Managing Erythropoietin Usage in a Large Veterans Healthcare System.

Erythropoietin (EPO) is used for many hematologic and other diseases and for adjunctive, supportive care of patients with cancer undergoing chemotherapy. However the cost is high, and excessive use may cause complications and/or compromise cancer survival. EPO utilization was the singlest largest pharmacy expense in the Central Arkansas Veterans Healthcare System and averaged $780,000 in fiscal year 2002–2003, with projections of over $2 million for the following year. We therefore studied methods to manage EPO usage through education, guideline development, monitoring, and through development of EPO-clinics modeled after coumadin-clinics. We designed and disseminated guidelines and algorithms for use of EPO, using national guidelines tailored to the specific needs of veterans and the Veterans Healthcare System. Guidelines for monitoring EPO included ongoing surveillance of iron status including iron and TIBC, ferritin, and reticulocyte hemoglobin measurements. Reticulocyte hemoglobin measurements were used as an immediate parameter of iron reserve and compared to iron profile as an indicator of iron status. Other monitoring included patient symptoms, blood counts, and course of disease. We stopped automatic refills of medication and required new prescriptions for each 6-week period so as to assure re-evaluation of the continued need for EPO and to assure titration of dosage to optimal hemoglobin and patient condition. We also flagged EPO orders in the V.A. computerized patient record system (CPRS) so that we could monitor compliance to guidelines. A pharmacy subcommittee reviewed patient profiles, symptoms, laboratory parameters, compliance to guidelines, and outcomes in relation to EPO usage. We also initiated an EPO-clinic, modeled after coumadin-clinics in which pharmacists, nurses, and physicians worked together to counsel patients about EPO, to titrate dose to best response, to prevent excess dosing, and to provide ongoing outpatient, inpatient and at-home education. Prior to initiation of the program, the projected annual cost of EPO was $2 million; after initiation of the program, the actual cost was $l.l5 million, or 43% less than the total projected amount. The program also resulted in greater attention to EPO usage, better staff and patient education, and to piloting of an EPO-clinic to coordinate medical, pharmacy, and psychosocial resources into a single clinic. This model may be effective in use of other, highly effective but very expensive medications being used in patients with hematologic disorders.