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Nuñez JH, Escudero B, Montenegro JD, Guerra Farfán E, Bartra-Ylla A, Angles-Crespo F. Evaluating the necessity of pre-transfusion testing in primary total hip arthroplasty: a systematic review and meta-analysis. Hip Int 2025; 35:226-238. [PMID: 40091165 DOI: 10.1177/11207000251317891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2025]
Abstract
INTRODUCTION The unnecessary over-ordering of routine pre-transfusion tests (blood typing, screening, and cross-matching) for surgical cases results in substantial avoidable costs and imposes an undue burden on transfusion services. This study specifically focuses on conducting a systematic review of the literature to assess the necessity of routine pre-transfusion tests before total hip arthroplasty (THA) and aims to provide a comprehensive summary of the outcomes associated with this practice. METHODS A systematic review and meta-analysis were conducted to analyse the study's characteristics, assess the prevalence of over-ordering, defined as ordering more routine pre-transfusion tests than clinically necessary, examine transfusion rates, and evaluate potential cost savings to the healthcare system. RESULTS The study included 12,178 patients. Pooled results revealed an 88.1% over-ordering pre-transfusion test rate (95% CI, 0.80-0.96; p < 0.001) among patients undergoing primary THA. The pooled prevalence of hospital transfusion rate was 11.9%, with a percentage of intraoperative transfusion of 0.4% (95% CI, 0.001-0.007; p = 0.007). There were statistically significant differences in preoperative haemoglobin (Hb) levels between patients not requiring 14.1 g/dl (95% CI, 13.2-14.9; p < 0.001) and those needing transfusion 11.9 g/dl (95% CI, 10.9-12.9; p < 0.001) (p < 0.001). The per-patient total cost savings ranged from 2.10 to 191.27 dollars. CONCLUSIONS Our findings indicate that routine pretransfusion testing for all patients undergoing primary THA may be unnecessary. We recommend restricting pre-transfusion test orders to patients with preoperative haemoglobin levels below 12 g/dl specifically in the context of unilateral primary THA, always considering individual patient and surgical risk factors. This focused approach has the potential to yield substantial cost savings for healthcare systems and transfusion services by mitigating the unnecessary over-ordering of pre-transfusion tests associated with these surgical procedures.
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Affiliation(s)
- Jorge H Nuñez
- Department of Orthopaedic Surgery, University Hospital of Mutua de Terrassa, Barcelona, Spain
- Artro-Esport, Centro Médico Teknon, Barcelona, Spain
- Department of Surgery University of Barcelona, Barcelona, Spain
| | - Berta Escudero
- Department of Orthopaedic Surgery, University Hospital of Mutua de Terrassa, Barcelona, Spain
- Department of Surgery University of Barcelona, Barcelona, Spain
| | - Juan Diego Montenegro
- Department of Orthopaedic Surgery, University Hospital of Mutua de Terrassa, Barcelona, Spain
- Department of Surgery University of Barcelona, Barcelona, Spain
| | | | - Agusti Bartra-Ylla
- Department of Surgery University of Barcelona, Barcelona, Spain
- Hip Unit, Department of Orthopaedic Surgery, University Hospital of Mutua de Terrassa, Barcelona, Spain
| | - Francesc Angles-Crespo
- Department of Surgery University of Barcelona, Barcelona, Spain
- Hip Unit, Department of Orthopaedic Surgery, University Hospital of Mutua de Terrassa, Barcelona, Spain
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Howgate DJ, Austin RP, Bingham JS, Spangehl MJ, Clarke HD. Routine Postoperative Hemoglobin and Hematocrit Tests Are Unnecessary Following Primary Total Hip and Knee Arthroplasty. Arthroplast Today 2024; 30:101502. [PMID: 39959365 PMCID: PMC11827069 DOI: 10.1016/j.artd.2024.101502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 07/01/2024] [Accepted: 08/09/2024] [Indexed: 02/18/2025] Open
Abstract
Background Acute blood loss and transfusion are recognized risks factors of total hip (THA) and total knee arthroplasty (TKA). This study aimed to investigate the clinical value of immediate postoperative hemoglobin and hematocrit (H&H) tests following primary elective THA and TKA. Methods This retrospective observational study was undertaken at a single academic hospital. Medical records were reviewed for a consecutive series of patients undergoing primary elective THA and TKA over a 12-month period. Patient demographic data; the use of preoperative anticoagulants; preoperative and postoperative blood test results; and the incidence of postoperative allogenic blood transfusion (ABT) were collected. The primary outcome measure was the incidence of postoperative ABT prescribed in response to the immediate postoperative H&H result. Results Overall, 367 eligible patients were included, with 167 THA (46%) and 200 TKA (54%) cases. Only 3 patients (0.8%) received a postoperative ABT; none on the day of surgery or on postoperative day 1. Immediate postoperative H&H tests were drawn in 246 patients (67%), but it did not influence clinical decision-making with regards to transfusion. No significant differences in ABT were observed in relation to patient age, sex, body mass index, operation (THA or TKA), or the use of preoperative anticoagulation medication. The incidence of ABT was significantly higher in patients with a combined preoperative hemoglobin <12.5 g/dL and hematocrit <40.0% (P = .003). Conclusions The incidence of postoperative blood transfusion following primary elective THA and TKA was low at 0.8%. Postoperative H&H tests were drawn in most patients but did not influence clinical management. Immediate postoperative hematological monitoring is unnecessary for most low-risk patients following uncomplicated primary elective THA and TKA.
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Affiliation(s)
| | - Roman P. Austin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
- University of New Mexico School of Medicine, Albuquerque, NM, USA
| | | | | | - Henry D. Clarke
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
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Nuñez JH, Colomina J, Angles F, Pallisó F, Acosta HF, Mateu D, Novellas M. Routine pretransfusion testing before primary total hip or knee arthroplasty are an expensive and wasteful routine. Systematic review and meta-analysis. Arch Orthop Trauma Surg 2024; 144:1585-1595. [PMID: 38416137 DOI: 10.1007/s00402-024-05243-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 02/17/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND The excessive routine ordering of pretransfusion tests (blood typing, screening, and cross-matching) for surgical cases incurs significant unnecessary costs and places an undue burden on transfusion services. This study aims to systematically review the literature regarding the necessity of routine pretransfusion tests before total hip arthroplasty (THA) or total knee arthroplasty (TKA) and summarize their outcomes. STUDY METHODS A systematic review and meta-analysis were performed. The study's characteristics, the prevalence of over-ordering pretransfusion tests, transfusion rates, and potential cost savings to the healthcare system were analyzed. RESULTS The study included 17,667 patients. Pooled results revealed a 96.3% over-ordering pretransfusion test rate (95% CI: 0.92-1.00; p < 0.001) among patients undergoing primary THA or TKA. The pooled prevalence of hospital transfusion rate was 3.6%. Notably, there were statistically significant differences in preoperative hemoglobin (Hb) levels between patients not requiring transfusion (Hb = 13.9 g/dl; 95% CI 12.59-15.20; p < 0.001) and those needing transfusion (Hb = 11.9 g/dl; 95% CI 10.69-13.01; p < 0.001) (p = 0.03). The per-patient total cost savings ranged from 28.63 to 191.27 dollars. DISCUSSION Our study suggests that routine pre-transfusion testing for all patients undergoing primary THA or TKA may be unnecessary. We propose limiting pretransfusion test orders to patients with preoperative hemoglobin levels below 12 g/dl in unilateral primary TKA or THA. This targeted approach can result in significant cost savings for healthcare systems and transfusion services by reducing the over-ordering of pretransfusion tests in these surgical procedures.
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Affiliation(s)
- Jorge H Nuñez
- Department of Orthopedic Surgery, Hospital Universitari Mútua Terrassa, Plaça del Doctor Robert, 5, Terrassa, Barcelona, 08221, Spain.
- Artro-Esport, Centro Médico Teknon, Carrer de Vilana, 12, Barcelona, 08022, Spain.
| | - Jordi Colomina
- Department of Orthopedic Surgery, University Hospital Santa Maria, Gestió de Serveis Sanitaris, Alcalde Rovira Roure, 44, Lleida, 25198, Spain
- Multidisciplinary Research Group in Musculoskeletal Pathology, Fragility and Pain Treatment, Institut de Recerca Biomèdica de Lleida Fundació Dr. Pifarré, IRBLleida, Av Alcalde Rovira Roure 80, Lleida, 25198, Spain
| | - Francesc Angles
- Department of Orthopedic Surgery, Hospital Universitari Mútua Terrassa, Plaça del Doctor Robert, 5, Terrassa, Barcelona, 08221, Spain
- Departament de Cirugia, Universitat de Barcelona, Barcelona, Spain
| | - Francesc Pallisó
- Department of Orthopedic Surgery, University Hospital Santa Maria, Gestió de Serveis Sanitaris, Alcalde Rovira Roure, 44, Lleida, 25198, Spain
- Multidisciplinary Research Group in Musculoskeletal Pathology, Fragility and Pain Treatment, Institut de Recerca Biomèdica de Lleida Fundació Dr. Pifarré, IRBLleida, Av Alcalde Rovira Roure 80, Lleida, 25198, Spain
| | - Héctor F Acosta
- Department of Orthopedic Surgery, University Hospital Santa Maria, Gestió de Serveis Sanitaris, Alcalde Rovira Roure, 44, Lleida, 25198, Spain
- Multidisciplinary Research Group in Musculoskeletal Pathology, Fragility and Pain Treatment, Institut de Recerca Biomèdica de Lleida Fundació Dr. Pifarré, IRBLleida, Av Alcalde Rovira Roure 80, Lleida, 25198, Spain
| | - David Mateu
- Departament de Cirugia, Universitat de Barcelona, Barcelona, Spain
- Department of Orthopaedic Surgery, Consorci Sanitari Integral, Hospital Moisés Broggi, Sant Joan Despí, Barcelona, 08970, Spain
| | - Marga Novellas
- Department of Anaesthesiology, Hospital Universitari Mútua Terrassa, Plaça del Doctor Robert, 5, Terrassa, Barcelona, 08221, España
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Volin J, Daniel J, Walter B, Herndon P, Tran D, Blumline J, Spillinger A, Karabon P, Fletcher C, Folbe A, Hafron J. Cost-effectiveness of routine type and screens in select urological surgeries. Int Urol Nephrol 2023; 55:823-833. [PMID: 36609935 DOI: 10.1007/s11255-022-03452-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE To evaluate the cost-effectiveness of obtaining a preoperative type and screen (T/S) for common urologic procedures. METHODS A decision tree model was constructed to track surgical patients undergoing two preoperative blood ordering strategies as follows: obtaining a preoperative T/S versus not doing so. The model was applied to the National (Nationwide) Inpatient Sample (NIS) data, from January 1, 2006 to September 30, 2015. Cost estimates for the model were created from combined patient-level data with published costs of a T/S, type and crossmatch (T/C), a unit of pRBC, and one unit of emergency-release transfusion (ERT). The primary outcome was the incremental cost per ERT prevented, expressed as an incremental cost-effectiveness ratio (ICER) between the two preoperative blood ordering strategies. A cost-effectiveness analysis determined the ICER of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500.00. RESULTS A total of 4,113,144 surgical admissions from 2006 to 2015 were reviewed. The overall transfusion rate was 10.54% (95% CI, 10.17-10.91) for all procedures. The ICER of preoperative T/S was $1500.00 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S. CONCLUSION Routine preoperative T/S for radical prostatectomy (rate = 3.88%) and penile implants (rate = .91%) does not represent a cost-effective practice for these surgeries. It is important for urologists to review their institution T/S policy to reduce inefficiencies within the preoperative setting.
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Affiliation(s)
- Joshua Volin
- Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, 48309, USA
| | - Joshua Daniel
- Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, 48309, USA
| | - Brianna Walter
- Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, 48309, USA.
| | - Patrick Herndon
- Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, 48309, USA
| | - Deanna Tran
- Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, 48309, USA
| | - James Blumline
- Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, 48309, USA
| | - Aviv Spillinger
- Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, 48309, USA
| | - Patrick Karabon
- Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, 48309, USA
| | - Craig Fletcher
- Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, 48309, USA
- Department of Urology, William Beaumont Hospital, Royal Oak, MI, 48073, USA
| | - Adam Folbe
- Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, 48309, USA
- Department of Urology, William Beaumont Hospital, Royal Oak, MI, 48073, USA
| | - Jason Hafron
- Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, 48309, USA
- Department of Urology, William Beaumont Hospital, Royal Oak, MI, 48073, USA
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Nuñez JH, Mateu Vicent D, Anglès F. Letter to the Editor on "Who is Still Receiving Blood Transfusions After Primary and Revision Total Joint Arthroplasty?". J Arthroplasty 2023; 38:e1. [PMID: 36608988 DOI: 10.1016/j.arth.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 09/20/2022] [Accepted: 10/04/2022] [Indexed: 01/06/2023] Open
Affiliation(s)
- Jorge H Nuñez
- Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Universitat de Barcelona, Barcelona, Spain; Artro-Esport, Centro Médico Teknon, Barcelona, Spain
| | - David Mateu Vicent
- Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Universitat de Barcelona, Barcelona, Spain
| | - Francesc Anglès
- Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Universitat de Barcelona, Barcelona, Spain
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DeMik DE, Carender CN, Bedard NA, Glass NA, Callaghan JJ, Brown TS. Response to Letter to the Editor From Nunez et al. J Arthroplasty 2023; 38:e2. [PMID: 36608989 DOI: 10.1016/j.arth.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/02/2022] [Accepted: 10/04/2022] [Indexed: 01/06/2023] Open
Affiliation(s)
- David E DeMik
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | | | | | - Natalie A Glass
- University of Iowa Department of Orthopedics and Rehabilitation, Iowa City, Iowa
| | - John J Callaghan
- University of Iowa Department of Orthopedics and Rehabilitation, Iowa City, Iowa
| | - Timothy S Brown
- Houston Methodist Orthopedics & Sports Medicine, Houston, Texas
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Christopher ZK, Verhey JT, Bruce MR, Bingham JS, Spangehl MJ, Clarke HD, Kraus MB. Routine Type and Screens Are Unnecessary in Primary Total Joint Arthroplasty: Follow-up After a Change in Practice. Arthroplast Today 2022; 19:101077. [PMID: 36605497 PMCID: PMC9807859 DOI: 10.1016/j.artd.2022.101077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 10/31/2022] [Accepted: 11/30/2022] [Indexed: 12/28/2022] Open
Abstract
Background Routine type and screens (T&S) prior to total hip (THA) and total knee arthroplasty (TKA) are common despite low transfusion rates. Our institution implemented a practice change after previously demonstrating a transfusion rate of 1.06%. The purpose of this study is to present the follow-up data 1 year after the practice change of discontinuing routine T&S orders in primary total joint arthroplasty. Methods A practice change was implemented discontinuing routine T&S orders prior to elective primary total joint arthroplasties. We retrospectively reviewed prospectively collected data on preoperative T&S, hemoglobin values, transfusion rates, bleeding disorders, and anticoagulation status. Results A total of 663 patients were included in the study (273 THAs and 390 TKAs). The cumulative transfusion rate was 0.75. No patients received an intraoperative transfusion. Three patients (1.1%) received a postoperative transfusion after THA, and 3 patients (0.5%) received a transfusion after TKA. The mean preoperative hemoglobin in the transfused patients was 12.1 g/dL. Thirteen patients underwent a preoperative T&S (2.0%), and only 2 required transfusion (15.4%). Only 1 patient who required transfusion was on preoperative anticoagulation, and no patients with bleeding disorders required transfusions. Discontinuing routine T&S resulted in an estimated cost savings of $124,325.50. Conclusions Discontinuation of routine T&S did not result in any adverse consequences. If required, T&S can safely be performed intraoperatively or postoperatively. Surgeons may consider obtaining a T&S if their preoperative hemoglobin is less than 11-12 g/dL or if significant blood loss is expected in a complex primary total joint arthroplasty.
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Affiliation(s)
- Zachary K. Christopher
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA,Corresponding author. Department of Orthopedic Surgery, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ 85054, USA. Tel.: +1 480 342 2377.
| | - Jens T. Verhey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Marcus R. Bruce
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - Henry D. Clarke
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Molly B. Kraus
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
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Booth AT, Allen S, Simianu VV, Jensen CC, Schermerhorn ML, George VV, Curran T. Selective type & screen for elective colectomy based on a transfusion risk score may generate substantial cost savings. Surg Endosc 2022; 36:8817-8824. [PMID: 35616730 DOI: 10.1007/s00464-022-09307-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 04/25/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Preoperative type and screen are currently recommended for all patients undergoing colectomy. We aimed to identify risk factors for transfusion and define a low-risk cohort of patients undergoing colectomy in whom type and screen may be safely avoided. METHODS We identified all patients undergoing elective colectomy in the National Surgical Quality Improvement Project-Targeted Colectomy files from 2012 to 2016. Patients transfused preoperatively and those undergoing other concurrent major abdominal procedures were excluded. We compared patients who received blood transfusion on the day of surgery to those who did not. Half of the cohort was randomly selected for development of a points-based model predicting blood transfusion on the day of surgery. This model was then validated using the remaining patients. RESULTS Of 61,964 patients undergoing colectomy, 3128 (5%) patients were transfused with 1290 (2.1%) occurring on the day of surgery. Preoperative anemia was the strongest predictor of blood transfusion on the day of surgery. Among patients with hematocrit > 35%, day of surgery transfusion risk was 0.8%; 99% of patients with hematocrit > 35% had a score 20 or less. Selective type and screen for patients with score ≤ 20 or hematocrit > 35% would avoid type and screen in 91% and 81% of patients, respectively. CONCLUSION Transfusion following elective colectomy is rare and can be accurately predicted by preoperative patient characteristics. Selective type and screen based on these parameters have the potential to prevent operative delays and lower cost.
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Affiliation(s)
- Alexander T Booth
- Department of Surgery, Medical University of South Carolina, 30 Courtenay Drive, Suite 249, MSC 295, Charleston, SC, 29425, USA
| | - Shelby Allen
- Department of Surgery, Medical University of South Carolina, 30 Courtenay Drive, Suite 249, MSC 295, Charleston, SC, 29425, USA
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | | | - Marc L Schermerhorn
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Virgilio V George
- Department of Surgery, Medical University of South Carolina, 30 Courtenay Drive, Suite 249, MSC 295, Charleston, SC, 29425, USA
| | - Thomas Curran
- Department of Surgery, Medical University of South Carolina, 30 Courtenay Drive, Suite 249, MSC 295, Charleston, SC, 29425, USA.
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Spillinger A, Allen M, Karabon P, Hojjat H, Shenouda K, Hussein IH, Jacob JT, Svider PF, Folbe AJ. Cost-Effectiveness of Routine Type and Screens in Select Endonasal Skull Base Surgeries. Skull Base Surg 2022; 83:e449-e458. [DOI: 10.1055/s-0041-1730896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
Abstract
Objective The study aimed to evaluate the cost-effectiveness of obtaining preoperative type and screens (T/S) for common endonasal skull base procedures, and determine patient and hospital factors associated with receiving blood transfusions.
Study Design Retrospective database analysis of the 2006 to 2015 National (nationwide) Inpatient Sample and cost-effectiveness analysis.
Main Outcome Measures Multivariate regression analysis was used to identify factors associated with transfusions. A cost-effectiveness analysis was then performed to determine the incremental cost-effectiveness ratio (ICER) of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500.
Results A total of 93,105 cases were identified with an overall transfusion rate of 1.89%. On multivariate modeling, statistically significant factors associated with transfusion included nonelective admission (odds ratio [OR]: 2.32; 95% confidence interval [CI]: 1.78–3.02), anemia (OR: 4.42; 95% CI: 3.35–5.83), coagulopathy (OR: 4.72; 95% CI: 2.94–7.57), diabetes (OR: 1.45; 95% CI: 1.14–1.84), liver disease (OR: 2.37; 95% CI: 1.27–4.43), pulmonary circulation disorders (OR: 3.28; 95% CI: 1.71–6.29), and metastatic cancer (OR: 5.85; 95% CI: 2.63–13.0; p < 0.01 for all). The ICER of preoperative T/S was $3,576 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S.
Conclusion Routine preoperative T/S does not represent a cost-effective practice for these surgeries using nationally representative data. A selective T/S policy for high-risk patients may reduce costs.
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Affiliation(s)
- Aviv Spillinger
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, Michigan, United States
- Office of Research, Oakland University William Beaumont School of Medicine, Oakland University, Rochester, Michigan, United States
| | - Meredith Allen
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, Michigan, United States
- Office of Research, Oakland University William Beaumont School of Medicine, Oakland University, Rochester, Michigan, United States
| | - Patrick Karabon
- Office of Research, Oakland University William Beaumont School of Medicine, Oakland University, Rochester, Michigan, United States
| | - Houmehr Hojjat
- Department of Otolaryngology—Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Kerolos Shenouda
- Department of Otolaryngology—Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Inaya Hajj Hussein
- Office of Research, Oakland University William Beaumont School of Medicine, Oakland University, Rochester, Michigan, United States
| | - Jeffrey T. Jacob
- Department of Neurosurgery, William Beaumont Hospital, Royal Oak, Michigan, United States
| | - Peter F. Svider
- Department of Otolaryngology, Hackensack University Medical Center, Hackensack, New Jersey, United States
| | - Adam J. Folbe
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, Michigan, United States
- Office of Research, Oakland University William Beaumont School of Medicine, Oakland University, Rochester, Michigan, United States
- Department of Otolaryngology—Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, United States
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Núñez JH, Bosch-García D, Escudero B, Martínez-Peñas J, Omiste I, Alonzo-González F, García de Frutos A, Ramírez M. Is routine blood typing and screening necessary for degenerative cervical spine surgery patients in specialty surgical hospitals? Transfusion 2022; 62:1199-1207. [PMID: 35460279 DOI: 10.1111/trf.16889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/22/2022] [Accepted: 03/27/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Blood loss warranting transfusion is a relatively rare requirement for degenerative cervical spine surgery. Despite this rarity, pretransfusion testing (blood typing, screening, and cross-matching) has become routine in most parts of the world. We sought to determine if such routine testing is necessary for patients who undergo degenerative cervical spine surgery patients in specialty surgical hospitals by (1) measuring the current rate of intraoperative transfusions in degenerative cervical spine surgery and (2) identifying risk factors for transfusions. STUDY METHODS Retrospective review was performed on patients who underwent degenerative cervical spine surgery in two institutions. Demographic and baseline clinical and laboratory data were collected and analyzed to identify predictors of transfusion. Bivariate and multivariate logistic regression analysis was performed to identify perioperative transfusion risk factors. RESULTS Overall transfusion rate was 1.9% (7/372), with no emergent transfusions. Decreases between preoperative and postoperative hemoglobin and hematocrit were 1.4 (SD 1.1) g/dL and 7.2 (SD 4.1) %, respectively. Multivariate logistic regression identified preoperative Hgb lower than 12 gr/dl (OR 27.62; 95% CI 4.31-176.96; p < 0.001) as significant independent transfusion risk factor. The receiver operating characteristic (ROC) curve for the model showed a very good discriminatory power with an area under the curve of 0.91. DISCUSSION Our study suggests that pretransfusion testing for all patients undergoing degenerative cervical spine surgery is unnecessary. We recommend that only patients with preoperative Hgb lower than 12 gr/dl would routinely need pretransfusion testing.
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Affiliation(s)
- Jorge H Núñez
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Barcelona, Spain
| | - David Bosch-García
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Barcelona, Spain
| | - Berta Escudero
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Barcelona, Spain
| | - Judith Martínez-Peñas
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Barcelona, Spain
| | - Irene Omiste
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Barcelona, Spain
| | - Francisco Alonzo-González
- Spine Unit. Department of Orthopedic Surgery, Hospital General de Accidentes Ceibal Del Instituto Guatemalteco de Seguridad Social, Sacatepéquez, Guatemala
| | - Ana García de Frutos
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Vall d' Hebron, Barcelona, Spain
| | - Manuel Ramírez
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Vall d' Hebron, Barcelona, Spain
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11
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Nuñez JH, Mora L, Carbonell C, Barro V, Casaccia M, Pérez M, Minguell J. Is routine blood typing and screening necessary before primary total hip or knee arthroplasty in the 21st century? Transfusion 2022; 62:316-323. [PMID: 35044714 DOI: 10.1111/trf.16796] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 11/18/2021] [Accepted: 12/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Blood loss warranting transfusion is a relatively rare complication of major-joint arthroplasty procedures like total knee arthroplasty (TKA) and total hip arthroplasty (THA). Despite this rarity, pre-transfusion testing (blood typing, screening, and cross-matching) has become routine. We sought to determine if such routine testing is necessary for patients who undergo a primary TKA or THA by (1) measuring the current rate of intraoperative transfusions in primary TKA and THA patients, (2) identifying risk factors for transfusions, and (3) calculating the costs of such blood typing and screening. STUDY METHODS We retrospectively examined the records of 992 patients who underwent primary TKA, THA, or unicompartmental knee arthroplasty (UKA) to identify patients requiring intra-operative or in-hospital postoperative transfusions. Demographic and baseline clinical and laboratory data also were collected and analyzed to identify predictors of transfusion. Cost analysis was performed. RESULTS The rate of intraoperative transfusion was 1.7% (17/992 patients), with rates of 2.1%, 1.6%, and 0% for TKA, THA, and UKA respectively. The in-hospital transfusion rate was 10.3%, with corresponding postoperative transfusion rates of 9.1%, 12.9%, and 2%. The only baseline variable significantly linked to transfusions on multivariable analysis was preoperative hemoglobin level, with preoperative Hgb <12 g/dl predictive of transfusions in both TKA (p = .02) and THA (p = .024) patients. DISCUSSION Our study suggests that pre-transfusion testing for all patients undergoing primary UKA, TKA or THA is unnecessary. We recommend reserving routine pre-transfusion testing for patients with preoperative hemoglobin levels below 12 g/dl.
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Affiliation(s)
- Jorge H Nuñez
- Department of Traumatology and Orthopaedic Surgery, University Hospital of Vall d'Hebron, Barcelona, Spain.,Commission for the Use of Blood and Blood Products, University Hospital of Vall d'Hebron, Barcelona, Spain.,Universidad Autónoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Lidia Mora
- Commission for the Use of Blood and Blood Products, University Hospital of Vall d'Hebron, Barcelona, Spain.,Department of Anesthesiology, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Carla Carbonell
- Department of Traumatology and Orthopaedic Surgery, University Hospital of Vall d'Hebron, Barcelona, Spain.,Universidad Autónoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Víctor Barro
- Department of Traumatology and Orthopaedic Surgery, University Hospital of Vall d'Hebron, Barcelona, Spain.,Universidad Autónoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Marcelo Casaccia
- Department of Traumatology and Orthopaedic Surgery, University Hospital of Vall d'Hebron, Barcelona, Spain.,Universidad Autónoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Marta Pérez
- Department of Traumatology and Orthopaedic Surgery, University Hospital of Vall d'Hebron, Barcelona, Spain.,Universidad Autónoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Joan Minguell
- Department of Traumatology and Orthopaedic Surgery, University Hospital of Vall d'Hebron, Barcelona, Spain.,Universidad Autónoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain
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12
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Nuñez JH, Angles F, Minguell-Monyart J. Letter to the Editor on "In the Era of Tranexamic Acid, Are Type and Screens for Primary Total Joint Arthroplasty Obsolete?". J Arthroplasty 2021; 36:e36-e37. [PMID: 33931151 DOI: 10.1016/j.arth.2021.01.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 01/20/2021] [Indexed: 02/02/2023] Open
Affiliation(s)
- Jorge H Nuñez
- Department of Orthopedic Surgery, University Hospital of Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain; Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Universitat de Barcelona, Terrassa, Barcelona, Spain; Member of the Commission for the Use of Blood and Blood Products, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Francesc Angles
- Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Universitat de Barcelona, Terrassa, Barcelona, Spain; Departament de Cirurgia Universitat de Barcelona, Barcelona, Spain
| | - Joan Minguell-Monyart
- Department of Orthopedic Surgery, University Hospital of Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain
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13
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Christopher ZK, Bruce MR, Reynolds EG, Spangehl MJ, Bingham JS, Kraus MB. Routine Type and Screens Are Unnecessary for Primary Total Hip and Knee Arthroplasties at an Academic Hospital. Arthroplast Today 2020; 6:941-944. [PMID: 33299914 PMCID: PMC7704355 DOI: 10.1016/j.artd.2020.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/05/2020] [Accepted: 10/17/2020] [Indexed: 11/30/2022] Open
Abstract
Background Despite decreasing transfusion rates, routine type and screens are frequently used before primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). The aims of this study were to characterize transfusion rates and identify any factors that affect the likelihood of transfusion to determine if it is safe to discontinue routine preoperative type and screens at an academic hospital. Methods A retrospective chart review was performed for all patients who underwent primary THA or TKA in 2019 at an academic institution by a fellowship-trained arthroplasty surgeon. Data on preoperative type and screens, transfusion rates, bleeding disorders, and anticoagulation status were obtained. Patients were considered to have a preoperative type and screen if it was performed within 30 days before surgery. Results Overall, 379 patients were included in the study. Of these, 210 underwent primary THA and 169 underwent primary TKA. Four patients received transfusions during their hospitalization for a cumulative transfusion rate of 1.06%. No patients received an intraoperative transfusion. One (0.59%) patient received a postoperative transfusion after TKA, and 3 (1.43%) patients received a postoperative transfusion after THA. The mean preoperative hemoglobin of the 4 transfused patients was 10.8 g/dL. Conclusions In summary, performing a preoperative routine type and screen is likely unnecessary at academic medical centers. Consideration for obtaining a type and screen may include complex primary surgeries or when patients have preoperative hemoglobin of less than 11 g/dL. Ultimately, preoperative type and screen should be considered on a case-by-case basis using clinical judgment.
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Affiliation(s)
| | - Marcus R Bruce
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | | | - Mark J Spangehl
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Joshua S Bingham
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Molly B Kraus
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
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Azizgolshani NM, Porter ED, Fay KA, Dunbar NM, Hasson RM, Millington TM, Finley DJ, Phillips JD. Preoperative Type and Screen is Unnecessary in Elective Anatomic Lung Resection and Esophagectomy. J Surg Res 2020; 255:411-419. [PMID: 32619855 PMCID: PMC10750229 DOI: 10.1016/j.jss.2020.05.087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/14/2020] [Accepted: 05/24/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Preoperative type and screen (TS) is routinely performed before elective thoracic surgery. We sought to evaluate the utility of this practice by examining our institutional data related to intraoperative and postoperative transfusions for two common, complex procedures. MATERIALS AND METHODS A single-center, retrospective review of a prospective thoracic surgery database was performed. Patients who underwent consecutive elective anatomic lung resection (ALR) and esophagectomy from January 2015 to April 2018 were included. Perioperative characteristics between patients who received transfusion of packed red blood cells and those who did not were compared. The rates of emergent and nonemergent transfusions were evaluated. Cost data were derived from institutional charges and Centers for Medicare & Medicaid Services fee schedules. RESULTS Of 370 patients, 16 (4.3%) received a transfusion and four (1.1%) were deemed emergent by the surgeons and 0 (0%) by blood bank criteria. For ALR (n = 321), 13 (4.0%) received a transfusion, and four (1.2%) were emergent. For esophagectomies (n = 49), three (6.1%) received a transfusion, and none were emergent. Patients who underwent ALR requiring a transfusion had a lower preoperative hemoglobin (11.7 versus 13.4 gm/dL, P = 0.001), higher estimated blood loss (1325 versus 196 mL, P < 0.001), and longer operative time (291 versus 217 min, P = 0.003) than nontransfused patients. Based on current volumes, eliminating TS in these patients would save at least an estimated $60,100 per year. CONCLUSIONS Emergent transfusion in ALR and esophagectomy is rare. Routine preoperative TS is most likely unnecessary for these cases. These results will be used in a quality improvement initiative to change practice at our institution.
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Affiliation(s)
- Nasim M Azizgolshani
- Geisel School of Medicine, Hanover, New Hampshire; Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Eleah D Porter
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kayla A Fay
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Rian M Hasson
- Geisel School of Medicine, Hanover, New Hampshire; Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Timothy M Millington
- Geisel School of Medicine, Hanover, New Hampshire; Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - David J Finley
- Geisel School of Medicine, Hanover, New Hampshire; Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Joseph D Phillips
- Geisel School of Medicine, Hanover, New Hampshire; Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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Vestermark GL, Rowe TM, Martin JR, Odum SM, Springer BD, Fehring TK. In the Era of Tranexamic Acid, are Type and Screens for Primary Total Joint Arthroplasty Obsolete? J Arthroplasty 2020; 35:2363-2366. [PMID: 32451280 DOI: 10.1016/j.arth.2020.04.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/13/2020] [Accepted: 04/19/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Advances in technique and perioperative blood management have improved transfusion rates following unilateral primary total joint arthroplasty and led some centers to change their preoperative blood ordering protocols. The purpose of this study is to determine whether deleting type and screens (T&S) from preoperative order sets was safe for patients undergoing primary total knee (TKA) and total hip arthroplasty (THA) and to identify patients who required allogenic blood transfusion. METHODS Prospectively collected data were reviewed to identify any patient with a hemoglobin (Hgb) drawn within 30 days of surgery who received a transfusion following a unilateral primary TKA or THA. RESULTS A total of 1255 patients met inclusion criteria. Of the total, 682 (54%) were TKAs and 573 (46%) were THAs. The mean preoperative Hgb was 11.5 g/dL with an average delta Hgb of 3.6 g/dL on postoperative day 1. No patient required an intraoperative transfusion. Fourteen patients (mean age and body mass index, 67.9 and 29.0) required a transfusion (1.1%) for postoperative blood loss anemia. Of those transfused, 13 (93%) of the patients underwent THA with the mean estimated blood loss of 378.6 mL. The total cost for a patient obtaining a T&S is $191.27. CONCLUSION In our series, the risk of blood transfusion was rare (1.1%) and occurred only secondary to postoperative blood loss anemia. There were no cases of intraoperative complication requiring urgent or emergent blood transfusion. Removing T&S from standard order sets for patients undergoing primary TKA or THA appears to be a safe and cost-effective practice.
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Affiliation(s)
| | | | | | - Susan M Odum
- OrthoCarolina Research Institute, Charlotte, NC; Atrium Health Musculoskeletal Institute, Chicago, IL
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