تجزیه و تحلیل به حداقل رساندن هزینه قبل از عمل جراحی اریتروپویتین در مقابل اهدای خون اتولوگ و آلوژن در آرتروپلاستی مفصل کل

Autologous blood donation and erythropoietin (EPO) have been shown to be effective in reducing allogeneic blood transfusion, but the cost-effectiveness of these interventions remains unclear. A cost minimization analysis was performed, comparing the total costs of allogeneic blood transfusion strategy and autologous and allogeneic blood transfusion strategy for 161 primary total hip arthroplasty (THA) and 195 total knee arthroplasty (TKA) patients. An EPO cost minimization model was constructed using a previously published algorithm for blood management after total joint arthroplasty. The least costly strategy was autologous blood donation in combination with allogeneic blood for THA and TKA patients at $856 and $892 per patient, respectively. The most costly strategy was allogeneic only at $1769 and $1352 per THA and TKA patient, respectively. The EPO strategy model predicted costs similar to the autologous and allogeneic. A strategy that combines autologous blood donation with EPO for patients who cannot donate autologous blood may provide the greatest cost savings and minimize allogeneic blood transfusion.

Our Medical Center Decision Support System was used to identify patients who underwent unilateral primary THA or TKA at our institution during an 11-month period (July 1, 2005, to May 31, 2006). Revision and bilateral procedures were excluded. Clinical laboratory electronic records were used to identify hemoglobin values. Blood bank electronic records were used to determine units transfused. Costs of allogeneic and autologous blood donation were obtained through our Medical Center Blood Bank and charge master. Costs of nursing time and administration were also included in the analysis. Cost of predonating autologous blood was dependent on where the blood was predonated. Erythropoietin was not used in our patients. A model was constructed using a blood conservation algorithm published by Pierson et al [10] to determine projected EPO use and cost. For THA patients, this model uses preoperative hemoglobin minus expected blood loss + 1 SD (4 g/dL + 1.1 = 5.1 g/dL). For TKA patients, this model uses preoperative hemoglobin minus expected blood loss + 1 SD (3.8 g/dL + 1 = 4.8 g/dL). Patients with estimated postoperative hemoglobin of less than 7 g/dL were modeled to receive EPO. Erythropoietin costs approximately $458 per 40,000 U injection based on our institutional pharmacy. Costs such as RN administration were also included.

Deciding which patients should use preoperative autologous blood donation, allogeneic blood, or preoperative EPO administration remains a clinical dilemma. There have been numerous studies to support the efficacy of both preoperative autologous blood donation and EPO. Our cost minimization analysis demonstrated that the least costly blood management strategy was the use of autologous and allogeneic blood donation for both THA and TKA patients at $856 and $892 per patient, respectively. The allogeneic only blood strategy was the most costly at $1769 and $1352 per THA and TKA patient, respectively. The EPO strategy model predicted costs similar to the autologous and allogeneic blood strategy at $969 and $960 per THA and TKA patient, respectively. Despite the autologous and allogeneic blood only strategy costing the least per patient, there was a large number of unused units. Eighty-four (51%) of 166 TKA autologous units and 38 (26%) of 148 of THA autologous units were never used. Therefore, the cost of an autologous unit actually transfused was $587 for TKA and $489 for THA. Several studies have validated the high number of unused autologous blood products in total joint arthroplasty. Bierbaum et al conducted a prospective review of 9482 patients who underwent total joint arthroplasty from 1996 to 1997 by 330 orthopedic surgeons. Forty-six percent (4409/9482) required a blood transfusion, 66% (2890/4409) had autologous blood transfusion, and 34% (1519/4409) had allogeneic blood. Sixty-one percent (5741/9482) predonated blood, but 45% of the predonated blood was not used. Nine percent (503/5741) of patients who predonated blood required allogeneic blood “breakthrough transfusions,” mostly after revision or bilateral procedures [11]. Hatzidakis et al [11] demonstrated an even higher rate of 56% wasted ABD units in their retrospective review of 489 patients who underwent total joint arthroplasty. Reducing the rate of unused autologous units or using the autologous units for other patients could decrease the overall costs of autologous blood donation. Perhaps if the wasted autologous units were screened similar to allogeneic blood, the wasted units could be used for allogeneic transfusion for other patients. Although this would increase the cost of the autologous blood, it could help address blood bank shortages. It should also be noted that autogenous blood donation may not be feasible for patients with coronary artery disease or anemia, and may induce anemia and lead to higher transfusion rates in other patients. Further cost savings could be achieved by better identifying patients, especially TKA patients, who will actually require autologous blood transfusion postoperatively (Fig. 7 and Fig. 8). The lack of strict and uniform transfusion triggers is a limitation of the study and certainly could affect the rate of the blood transfusions. Because the lowest mean hemoglobin during the hospitalization was 8.4 g/dL and the mean discharge hemoglobin was more than 10 g/dL, it is fair to assume that our goal hemoglobin was close to 10 g/dL. A less aggressive transfusion strategy, such as a goal hemoglobin of more than 8 g/dL, would lower overall autologous and allogeneic transfusions and result in decreased costs. Our cost minimization analysis showed that preoperative EPO would be significantly less costly than allogeneic blood transfusion and could save $800 per THA patient and $392 per TKA patient. Significant cost savings could be achieved by using preoperative EPO for patients who are unwilling or unable to predonate blood before surgery. A strategy that properly screens patients and combines autologous blood donation and EPO might reduce overall costs and greatly limit allogeneic blood exposure. Further studies are needed to evaluate this.