Is Preoperative Type and Screen High-value Care? A Cost-effectiveness Analysis of Performing Preoperative Type and Screen Prior to Urogynecological Surgery.

INTRODUCTION AND HYPOTHESIS: Routine preoperative type and screen (T&S) is often ordered prior to urogynecological surgery but is rarely used. We aimed to assess the cost effectiveness of routine preoperative T&S and determine transfusion and transfusion reaction rates that make universal preoperative T&S cost effective. METHODS: A decision tree model from the health care sector perspective compared costs (2020 US dollars) and effectiveness (quality-adjusted life-years, QALYs) of universal preoperative T&S (cross-matched blood) vs no T&S (O negative blood). Our primary outcome was the incremental cost-effectiveness ratio (ICER). Input parameters included transfusion rates, transfusion reaction incidence, transfusion reaction severity rates, and costs of management. The base case included a transfusion probability of 1.26%; a transfusion reaction probability of 0.0013% with or 0.4% without T&S; and with a transfusion reaction, a 50% probability of inpatient management and 0.0042 annual disutility. Costs were estimated from Medicare national reimbursement schedules. The time horizon was surgery/admission. We assumed a willingness-to-pay threshold of $150,000/QALY. One- and two-way sensitivity analyses were performed. RESULTS: The base case and one-way sensitivity analyses demonstrated that routine preoperative T&S is not cost effective, with an ICER of $63,721,632/QALY. The optimal strategy did not change when base case cost, transfusion probability, or transfusion reaction disutility were varied. Threshold analysis revealed that if transfusion reaction probability without T&S is >12%, routine T&S becomes cost effective. Scenarios identified as cost effective in the threshold and sensitivity analyses fell outside reported rates for urogynecological surgery. CONCLUSIONS: Within broad ranges, preoperative T&S is not cost effective, which supports re-evaluating routine T&S prior to urogynecological surgery.

Economic Evaluation of National Patient Blood Management Clinical Guidelines in Cardiac Surgery.

OBJECTIVES: To the best of our knowledge, no published clinical guidelines have ever undergone an economic evaluation to determine whether their implementation represented an efficient allocation of resources. Here, we perform an economic evaluation of national clinical guidelines designed to reduce unnecessary blood transfusions before, during, and after surgery published in 2012 by Australia's sole public blood provider, the National Blood Authority (NBA). METHODS: We performed a cost analysis from the government perspective, comparing the NBA's cost of implementing their perioperative patient blood management guidelines with the estimated resource savings in the years after publication. The impact on blood products, patient outcomes, and medication use were estimated for cardiac surgeries only using a large national registry. We adopted conservative counterfactual positions over a base-case 3-year time horizon with outcomes predicted from an interrupted time-series model controlling for differences in patient characteristics and hospitals. RESULTS: The estimated indexed cost of implementing the guidelines of A$1.5 million (2018-2019 financial year prices) was outweighed by the predicted blood products resource saving alone of A$5.1 million (95% confidence interval A$1.4 million-A$8.8 million) including savings of A$2.4 million, A$1.6 million, and A$1.2 million from reduced red blood cell, platelet, and fresh frozen plasma use, respectively. Estimated differences in patient outcomes were highly uncertain and estimated differences in medication were financially insignificant. CONCLUSIONS: Insofar as they led to a reduction in red blood cell, platelet, and fresh frozen plasma use during cardiac surgery, implementing the perioperative patient blood management guidelines represented an efficient use of the NBA's resources.

Transfusion Preparedness in the Labor and Delivery Unit: An Initiative to Improve Safety and Cost.

OBJECTIVE: To evaluate patient safety, resource utilization, and transfusion-related cost after a policy change from universal type and screen to selective type and screen on admission to labor and delivery. METHODS: Between October 2017 and September 2019, we performed a single-center implementation study focusing on risk-based type and screen instead of universal type and screen. Implementation of our policy was October 2018 and compared 1 year preimplementation with 1 year postimplementation. Patients were risk-stratified in alignment with California Maternal Quality Care Collaborative recommendations. Under the new policy, the blood bank holds a blood sample for processing (hold clot) on patients at low- and medium-risk of hemorrhage. Type and screen and crossmatch are obtained on high-risk patients or with a prior positive antibody screen. We collected patient outcomes, safety and cost data, and compliance and resource utilization metrics. Cost included direct costs of transfusion-related testing in the labor and delivery unit during the study period, from a health system perspective. RESULTS: In 1 year postimplementation, there were no differences in emergency-release transfusion events (4 vs 3, P>.99). There were fewer emergency-release red blood cell (RBC) units transfused (9 vs 24, P=.002) and O-negative RBC units transfused (8 vs 18, P=.016) postimplementation compared with preimplementation. Hysterectomies (0.05% vs 0.1%, P=.44) and intensive care unit admissions (0.45% vs 0.51%, P=.43) were not different postimplementation compared with preimplementation. Postimplementation, mean monthly type and screen-related costs (ABO typing, antibody screen, and antibody workup costs) were lower, $9,753 compared with $20,676 in the preimplementation year, P<.001. CONCLUSION: Implementation of selective type and screen policy in the labor and delivery unit was associated with projected annual savings of $181,000 in an institution with 4,000 deliveries per year, without evidence of increased maternal morbidity.

Patient blood management and blood conservation - Complimentary concepts and solutions for blood establishments and clinical services in South Africa and beyond.

Blood transfusions come with risks and high costs, and should be utilized only when clinically indicated. Decisions to transfuse are however not always well informed, and lack of clinician knowledge and education on good clinical transfusion practices contribute to the inappropriate use of blood. Low and middle-income countries in particular take much strain in their efforts to address blood safety challenges, demand-supply imbalances, high blood costs as well as high disease burdens, all of which impact blood usage and blood collections. Patient blood management (PBM), which is a patient-focused approach aimed at improving patient outcomes by preemptively diagnosing and correcting anaemia and limiting blood loss by cell salvage, coagulation optimization and other measures, has become a major approach to addressing many of the challenges mentioned. The associated decrease in the use of blood and blood products may be perceived as being in competition with blood conservation measures, which is the more traditional, but primarily product-focused approach. In this article, we hope to convey the message that PBM and blood conservation should not be seen as competing concepts, but rather complimentary strategies with the common goal of improving patient care. This offers opportunity to improve the culture of transfusion practices with relief to blood establishments and clinical services, not only in South Africa and LMICs, but everywhere. With the COVID-19 pandemic impacting blood supplies worldwide, this is an ideal time to call for educational interventions and awareness as an active strategy to improve transfusion practices, immediately and beyond.

Transfusion burden following reduced intensity allogeneic hematopoietic cell transplantation: Impact of donor type.

BACKGROUND: Transfusions are essential for allogeneic hematopoietic cell transplant (HCT), yet they are influenced by graft, donor, and other factors. STUDY DESIGN: We analyzed transfusions in 165 adult reduced intensity HCTs (2016-2019): HLA matched sibling donor (MSD) (n = 59), matched URD (n = 25), UCB (n = 33), and haploidentical (haplo, n = 48) detailing the cumulative incidence of platelet and RBC transfusion independence, total transfusions (day-10 to day+100) plus transfusion densities (per week) over 110 days. RESULTS: Platelet recovery to 20 × 109 /L by 6 months occurred in 39/48 (81.25%) haplo recipients (median 33 [range, 0-139]) days vs. 58/59 (98.3%) MSD (median 10 [0-37]), 21/25 (84%) matched URD (median 20 [0-153]), and 29/33 (87.87%) UCB (median 48 [29-166]) days, p < .01. Regression analysis demonstrated a lower likelihood of prompt platelet recovery in matched URD, UCB, or haplo HCTs vs. MSD. Recovery to platelet independence was quickest in MSD (median 8 days [range 0-94]), vs. URD (median 16 days [0-99]), UCB (median 57 [0-94]), or haplo (median 45 [12-97]) days, p < .01. Platelet needs were unaffected by age, conditioning, or acute GVHD. RBC transfusion independence was achieved in 78% of MSD, 64% URD, and 82% UCB, though less frequent (58%) and slowest in haplo recipients, p < .01. All haplo and UCB recipients required platelet transfusions vs. only 51% of MSD and 76% of URD. RBC needs were highest in UCB and haplo HCTs. DISCUSSION: The transplant donor influences the transfusion burden with greater platelet and RBC needs in haplo and UCB HCT which directly contributes to increased cost of care.

Effect of donor type on volume of blood transfusions required after allogeneic hematopoietic cell transplantation.

We reviewed blood product use in 729 consecutive allogeneic hematopoietic cell transplantation (allo-HCT) recipients at our center to assess the volume of red blood cells (RBCs) and platelets required after allo-HCT. The median number of bags required by day 30 was 4 for RBCs (range 0-22) and 9.5 for platelets (0-53). Multivariate analysis showed that related peripheral blood stem cell transplantation (PBSCT) required a significantly lower RBC transfusion volume by day 30 compared to unrelated bone marrow transplantation (UBMT). PBSCT from haplo-identical related donors and cord blood transplantation (CBT) required a significantly greater RBC transfusion volume. For platelet transfusion, related and unrelated PBSCT required a significantly lower volume than UBMT, and CBT a greater volume. Other factors independently associated with greater RBC transfusion volume were male sex, disease status other than complete remission, and major ABO mismatch. For platelet transfusion, these were male sex, disease status, and HCT-specific comorbidity index of 1. Although the burden of blood transfusions may not be the most important factor when choosing a donor type, our findings may provide a foundation for nationwide strategies to prepare blood products and inform aspects of national healthcare expenditures.

Assessment of blood supply and usage pre- and during COVID-19 pandemic: A lesson from non-voluntary donation.

BACKGROUND: Ensuring steady stream of safe blood is the ultimate goal of blood transfusion practice. The current COVID-19 pandemic has affected almost every part of life and economy. Consequently, this study sets off to assess the effect of the pandemic on blood supply and blood transfusion in the University of Calabar Teaching Hospital. METHODS: Data from the Donor Clinic and Blood Group Serology Unit of the University of Calabar Teaching Hospital were retrospectively extracted to evaluate supply and use of blood before and during COVID-19 pandemic. RESULT: A total of 1638 donors were recorded within the study period. Age range 15-29 and 30-44 years constituted majority of the subjects (58.9% and 33.4%, respectively). The donor pool were male-dominated. Commercial donors (61.7%) and family replacement donors (30.6%) constituted majority of the donor pool. Most of the donor pool were students (37.1%), public servants (22.8%) and artisans (18.6%). A concomitant decrease of 26.1% and 18.9% were recorded in blood donation and request during the COVID-19 pandemic. CONCLUSION: Blood supply was not significantly affected in our study center as both requests and donations decreased. Consideration for improving family replacement donation was advised.

Patient blood management interventions do not lead to important clinical benefits or cost-effectiveness for major surgery: a network meta-analysis.

BACKGROUND: Patient blood management (PBM) interventions aim to improve clinical outcomes by reducing bleeding and transfusion. We assessed whether existing evidence supports the routine use of combinations of these interventions during and after major surgery. METHODS: Five systematic reviews and a National Institute of Health and Care Excellence health economic review of trials of common PBM interventions enrolling participants of any age undergoing surgery were updated. The last search was on June 1, 2019. Studies in trauma, burns, gastrointestinal haemorrhage, gynaecology, dentistry, or critical care were excluded. The co-primary outcomes were: risk of receiving red cell transfusion and 30-day or hospital all-cause mortality. Treatment effects were estimated using random-effects models and risk ratios (RR) with 95% confidence intervals (CIs). Heterogeneity assessments used I2. Network meta-analyses used a frequentist approach. The protocol was registered prospectively (PROSPERO CRD42018085730). RESULTS: Searches identified 393 eligible randomised controlled trials enrolling 54 917 participants. PBM interventions resulted in a reduction in exposure to red cell transfusion (RR=0.60; 95% CI 0.57, 0.63; I2=77%), but had no statistically significant treatment effect on 30-day or hospital mortality (RR=0.93; 95% CI 0.81, 1.07; I2=0%). Treatment effects were consistent across multiple secondary outcomes, sub-groups and sensitivity analyses that considered clinical setting, type of intervention, and trial quality. Network meta-analysis did not demonstrate additive benefits from the use of multiple interventions. No trial demonstrated that PBM was cost-effective. CONCLUSIONS: In randomised trials, PBM interventions do not have important clinical benefits beyond reducing bleeding and transfusion in people undergoing major surgery.

Costs associated with transfusion therapy in patients with myelodysplastic syndromes in Sweden: a nationwide retrospective cohort study.

BACKGROUND AND OBJECTIVES: Blood transfusion is a cornerstone therapy for many patients with myelodysplastic syndromes (MDS), but ranges from few to no transfusions to intensive transfusion therapy. To date, no large studies have described transfusion use or costs for patients with MDS, accounting for the range of disease severity. MATERIALS AND METHODS: A nationwide cohort study was conducted with all patients diagnosed with MDS in Sweden between 2008 and 2017, based on the Swedish MDS register and the Swedish part of the Scandinavian Donations and Transfusions Database 3 (SCANDAT3-S). Patients were followed from diagnosis until death, emigration, allogeneic hematopoietic stem cell transplantation or end of follow-up. Average cumulative transfusion count and costs over time were calculated, stratified by the revised international prognostic scoring system (IPSS-R) and age at diagnosis. Costs calculations used data on incident transfusions and laboratory testing and were divided into: direct material costs, direct labour costs and laboratory costs. RESULTS: In total, 2311 patients were included in the cohort. In the first four years after diagnosis, patients in the very low IPSS-R category received on average 25 red cell (95% confidence interval, 20-32) and 4 (3-7) platelet transfusions. Conversely, patients in the very high-risk category received on average 171 (135-200) red cell and 66 (51-78) platelet transfusions. Correspondingly, transfusion costs ranged from $8805 ($6482-$11 625) to $80 106 ($61 460-$95 792). CONCLUSION: Transfusion count and costs for patients with MDS increased markedly with IPSS-R risk category, but were similar across age groups. Transfusion costs were considerable for the highest IPSS-R risk categories.

The Utility of Obtaining a Complete Blood Count After Total Knee Arthroplasty in the Era of Tranexamic Acid.

Questioning the routine use of postoperative laboratory tests is a strategy to combat rising health care costs. The goal of this study was to determine the utility and cost of routine postoperative complete blood count (CBC) testing after primary total knee arthroplasty (TKA) in the era of tranexamic acid (TXA). This retrospective chart review identified patients who underwent primary TKA performed by a single surgeon at a single private institution during a 2-year period. All patients received TXA intraoperatively. Exact tests were used to determine whether there was a significant difference in transfusion rates between patients with and without preoperative anemia. Of 628 primary TKA procedures, 390 patients (62.10%) had anemia postoperatively. However, only 1 patient (0.16%) required transfusion. A total of 956 CBC tests were performed without intervention, at a total cost of $116,804.08. In addition, 1 of 26 patients with preoperative anemia vs 0 of 602 patients without preoperative anemia required transfusion (P=.04). Healthy patients undergoing primary TKA who receive TXA do not require postoperative CBC. This change has the potential to reduce this laboratory cost by more than 97% compared with the current practice of obtaining postoperative CBC testing for every patient undergoing TKA. Only patients with preoperative anemia should undergo postoperative CBC testing to help to identify those who require transfusion. The potential health care savings associated with eliminating routine postoperative CBC testing are substantial and should be considered by arthroplasty surgeons. [Orthopedics. 2021;44(1):e26-e30.].

Racial/ethnic and gender disparities in the use of erythropoiesis-stimulating agents and blood transfusions: cancer management under Medicare's reimbursement policy.

BACKGROUND: Because of increasing safety concerns related to erythropoiesisstimulating agents (ESAs), the Centers for Medicare & Medicaid Services issued a Medicare reimbursement policy change regarding these medications in cancer patients. However, the policy established an absolute hemoglobin or hematocrit threshold to qualify for reasonable use but did not take the effect of gender and racial/ethnic differences in hemoglobin levels into consideration. OBJECTIVE: To examine disparities in the use of ESAs and blood transfusions after the Medicare policy change. METHODS: This study was an exploratory treatment effectiveness study and used the SEER-Medicare linked database. The treatment group was composed of cancer patients, whereas the control group was composed of chronic kidney disease patients. An interrupted time series design was used to examine the effect of the Medicare policy change on the use of ESAs and blood transfusions in different gender and racial/ethnic groups. RESULTS: The Medicare reimbursement policy change had an immediate effect on reducing the use of ESAs by 50% and increasing the use of blood transfusions by 10%. The immediate effect of the policy change on the monthly utilization of ESAs was 2 times greater in females (60% reduction) than males (30% reduction). Females had a 10% immediate increase in the monthly utilization of blood transfusions after the policy change. The policy change had the same immediate effect of a 50% reduction on the use of ESAs for Whites, African Americans/Blacks, and Latinos. African Americans/Blacks had a 50% immediate increase in the monthly utilization of blood transfusions after the policy change. CONCLUSIONS: Gender and racial/ethnic disparities were associated with the Medicare reimbursement policy change in the use of ESAs and blood transfusions. Thus, future policy considerations should keep biologic differences across gender and racial/ethnic groups in mind. DISCLOSURES: This study was funded by the SPARC Research Grant. The funder had no role in any part of this study. The authors have nothing to disclose.

How do we use electronic clinical decision support and feedback to promote good transfusion practice.

This report describes the evolution of the electronic clinical decision support system (CDSS) and feedback methods at our center and the challenges and lessons learned. The electronic blood product order with integrated CDSS ensures collection of data regarding the patient's clinical condition and the justification for the blood product order. An alert is generated in real time if the order is placed outside agreed guidelines. We have provided feedback in several ways. We began with monthly review meetings with the junior hematology clinicians responsible for ordering blood. This was successful in reducing unjustified transfusions in this setting. We expanded the feedback to the rest of our hospitals in two ways. First, a dashboard was developed allowing visualization of ordering data by clinicians. Second, these data were summarized on a quarterly basis into a report circulated to the senior clinical staff by e-mail. Finally, a daily report collates all orders placed for blood products that have triggered a CDSS alert from the previous day. A multidisciplinary team reviews these daily. If an order appears unjustified the specialist transfusion clinician contacts the prescribing clinician to ask for further information and, if necessary, provides education. The CDSS and feedback, allied with other patient blood management measures, have reduced total blood product costs for our hospitals by 26% over 6 years. The description of how we have developed and implemented CDSS and feedback to influence transfusion practice may be of particular value to others developing their own systems.

Designing an optimal inventory management model for the blood supply chain: Synthesis of reusable simulation and neural network.

Blood supply managers in the blood supply chain have always sought to create enough reserves to increase access to different blood products and reduce the mortality rate resulting from expired blood. Managers' adequate and timely response to their customers is considered vital due to blood perishability, uncertainty of blood demand, and the direct relationship between the availability/lack of blood supply and human life. Further to this, hospitals' awareness of the optimal amount of requests from suppliers is vital to reducing blood return and blood loss, since the loss of blood products surely leads to high expenses. This paper aims to design an optimal management model of blood transfusion network by a synthesis of reusable simulation technique (applicable to all bases) and deep neural network (the latest neural network technique) with multiple recursive layers in the blood supply chain so that the costs of blood waste, return, and shortage can be reduced. The model was implemented on and developed for the blood transfusion network of Khorasan Razavi, which has 6 main bases active from October 2015 to October 2017. In order to validate the data, the data results of the variables examined with the real data were compared with those of the simulation, and the insignificant difference between them was investigated by t test. The solution of the model facilitated a better prediction of the amount of hospital demand, the optimal amount of safety reserves in the bases, the optimal number of hospital orders, and the optimal amount of hospital delivery. This prediction helps significantly reduce the return of blood units to bases, increase availability of inventories, and reduce costs.

Cost-effectiveness evaluation of the PROPPR trial transfusion protocols.

BACKGROUND: There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period. STUDY DESIGN AND METHODS: International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments. RESULTS: The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained. CONCLUSION: The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.

Serial prophylactic exchange blood transfusion in pregnant women with sickle cell disease (TAPS-2): study protocol for a randomised controlled feasibility trial.

BACKGROUND: Pregnancies in women with sickle cell disease (SCD) are associated with a higher risk of sickle and pregnancy complications. Limited options exist for treating SCD during pregnancy. Serial prophylactic exchange blood transfusion (SPEBT) has been shown to be effective in treating SCD outside pregnancy, but evidence is lacking regarding its use during pregnancy. The aim of this study is to assess the feasibility and acceptability of conducting a future phase 3 randomised controlled trial (RCT) to establish the clinical and cost effectiveness of SPEBT in pregnant women with SCD. METHODS: The study is an individually randomised, two-arm, feasibility trial with embedded qualitative and health economic studies. Fifty women, 18 years of age and older, with SCD and a singleton pregnancy at ≤ 18 weeks' gestation will be recruited from six hospitals in England. Randomisation will be conducted using a secure online database and minimised by centre, SCD genotype and maternal age. Women allocated to the intervention arm will receive SPEBT commencing at ≤ 18 weeks' gestation, performed using automated erythrocytapheresis every 6-10 weeks until the end of pregnancy, aiming to maintain HbS% or combined HbS/HbC% below 30%. Women in the standard care arm will only receive transfusion when clinically indicated. The primary outcome will be the recruitment rate. Additional endpoints include reasons for refusal to participate, attrition rate, protocol adherence, and maternal and neonatal outcomes. Women will be monitored throughout pregnancy to assess maternal, sickle, and foetal complications. Detailed information about adverse events (including hospital admission) and birth outcomes will be extracted from medical records and via interview at 6 weeks postpartum. An embedded qualitative study will consist of interviews with (a) 15-25 trial participants to assess experiences and acceptability, (b) 5-15 women who decline to participate to identify barriers to recruitment and (c) 15-20 clinical staff to explore fidelity and acceptability. A health economic study will inform a future cost effectiveness and cost-utility analysis. DISCUSSION: This feasibility study aims to rigorously evaluate SPEBT as a treatment for SCD in pregnancy and its impact on maternal and infant outcomes. TRIAL REGISTRATION: NIH registry (www.clinicaltrials.gov), registration number NCT03975894 (registered 05/06/19); ISRCTN (www.isrctn.com), registration number ISRCTN52684446 (retrospectively registered 02/08/19).

Economic value of clinical decision support allied to direct data feedback to clinicians: blood usage in haematology.

BACKGROUND AND OBJECTIVES: Responding to national and local pressures to reduce the amount of blood transfused, the haematology department of Oxford University Hospitals (OUH), UK implemented an electronic blood-ordering system with clinical decision support. This intervention targeted junior doctors, giving regular feedback on their transfusion practices with respect to clinical guidelines. METHODS: We evaluated the incremental costs of the intervention using interrupted time series methods to compare red blood cell and platelet usage before and after the intervention was implemented. Difference-in-differences analysis was used to control for external factors that would affect the use of blood products over time. Reductions in blood usage were balanced against intervention costs. RESULTS: The base case analysis showed an average cost saving to the department of £89 304 annually as a result of the intervention. Scenario analyses suggested that the savings may have been greater still, had the increasing trend in blood use prior to the intervention continued in the absence of the intervention. CONCLUSION: An electronic blood-ordering system with clinical decision support can reduce blood transfusions and associated healthcare costs. Focusing on improving junior doctors' transfusion practice is expected to have a knock-on benefit in terms of dissemination of good transfusion practice both within their own department and others as they continue their training.

Reducing preoperative blood orders and costs for radical prostatectomy.

Aim: A maximum surgical blood order schedule (MSBOS) was implemented at our institution to optimize preoperative blood ordering and reduce unnecessary blood preparation for patients undergoing radical prostatectomy (RP), a common urologic procedure. Materials & methods: We conducted a retrospective review of patients who underwent RP from 2010 to 2016 and categorized patients by date of RP (pre- or post-MSBOS) and compared preoperative blood-ordering practices. Results: After MSBOS implementation, preoperative blood orders changed from predominantly type and cross-match 2 units (53%) to no sample (56%) for robot-assisted laparoscopic RP, and from mostly type and cross-match 2 units (62%) to type and screen (75%) for open RP with resultant cost savings. Conclusion: MSBOS implementation and compliance decreases unnecessary preoperative blood orders.

Gelatin-thrombin hemostatic matrix in neurosurgical procedures: hemostatic effectiveness and economic value of clinical and surgical procedure-related benefits.

BACKGROUND: Gelatin-thrombin hemostatic matrix (FloSeal®) use is associated with shorter surgical times and less blood loss, parameters that are highly valued in neurosurgical procedures. We aimed to assess the effectiveness of gelatin-thrombin in neurosurgical procedures and estimate its economic value. METHODS: In a 6-month retrospective evaluation at 2 hospitals, intraoperative and postoperative information were collected from patients undergoing neurosurgical procedures where bleeding was controlled with gelatin-thrombin matrix or according to local bleeding control guidelines (control group). Study endpoints were: length of surgery, estimated blood loss, hospitalization duration, blood units utilized, intensive care unit days, postoperative complications, and time to recovery. Statistical methods compared endpoints between the gelatin-thrombin and control groups and resource utilization costs were estimated. RESULTS: Seventy-eight patients (38 gelatin-thrombin; 40 control) were included. Gelatin-thrombin was associated with a shorter surgery duration than control (166±40 versus 185±55 minutes, P=0.0839); a lower estimated blood loss (185±80 versus 250±95 mL; P=0.0017); a shorter hospital stay (10±3 versus 13±3 days; P<0.001); fewer intensive care unit days (10 days/3 patients and 20 days/4 patients); and shorter time to recovery (3±2.2 versus 4±2.8 weeks; P=0.0861). Fewer gelatin-thrombin patients experienced postoperative complications (3 minor) than the control group (5 minor; 3 major). No gelatin-thrombin patient required blood transfusion; 5 units were administered in the control group. The cost of gelatin-thrombin (€ 268.40/unit) was offset by the shorter surgery duration (difference of 19 minutes at € 858/hour) and the economic value of improved the other endpoint outcomes (i.e., shorter hospital stay, lesser blood loss/lack of need for transfusion, fewer intensive care unit days, and complications). CONCLUSIONS: The use of gelatin-thrombin hemostatic matrix in patients undergoing neurosurgical procedures was associated with better intra- and postoperative parameters than conventional hemostasis methods, with these parameters having substantial economic benefits.

Implementation of a Preoperative Anemia Clinic Utilizing a Minimal Staffing Model.

We present a process map for the implementation of a program to treat preoperative anemia utilizing 1 existing anesthesiologist in the preoperative evaluation clinic. In the first 7 months postimplementation, 342 patients were screened for anemia, 166 were diagnosed, and 107 were treated. The mean increase in hemoglobin in treated patients was ~2 g/dL (range 0-4.9 g/dL). Two patients' surgeries were delayed in favor of treatment and 3 surgical patients, who had received 2 complete iron infusions, received an intraoperative transfusion. The total revenue generated for the institution was enough to subsidize the cost of an additional anesthesiologist.