with pharmacist-managed ESA clinics (nϭ314) and at six sites with usual care only (nϭ167); outpatients were followed for 6 months in 2009. We took a VA perspective with projections over a five-year time horizon; costs and effectiveness values were discounted at 3%/yr. Strategy-specific likelihoods of target range hemoglobin values (10-12 g/dl) were based on study results. Utilities for ND-CKD and ESA-related adverse events and their likelihood were obtained from the literature. ESA costs were based on average monthly epoetin and darbepoetin doses per patient during the study and VA ESA cost data. RESULTS: In the base case analysis, cost and effectiveness were $12,500 and 2.096 quality-adjusted life-years (QALYs) in the pharmacistmanaged ESA clinics and $15,500 and 2.093 QALYs in usual care; ESA clinics dominated usual care. In one-way sensitivity analyses, ESA clinics no longer dominated if their patients' probability of being in the target range fell to 0.54 (base case 0.71) or if the mean cost/month of epoetin or darbepoetin in ESA clinics increased to approximately $360 (base case $211) or $460 (base case $250), respectively. When all parameters were varied simultaneously in a probabilistic sensitivity analysis, ESA clinics were favored Ն80% of the time regardless of willingness-to-pay threshold. CONCLUSIONS: Pharmacist-managed ESA clinics were less costly and more effective than usual care in patients receiving ESAs for anemia and ND-CKD. Results were robust to variation and support the use of pharmacist-managed ESA clinics.
The ADM system decreased the workload of pharmacy technicians, whereas it required more time from pharmacists. However, the increased workload of pharmacists was associated with more comprehensive patient care functions, which resulted from the redesigned work process.
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