A cost-effectiveness evaluation of preoperative type-and-screen testing for vaginal hysterectomy

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.

The clinical utility of routine postoperative hemoglobin and creatinine after reconstructive surgery for apical pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Postoperative laboratory tests are routinely ordered after apical prolapse repair on asymptomatic patients. We hypothesize that routine serum hemoglobin (Hb) and creatinine (Cr) have limited clinical utility in the postoperative period in asymptomatic patients.

METHODS

This is a retrospective cohort study of patients who underwent surgical repair of apical prolapse between 2017 and 2019 at our institution. Subjects were divided into two groups postoperatively: symptomatic and asymptomatic anemia. Symptomatic patients were defined as having one or more of the following: blood pressure (BP) <90/60, heart rate (HR) >100, urine output <30 cc/h, subjective dizziness, flank pain, or abdominal pain. The primary aim was to evaluate the utility of postoperative serum Hb and Cr in symptomatic and asymptomatic patients. Fisher's exact and Mann-Whitney tests analyzed categorical and continuous data respectively. A total of 325 patients were included.

RESULTS

Patients with symptomatic anemia had a larger decrease in Hb on postoperative day 1 (POD1) with a mean decrease of -18.11% (± 6.64) compared with asymptomatic patients, who had a mean difference of -15.49% (± 5.63; p < 0.001). The total cost of tests evaluating Hb was US$61,745. Patients with symptomatic acute kidney injury had an increase in Cr on POD1 compared with asymptomatic patients, with a mean increase of 0.23% (± 16.06) and -3.07% (± 13.10) respectively (p < 0.05). The total cost of tests including Cr was US$131,812.

CONCLUSIONS

Our results indicate that routine postoperative Hb and Cr testing for apical prolapse should be reserved for symptomatic patients as it has minimal clinical value in asymptomatic patients and contributes to increased overall health care cost.

Perioperative group and save testing are not routinely indicated for emergency laparoscopic appendicectomy and laparoscopic hernia repairs: A North West London retrospective study

INTRODUCTION

Two valid group and saves are commonly required for patients undergoing laparoscopic appendicectomy and laparoscopic hernia repairs preoperatively; however, perioperative blood transfusions are seldom required. This is financially burdensome and frequently leads to delays in theatre lists. We performed a retrospective analysis to investigate blood transfusions performed perioperatively and within 28 days of these procedures.

METHOD

We used our electronic records to collect data of all laparoscopic appendectomies and laparoscopic hernia repairs between March 2017 and March 2021. Patients of any age undergoing these operations were included. Patients requiring concomitant intra-abdominal surgery or who had incomplete medical records were excluded.

RESULTS

A total of 1891 patients were included, of which 1462 (77.3%) had a laparoscopic appendicectomy versus 429 (22.7%) who had a laparoscopic hernia repair. In all, 3507 group and saves were taken costing £47,398.50. One patient (0.068%) required emergency blood transfusion (4 units of red cells) secondary to major haemorrhage.

CONCLUSION

Our findings demonstrate that the incidence of perioperative blood transfusions for laparoscopic appendicectomy and laparoscopic hernia repairs is low, challenging the indication for routine preoperative group and saves.

Routine group and save screening prior to emergency laparoscopic surgery

INTRODUCTION

Two group and save (G&S) samples are routinely collected from patients undergoing diagnostic laparoscopy and/or emergency appendicectomy. We aimed to identify the necessity of this practice by looking at the perioperative transfusion rates.

METHODS

Data were obtained from our electronic theatre system for all patients who underwent emergency laparoscopic surgery (specifically diagnostic laparoscopy and/or laparoscopic appendicectomy) between January 2017 and December 2018. Records were reviewed for the number of G&S samples sent and perioperative transfusion rates.

RESULTS

A total of 451 patients were included in the study. The numbers of procedures performed in 2017 and 2018 were 202 (44.8%) and 249 (55.2%), respectively. The total number of samples sent was 930. Only 786 (84.5%) samples were processed and the rest were rejected for various reasons. Of the 451 patients included in the study, 308 (68.3%) had two G&S samples sent, whereas 41 patients (9.1%) had only one G&S sample sent. Fifty-six (12.4%) and 20 (4.4%) patients had three and four G&S samples sent, respectively. Only two patients required transfusion perioperatively (0.4%), and the indication in both was irrelevant to the primary operation.

CONCLUSIONS

These results demonstrate a near-zero transfusion rate in this patient cohort. Omitting G&S is safe and potentially saves time and resources.

Examining the Utility and Cost of Routine Type and Screen Prior to Minimally Invasive Hysterectomy

Background and Objectives:

Pre-operative type and screen (T&S) is typically obtained if a patient is expected to require a blood transfusion; however, in cases of minimal blood loss, routine T&S may be unnecessary. The objective of our study was to examine the utility and cost of routine pre-operative T&S prior to minimally invasive hysterectomies (MIH).

Methods:

We performed a retrospective chart review of all MIH from January 1, 2018 to December 31, 2019. Patient demographics and surgical parameters were abstracted. The proportion of MIH with a preoperative T&S was compared to the rate of peri-operative blood transfusion. Statistical tests were used where appropriate. Logistic regression was used to examine the relationship between pre-operative hemoglobin (Hgb) and peri-operative transfusion.

Results:

Patients (n = 307) with a mean age of 54 (standard deviation = 12.6) underwent MIH. T&S was ordered in 42.7% of cases, with 2.9% requiring a blood transfusion. Two-thirds of women receiving a transfusion had a history of anemia (p = .004). Women with a pre-operative Hgb < 10.6 gm/dL (n = 30) had a 27% probability of a transfusion, while those with a pre-operative Hgb > 10.6 gm/dL (n = 264) had a 99% probability of no transfusion. A T&S costs ∼$190 at our institution; if routine T&S was eliminated prior to MIH, cost savings is projected to be ∼$11,590 annually.

Conclusion:

Approximately 42.7% of MIH had T&S ordered, but only 2.9% received transfusions. Most patients who required a transfusion had a history of anemia. Significant cost savings could be incurred if routine T&S was eliminated prior to MIH.

Preoperative Type and Screen is Unnecessary in Elective Anatomic Lung Resection and Esophagectomy

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.

An audit of perioperative blood transfusions in a regional hospital to rationalise a maximum surgical blood ordering schedule

Appropriate preoperative blood typing and cross-matching is an important quality improvement target to minimise costs and rationalise the use of blood bank resources. This can be facilitated using a maximum surgical blood ordering schedule (MSBOS) for specific operations. It is recommended that individual hospitals develop a site-specific MSBOS based on institutional data, but this is challenging in non-tertiary centres without electronic databases. Our aim was to audit our perioperative blood transfusions to develop a site-specific MSBOS. A retrospective audit of blood transfusions in surgical patients in our regional referral hospital was conducted using five years' coded administrative data. Procedures with higher transfusion rates warranting preoperative testing (type and screen with or without subsequent cross-matching) were identified. There were about 15,000 eligible surgical procedures performed in our institution over the audit period. The need for preoperative testing was identified for only a few procedures, namely laparotomy, bowel resection, major amputation, joint arthroplasty, hip/femur fracture and humerus surgery, and procedures for obstetric complications. We observed a reduction in transfusion rates over time for total joint arthroplasty. The use of coding data represents an efficient method by which centres without electronic anaesthesia information management systems can conduct large-scale audits to develop a site-specific MSBOS. This would represent a significant improvement for hospitals that currently base preoperative testing recommendations on expert opinion alone. As many procedures in regional centres have very low transfusion rates, hospitals with a similar case mix to ours could consider selectively auditing higher-risk operations where local data is most likely to alter testing recommendations.

The incidence of transfusion and associated risk factors in pelvic reconstructive surgery

BACKGROUND

Almost 400,000 female pelvic reconstructive operations were performed in 2010 for urinary incontinence and pelvic organ prolapse in the United States, and it is likely that this will continue to increase each year. There is a lack of population-based data evaluating the risk of blood transfusion after urogynecologic procedures.

OBJECTIVE

We sought to assess the incidence of blood transfusion related to pelvic reconstructive surgery in a large national surgical quality database and to identify transfusion-associated risk factors.

STUDY DESIGN

This retrospective cohort study was performed using the National Surgical Quality Improvement Program database from the years 2010 through 2014. All women undergoing surgery for pelvic floor disorders were identified by Current Procedural Terminology code. Demographic and clinical variables were abstracted. The incidence of blood transfusion was determined. A multivariate logistic regression analysis was performed to identify clinical factors independently associated with blood transfusion.

RESULTS

A total of 54,387 women underwent pelvic reconstructive surgery from 2010 through 2014 in the National Surgical Quality Improvement Program database. Of these subjects, 686 (1.26%) received a blood transfusion. The median age was 57 (range 28-89) years. Of the population, 0.81% was underweight (body mass index <18.5), 27.0% was normal weight (body mass index 18.5-24.9), 35.6% was overweight (body mass index 25-29.9), and 36.7% was obese (body mass index ≥30). The majority of subjects in the study cohort were Caucasian (91.4%) followed by African Americans (4.6%); the remainder included Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander. Hispanic ethnicity was reported in 9.3% of the population. American Society of Anesthesiologists class 1 and 2 represented a majority of the sample (76.5%). Concomitant hysterectomy was performed in 20,735 (38.1%) of the population. In the multivariate analysis, preoperative hematocrit <30% (odds ratio, 13.68; 95% confidence interval, 10.65-17.59), history of coagulopathy (odds ratio, 3.74; 95% confidence interval, 2.50-5.60), and concomitant hysterectomy (odds ratio, 1.77; 95% confidence interval, 1.49-2.12) were factors independently associated with receiving blood transfusion (all P < .05). When compared to American Society of Anesthesiologists class 1, patients who were class 3 (odds ratio, 2.82, P < .01; 95% confidence interval, 2.02-3.93) or class 4 (odds ratio, 6.56, P < .01; 95% confidence interval, 3.65-11.78) were more likely to require a transfusion. When compared to Caucasians, African Americans (odds ratio, 1.73, P < .01; 95% confidence interval, 1.27-2.36) and Hispanics (odds ratio, 1.92, P < .01; 95% confidence interval, 1.54-2.40) were more likely to require a transfusion. In this cohort, overweight (odds ratio, 0.75; 95% confidence interval, 0.62-0.93) and obese (odds ratio, 0.61; 95% confidence interval, 0.49-0.75) subjects were less likely to receive a transfusion. When compared to a vaginal approach, patients who had a minimally invasive approach (odds ratio, 0.63; 95% confidence interval, 0.49-0.83) were less likely to receive a transfusion, while those with an open approach were more likely to receive a transfusion (odds ratio, 5.43; 95% confidence interval, 4.49-6.56). Age was not a risk factor for transfusion.

CONCLUSION

Transfusion after pelvic reconstructive surgery is uncommon. The variables associated with transfusion are preoperative hematocrit <30%, American Society of Anesthesiologists class, bleeding disorders, nonwhite race, Hispanic ethnicity, and concomitant hysterectomy. Recognition of these factors can help guide preoperative counseling regarding transfusion risk after pelvic reconstructive surgery and individualize preoperative preparation.

Non-decent Vaginal Hysterectomy in Rural Setup of MP: A Poor Acceptance

OBJECTIVE

NDVH is a minimally invasive, safe, effective, and economical surgery. Still AH is preferred for benign gynaecological indications. Our study aims to promote NDVH in all technically possible cases by adequate counselling of the patient.

METHODS

This prospective observational study enrolled 100 women seeking hysterectomy for benign gynaecological conditions (excluding prolapse) in a teaching hospital. Women were counselled on the basis of 'PREPARED' questionnaire to assess their awareness about NDVH and were offered NDVH as the proposed surgery and result is analysed.

RESULTS

We observed that there was a little awareness about NDVH and its outcome among the subjects. Ten out of 100 patients refused to perform NDVH after counselling and underwent TAH. Rest of the 90 patients opted for NDVH. Forty out of 90 patients were aware about NDVH, but they were sceptical about the outcome, and 50 were totally unaware. After applying 'PREPARED' questionnaire and counselling, we could motivate them to accept NDVH. It was successful in all cases except one where laparotomy was done for ovarian artery retraction. With no significant post-operative complications, early return to routine activity and low cost of surgery, all patients were satisfied with surgical outcome and improved quality of life.

CONCLUSION

We conclude that patients accept the surgery with open mind after proper counselling and detailing of the procedure. Most of the abdominal hysterectomy can be converted successfully to NDVH in technically feasible cases by experienced hands so adequate training to gynaecology residents is the need of the time. NDVH is economical to the patient as well as for the healthcare system.

Perioperative Laboratory Abnormalities in Gynecologic Oncology Surgical Patients

Background: Laboratory blood testing incurs financial costs and the blood draws can increase discomfort, yet minimal data exists regarding routine testing in gynecologic oncology surgical patients. Additionally, an increasing number of gynecologic oncology surgeries are performed via a laparoscopic approach. Thus, further investigation into perioperative laboratory testing for gynecologic oncology patients is warranted. An increasing number of gynecologic oncology surgeries are performed via a laparoscopic approach. Thus, further investigation into perioperative laboratory testing for gynecologic oncology patients is warranted. Objective: The aims of this study were (1) to evaluate the frequency and etiology of perioperative laboratory test abnormalities in patients undergoing laparoscopic and laparotomy surgery in a gynecologic oncology service, and (2) to establish an evidence-based algorithm to reduce unnecessary laboratory testing. Materials and Methods: A single-institution retrospective study was completed, investigating laparoscopic and laparotomic surgeries over 4 years. Information on preoperative and postoperative laboratory data, surgical parameters, perioperative interventions, and patient demographics was collected. Quality-assurance data were reviewed. Data were tabulated and analyzed using Statistical Product and Service Solutions (SPSS) version 22. A Student's t-test was used to test for group differences for continuous variables with equal variance, the Mann-Whitney–U test for continuous variables when unequal variance was detected, and Pearson's χ² was used to investigate categorical variables of interest. p-Values <0.05 were considered to be statistically significant. Logistic regression was performed to investigate the relationships among multiple predictors and each identified outcome. Results: The study included 481 subjects (168 laparoscopies, 313 laparotomies). Patients undergoing laparoscopy were, on average, younger (53.5 versus 57.4), with lower body mass indexes (29.7 versus 33.0) and lower rates of diabetes (10.7% versus 19.5%), compared to patients undergoing laparotomy. Overall, >98% of patients underwent at least one preoperative and postoperative laboratory test, totaling 8060 preoperative and 5784 postoperative results. The laparoscopy group was significantly less likely to have postoperative metabolic abnormalities or to undergo perioperative blood transfusion. Patients taking an angiotensin-converting-enzyme inhibitor, angiotensin-II–receptor blocker, or diuretic were significantly more likely to have elevated creatinine preoperatively (odds ratio [OR]: 5.0; p < 0.001) and postoperatively (OR: 7.1; p < 0.001), and this remained true for each group when divided by surgical approach. Perioperative complications meeting institutional quality assurance criteria occurred in 1.7% of laparoscopy patients compared to 11.8% of laparotomy patients (p < 0.001); perioperative laboratory testing was not a factor in the diagnosis of these complications. Conclusions: Clinically significant laboratory abnormalities are uncommon and are less likely to be found on routine perioperative testing in gynecologic oncology patients undergoing laparoscopy, compared to patients undergoing laparotomy. This suggests a role for limiting perioperative laboratory blood testing. (J GYNECOL SURG 32:111)

Clinical utility of postoperative hemoglobin level testing following total laparoscopic hysterectomy

OBJECTIVE

To determine the clinical utility of hemoglobin level testing in guiding postoperative care following total laparoscopic hysterectomies performed for benign indications.

STUDY DESIGN

Retrospective cohort study.

RESULTS

A total of 629 women underwent total laparoscopic hysterectomies during the 24 month study period. Only 16 (2.5%) developed symptoms and/or signs suggestive of hemodynamic compromise. When compared to asymptomatic patients, symptomatic patients had a larger decrease in postoperative hemoglobin level (2.66 vs 1.80g/dL, P = .007) and were more likely to undergo blood transfusion, pelvic imaging or reoperation (P < .001). Women with a smaller body mass index and/or higher intraoperative intravenous fluid volume were more likely to have a larger decrease in postoperative hemoglobin level (P < .05). Past surgical history, duration and complexity of the hysterectomy, estimated surgical blood loss, uterine weight, and perioperative use of intravenous ketorolac were not associated with a greater decrease in postoperative hemoglobin (P > .05). Using the University of Pittsburgh Medical Center's annual laparoscopic hysterectomy rate and insurance companies' reimbursement for blood hemoglobin testing, we estimated the national annual cost for hemoglobin testing following total laparoscopic hysterectomy to be $2,804,662.

CONCLUSION

Hemoglobin level testing has little clinical benefit following elective total laparoscopic hysterectomy and should be reserved for patients who develop signs or symptoms suggestive of acute anemia. Heath care cost savings can be substantial if this test is no longer routinely requested following total laparoscopic hysterectomies.

Routine preoperative typing and screening: a safeguard or a misuse of resources

The probability of requiring blood products for cholecystectomy, hernia repair, and appendectomy is low. The authors, therefore, suggest the elimination of routine typing and screening before these procedures.

Objective:

To assess the necessity of routine preoperative type and screen testing before a cholecystectomy, hernia repair, or appendectomy based on the risk of transfusion in our department.

Method:

We conducted a retrospective analysis of the surgical database of patients who underwent a cholecystectomy, a hernia repair, or an appendectomy at Maimonides Medical Center over a 2-year period and examined the number of patients who actually received transfusions either on the day of surgery or on postoperative day 1.

Result:

We examined 3424 patients who underwent a cholecystectomy, hernia repair, or appendectomy over a 2-year period and examined how many patients required an RBC transfusion on the day of surgery or on postoperative day 1. Of our 3424 patients, 11 required a transfusion (1 appendectomy, 5 cholecystectomy, and 5 hernia repair) in the aforementioned time frame. Consequently, the risk of undergoing a transfusion in this perioperative period is 0.32%.

Conclusion:

With this low probability of requiring blood products during or immediately after surgery, our data and supporting literature firmly support the elimination of the routine type and screens before cholecystectomy, hernia repair, and appendectomy without diminishing the quality of patient care.

Do asymptomatic patients require routine hemoglobin testing following uneventful, unplanned cesarean sections?

OBJECTIVE

To determine the clinical usefulness of routine postoperative hemoglobin testing after unplanned, uneventful cesarean sections in low-risk women without any signs or symptoms of anemia and to identify possible risk factors for hemorrhage.

MATERIALS AND METHODS

Retrospective analysis of the charts of all women who underwent non-elective and uneventful cesarean section over 12 months was performed and demographic data, estimated blood loss at surgery, pre- and post-operative hemoglobin values, postoperative symptoms suggesting anemia, and incidence of transfusion were tabulated. Statistical analysis was done with Student t test and Mann-Whitney U test.

RESULTS

A total of 2,450 women were delivered during the study period among whom 743 of them (30.3%) underwent cesarean section. Among the cesarean sections, 421 (56.6%) were found to be unplanned and uneventful operations performed in low-risk women with no postoperative signs or symptoms for anemia. The mean preoperative hemoglobin of the low-risk asymptomatic women was 11.7+/-1.99 g/dl, whereas it was 11.24+/-1.99 g/dl, postoperatively (P<0.001). In 72% of the patients, there was a drop in hemoglobin concentrations, whereas 24.5% experienced an increase and 3.5% showed no change, postoperatively. Only one woman experienced a drop of greater than 30% in hemoglobin concentration. Since the woman did not show any signs of hemodynamic instability or symptoms of anemia, she was not transfused.

CONCLUSION

Our findings suggest that routine hemoglobin testing following uneventful, unplanned cesarean section neither change postoperative management nor determine the patients requiring blood transfusion.

A reduction in type and screen: preoperative prediction of RBC transfusions in surgery procedures with intermediate transfusion risks

In many patients, a 'type and screen' procedure is routinely performed before surgery. However, most patients are not transfused after all. Can we predict, which surgical patients will and will not be transfused, to reduce the number of these investigations? We studied 1482 consecutive surgical patients with intermediate risk for transfusion. Multivariate logistic regression modelling and the area under the Receiver Operating Characteristic curve (ROC area) were used to quantify how well age, gender, surgical procedure, emergency or elective surgery and anaesthetic technique predicted transfusion, and whether the preoperative haemoglobin concentration had added predictive value. Gender, age > or =70 yr, and type of surgery were independent predictors of transfusion, with a ROC area of 0.75 (95% CI: 0.72-0.79). Validating this model with an easily used prediction rule in a second patient population yielded a ROC area of 0.70 (95% CI: 0.63-0.77). With this rule type and screen could correctly be withheld in 35% of these patients. In the remaining 65% of the patients, a further reduction in type and screen investigations of 15% could be achieved using the preoperative haemoglobin concentration. Using a simple prediction rule, preoperative type and screen investigations in patients who have to undergo surgery procedures with intermediate transfusion risk can be avoided in about 50%. This may reduce patient burden and hospital costs (on average: 3 million US$ per 100 000 procedures).

Assessment of perioperative blood transfusion in cardiac surgery using administrative data

We have analysed the blood transfusion requirements in 288 consecutive adult patients undergoing cardiac surgery using data from the discharge reports, coded in accordance with the international disease classification. 114 patients were transfused (39.6%). The transfusion rate was higher in patients with a principal diagnosis of two valve disorders, acute/subacute ischemic heart disease, congenital anomalies, tumour and injuries. All of these had a transfusion rate greater than 50%. Controlling the confounding effects by multivariate logistic regression analysis, there was an adjusted association of the transfusion rate only with the principal diagnosis and with sex, not with type of admission, preoperative anemia, surgical procedure or age.

Managed care and assessment of clinical outcomes

While managed care strategies have been associated with reductions in the utilization of clinical resources, their impact on health care outcomes in general, and women's health services, in particular, remains unclear. This review summarizes recent literature regarding the impact of managed care on clinical resource use, outcomes of women's health services, and cost effectiveness of women's health care processes. Implications of these findings for women's health providers, women's health services and policy, and health services research are discussed.