A systematic literature review of the cost-effectiveness of erythropoietin in orthopedic surgery: There is a need for differentiation between total hip and knee arthroplasty

OBJECTIVES: Erythropoietin has been widely adapted into clinical practice in orthopedic surgery to prevent anemia and ultimately lower the use of allogeneic blood transfusions. Its safety and efficacy has been shown in various randomized clinical trials. Questions regarding the cost-effectiveness of this treatment, however, have yet to be answered conclusively. Notably, current indication guidelines are based on preoperative hemoglobin levels, but do not differentiate between total hip arthroplasty (THA) and total knee arthroplasty (TKA). This literature review aims at analyzing the cost-effectiveness of preoperative erythropoietin as blood sparing measure in patients undergoing elective orthopedic surgery, specifically THA and TKA. Additionally, patient inclusion criteria are analyzed in order to identify the potentially most cost-effective patient subgroups, e.g. based on preoperative hemoglobin levels, primary or revisional surgery and THA versus TKA. METHODS: Systematic literature review. RESULTS: A MEDLINE database search and subsequent exclusion of irrelevant or inaccessible papers resulted in the inclusion of 8 research articles that at least partially performed a cost-effectiveness or cost-benefit analysis of erythropoietin in orthopedic surgery. Four of the studies concluded erythropoietin is not cost-effective, three studies were not able to draw a conclusion based on their data, and one study found erythropoietin cost-effective. CONCLUSIONS: We found that studies were difficult to compare, with inclusion criteria and comparators varying among studies. Notably, most economic evaluations were substantially lacking depth and did not comply with common guidelines for pharmacoeconomic research. Although some articles found erythropoietin generally not cost-effective, their data did suggest otherwise within certain patient subgroups. Patients with lower preoperative hemoglobin levels, primary surgery and THA benefitted the most from erythropoietin. Additionally, most studies seemed to overestimate treatment costs, using outdated prices or neglecting competitively priced biosimilars. Therefore, a more differentiated approach is required to elucidate the costeffectiveness of erythropoietin in orthopedic surgery, discriminating between total hip and knee arthroplasty.