 point out, RBC transfusion is associated with numerous adverse effects including increased infection risk and transfusion-associated acute lung injury (TRALI). The final consideration is that major practice changes occurred during the 20-year study period. RBC transfusion rates were extremely high, 60%–80%, in some of the control groups in the pooled studies. Also, there was no description of antifibrinolytic drug use in several studies, even though these drugs are now used ubiquitously in cardiac surgery. Finally, increased use of point-of-care viscoelastic coagulation testing has helped to reduce RBC transfusion in contemporary practice, and this is not reflected in many of the studies in the meta-analysis. Taken together, we feel that the efficacy of erythropoietin demonstrated in the meta-analysis may not translate into comparable gains in contemporary practice. We suggest that erythropoietin should be prescribed individually based on each hospital’s patient population, clinical experience, and reimbursement system. Michael Mazzeffi, MD, MPH, MScJonathan H. Chow, MDKenichi Tanaka, MDDepartment of AnesthesiologyUniversity of Maryland School of MedicineBaltimore, Maryland[email protected]" @default.
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• W2953313251 date "2019-09-01" @default.
• W2953313251 modified "2023-09-24" @default.
• W2953313251 title "Preoperative Erythropoietin in Cardiac Surgery" @default.
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• W2953313251 doi "https://doi.org/10.1213/ane.0000000000004296" @default.
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