From Overuse to Oversight: Curbing Excessive Inpatient Erythropoiesis-Stimulating Agent Use

Background: Erythropoiesis-stimulating agents (ESA) are frequently used in the treatment of anemia associated with end-stage renal disease (ESRD). However, ESA use in hospitalized patients—particularly in the era of long-acting ESA in outpatient clinics —can lead to unnecessary cost, risk of adverse outcomes, and deviation from clinical guidelines. At our institution, internal audits revealed a high volume of ESA orders with variable clinical justification. This quality improvement (QI) project aimed to reduce unnecessary ESA use by restricting ordering privileges to pharmacy staff, thereby aligning inpatient ESA prescribing with best practices and ensuring clinical oversight. Methods: This QI initiative was implemented at a large academic hospital and focused on modifying ordering privileges for ESA. Prior to the intervention, inpatient providers were able to place ESA orders directly. Beginning in November 2023, ESA ordering was restricted to clinical pharmacists, who reviewed requests for appropriateness based on established institutional guidelines, dialysis treatment plans, and laboratory parameters. Baseline ESA prescribing data were collected for a 12-month pre-intervention period. The number of unique ESA orders was then compared to a 12-month period following implementation of the ordering restriction. The primary outcome was a comparison of the number of unique inpatient ESA orders during the two periods. Results: In the 12 months prior to implementation, there were 1,939 unique ESA orders placed for inpatients. In the 12 months following restriction of ordering privileges, the number of unique ESA orders decreased to 203, representing an 89.5% reduction in ESA utilization and an estimated cost savings of approximately $140,000. No adverse patient outcomes related to anemia management were identified during the post-intervention period based on internal clinical audits. Conclusion: Restricting ESA ordering privileges to pharmacy staff led to a substantial reduction in inappropriate prescribing, with unique ESA orders decreasing from 1,939 to 203 in the year following implementation—an 89.5% reduction and $140,000 cost savings. This targeted intervention effectively eliminated unnecessary use, ensured adherence to clinical guidelines, and demonstrated the impact of inpatient ESA stewardship on improving medication safety and resource utilization.