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.

A systematic review and network meta-analysis of incentive- and non-incentive-based interventions for increasing blood donations.

BACKGROUND AND OBJECTIVES: Blood services are tasked with efficiently maintaining a reliable blood supply, and there has been much debate over the use of incentives to motivate prosocial activities. Thus, it is important to understand the relative effectiveness of interventions for increasing donations. MATERIALS AND METHODS: This systematic review used a broad search strategy to identify randomized controlled trials comparing interventions for increasing blood donations. After full-text review, 28 trials from 25 published articles were included. Sufficient data for meta-analysis were available from 27 trials. Monetary incentives were assumed to be equivalent regardless of value, and non-monetary incentives were assumed to be equivalent regardless of type. Non-incentive-based interventions identified included existing practice, letters, telephone calls, questionnaires, and the combination of a letter & telephone call. A network meta-analysis was used to pool the results from identified trials. A subgroup analysis was performed in populations of donors and non-donors as sensitivity analyses. RESULTS: The best performing interventions were letter & telephone call and telephone call-only with odds ratios of 3·08 (95% CI: 1·99, 4·75) and 1·99 (95% CI: 1·47, 2·69) compared to existing practice, respectively. With considerable uncertainty around the pooled effect, we found no evidence that monetary incentives were effective at increasing donations compared to existing practice. Non-monetary incentives were only effective in the donor subgroup. CONCLUSION: When pooling across modes of interventions, letter & telephone call and telephone call-only are effective at increasing blood donations. The effectiveness of incentives remains unclear with limited, disparate evidence identified.

Impact of patient blood management guidelines on blood transfusions and patient outcomes during cardiac surgery.

OBJECTIVE: In March 2012, Australia's National Blood Authority published national patient blood-management guidelines for perioperative care developed by a systematic review and clinical expert opinion. This study assesses how blood transfusions and patient outcomes in cardiac surgery changed after the guidelines were published. METHODS: Blood transfusions and patient outcomes in cardiac surgery were compared before and after implementation of the guidelines using an interrupted time series analysis. The evaluation included red blood cells, platelets, cryoprecipitate, fresh-frozen plasma, 30-day mortality, 30-day readmissions, and hospital and intensive care length of stay. Patient characteristics were controlled for along with hospital characteristics using fixed effects. Different responses across institutional settings were assessed with an expanded difference-in-differences model. RESULTS: After the guidelines were published, our model found a significant reduction in red blood cell, platelet, and fresh-frozen plasma transfusions. There was also a significant reduction in hospital length of stay but no significant impact on cryoprecipitate, 30-day mortality, 30-day readmissions, or intensive care unit length of stay. The subgroup analyses found no differences with regards to institutional settings. CONCLUSIONS: Following the publication of the guidelines, there was a measurable reduction in perioperative blood transfusions in cardiac surgery with an associated reduction in hospital length of stay but no detectable differences in other patient outcomes.

The Cost Effectiveness of Nalmefene for Reduction of Alcohol Consumption in Alcohol-Dependent Patients with High or Very High Drinking-Risk Levels from a UK Societal Perspective.

AIM: To evaluate costs and health outcomes of nalmefene plus psychosocial support, compared with psychosocial intervention alone, for reducing alcohol consumption in alcohol-dependent patients, specifically focusing on societal costs related to productivity losses and crime. METHODS: A Markov model was constructed to model costs and health outcomes of the treatments over 5 years. Analyses were conducted for nalmefene's licensed population: adults with both alcohol dependence and high or very high drinking-risk levels (DRLs) who do not require immediate detoxification and who have high or very high DRLs after initial assessment. The main outcome measure was cost per quality-adjusted life-year (QALY) gained as assessed from a UK societal perspective. Alcohol-attributable productivity loss, crime and health events occurring at different levels of alcohol consumption were taken from published risk-relation studies. Health-related and societal costs were drawn from public data and the literature. Data on the treatment effect, as well as baseline characteristics of the modelled population and utilities, came from three pivotal phase 3 trials of nalmefene. RESULTS: Nalmefene plus psychosocial support was dominant compared with psychosocial intervention alone, resulting in QALYs gained and reduced societal costs. Sensitivity analyses showed that this conclusion was robust. Nalmefene plus psychosocial support led to per-patient reduced costs of £3324 and £2483, due to reduced productivity losses and crime events, respectively. CONCLUSION: Nalmefene is cost effective from a UK societal perspective, resulting in greater QALY gains and lower costs compared with psychosocial support alone. Nalmefene demonstrates considerable public benefits by reducing alcohol-attributable productivity losses and crime events in adults with both alcohol dependence and high or very high DRLs who do not require immediate detoxification and who have high or very high DRLs after initial assessment.