Appropriateness of the use of intravenous immune globulin before and after the introduction of a utilization control program.

Intravenous immune globulin (IVIG), a fractionated blood product extracted from pooled human plasma from blood donations, is given intravenously to treat primary immune deficiency diseases and a wide array of autoimmune diseases, infections and other conditions. For some conditions, IVIG has been shown to be efficacious in randomized controlled trials, but often the evidence of benefit is less rigorous, with just case reports or uncontrolled case series suggesting benefit.1-8 Many of these conditions without evidence of efficacy are frequently treated with IVIG, which may not always be appropriate. Even in diseases where efficacy has been shown, appropriate use will depend on the stage and severity of the condition and perhaps other factors. Inappropriate use of IVIG exposes patients to unnecessary risks from adverse reactions9 and increases health care expenditures because of the high cost of IVIG. IVIG use in Canada more than quadrupled in the 1990s,10 and a typical course of IVIG (2 g/kg) for acute treatment currently costs more than Can$10 000. Also of concern is the marked regional disparity in IVIG use. In 2001/02, the province of British Columbia (BC) used 0.07 g of IVIG per capita, whereas the province of Alberta used 0.12 g per capita.11 Such marked variation suggests the possibility of either overuse (inappropriate use) or underuse.12,13 Concerns about inappropriate use prompted BC to introduce the IVIG Management Program in 2002. This province-wide program involved the provision of a handbook on IVIG utilization management with guidelines for prescribers, and a more specific request form intended to reduce inappropriate use.10 Alberta, in contrast, did not undertake any concerted program to manage IVIG use. We used this “natural experiment” to formally assess the appropriateness of IVIG use in BC and Alberta and the effectiveness of BC’s program.