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Objective: The objective of this study was to assess the cost effectiveness of using epoetin-α (erythropoietin) to augment preoperative autologous donation (PAD) of blood prior to elective cardiac surgery. Design and setting: We designed a decision-analytic model incorporating the risk of receiving allogeneic blood, the costs of blood products, the likelihood of developing transfusion-related diseases, the costs of transfusion-related diseases and their impact on life expectancy, and the effect of epoetin-α on the probability of transfusion. Interventions: The efficacy of epoetin-α was derived from data from a meta-analysis of published randomised trials comparing the use of epoetin-α to augment PAD with the use of PAD alone. Estimates for the other parameters were obtained by a systematic review of the literature. Main outcome measures and results: The use of epoetin-α reduced the proportion of patients receiving allogeneic transfusions by 60% (from 31.6 to 12.7%). However, this led to only a modest benefit of 0.000035 life years gained per patient and an incremental cost per life year gained of $Can44.6 million (1998 Canadian dollars). A detailed sensitivity analysis confirmed that the cost-effectiveness ratio was larger than that which is generally considered acceptable. Conclusions: Our study indicates that the use of epoetin-α to reduce perioperative allogeneic transfusions in cardiac surgery is not cost effective. [ABSTRACT FROM AUTHOR]