Abstract
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.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data Availability
All data analyzed during this study are included in this published article and its supplementary information files.
References
Tjaden A, Codispoti N, Yang LC, Pham T. Examining the utility and cost of routine type and screen prior to minimally invasive hysterectomy. JSLS. 2021;25(3):e2021.00020.
Ransom SB, McNeeley SG, Hosseini RB. Cost-effectiveness of routine blood type and screen testing before elective laparoscopy. Obstet Gynecol. 1995;86(3):346–8.
Brueseke TJ, Wilkins MF, Willis-Gray MG, et al. Transfusion rates and the utility of type and screen for pelvic organ prolapse surgery. Female Pelvic Med Reconstr Surg. 2020;26(1):51–5.
Swenson CW, Kamdar NS, Harris JA, Uppal S, Campbell DA Jr, Morgan DM. Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications. Am J Obstet Gynecol. 2016;215(5):650.e1–8.
Ransom SB, McNeeley SG, Malone JM Jr. A cost-effectiveness evaluation of preoperative type-and-screen testing for vaginal hysterectomy. Am J Obstet Gynecol. 1996;175(5):1201–3.
Erekson EA, Yip SO, Ciarleglio MM, Fried TR. Postoperative complications after gynecologic surgery. Obstet Gynecol. 2011;118(4):785–93.
O'Leary BD, Dempsey M, Agnew GJ. Blood transfusion after vaginal hysterectomy for pelvic organ prolapse. Ir J Med Sci. 2019;188(1):265–6.
Geller EJ, Siddiqui NY, Wu JM, Visco AG. Short-term outcomes of robotic sacrocolpopexy compared with abdominal sacrocolpopexy. Obstet Gynecol. 2008;112(6):1201–6.
Unger CA, Paraiso MF, Jelovsek JE, Barber MD, Ridgeway B. Perioperative adverse events after minimally invasive abdominal sacrocolpopexy. Am J Obstet Gynecol. 2014;211(5):547.e1–8.
Stepp KJ, Barber MD, Yoo EH, Whiteside JL, Paraiso MF, Walters MD. Incidence of perioperative complications of urogynecologic surgery in elderly women. Am J Obstet Gynecol. 2005;192(5):1630–6.
Lambrou NC, Buller JL, Thompson JR, Cundiff GW, Chou B, Montz FJ. Prevalence of perioperative complications among women undergoing reconstructive pelvic surgery. Am J Obstet Gynecol. 2000;183(6):1355–8 discussion 1359–60.
Pandya LK, Lynch CD, Hundley AF, Nekkanti S, Hudson CO. The incidence of transfusion and associated risk factors in pelvic reconstructive surgery. Am J Obstet Gynecol. 2017;217(5):612.e1–8.
Geifman-Holtzman O, Wojtowycz M, Kosmas E, Artal R. Female alloimmunization with antibodies known to cause hemolytic disease. Obstet Gynecol. 1997;89(2):272–5.
Saverimuttu J, Greenfield T, Rotenko I, Crozier J, Jalaludin B, Harvey M. Implications for urgent transfusion of uncrossmatched blood in the emergency department: the prevalence of clinically significant red cell antibodies within different patient groups. Emerg Med (Fremantle). 2003;15(3):239–43.
Mulay SB, Jaben EA, Johnson P, Badjie K, Stubbs JR. Risks and adverse outcomes associated with emergency-release red blood cell transfusion. Transfusion. 2013;53(7):1416–20.
Goodell PP, Uhl L, Mohammed M, Powers AA. Risk of hemolytic transfusion reactions following emergency-release RBC transfusion. Am J Clin Pathol. 2010;134(2):202–6.
Eder AF, Chambers LA. Noninfectious complications of blood transfusion. Arch Pathol Lab Med. 2007;131(5):708–18.
Sanders GD, Neumann PJ, Basu A, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine. JAMA. 2016;316(10):1093–103.
Husereau D, Drummond M, Augustovski F, et al. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. BJOG. 2022;129(3):336–44.
Centers for Medicare & Medicaid Services. Clinical Laboratory Diagnostic Fee Schedule. https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs. Accessed 23 February 2021.
Centers for Medicare & Medicaid Services. MS-DRG Classifications and Software. https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/ms-drg-classifications-and-software. Accessed 23 February 2021.
Centers for Medicare & Medicaid Services. Physician Fee Schedule. https://www.cms.gov/medicare/payment/fee-schedules/physician/lookup-tool. Accessed February 23, 2021.
Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York State: an analysis of 10 years' experience. Transfusion. 2000;40(10):1207–13.
Harvey AR, Basavaraju SV, Chung KW, Kuehnert MJ. Transfusion-related adverse reactions reported to the National Healthcare Safety Network Hemovigilance Module, United States, 2010 to 2012. Transfusion. 2015;55(4):709–18.
Linden JV, Paul B, Dressler KP. A report of 104 transfusion errors in New York State. Transfusion. 1992;32(7):601–6.
Panch SR, Montemayor-Garcia C, Klein HG. Hemolytic transfusion reactions. N Engl J Med. 2019;381(2):150–62.
Kumar R, Malapati S, Singh SRK, Mamedov B, Shah MR, Bhandari S. Incidence and outcomes of acute transfusion reactions in hospitalized patients in the United States. Blood. 2020;136(Suppl 1):30–1.
Spackman E, Sculpher M, Howard J, et al. Cost-effectiveness analysis of preoperative transfusion in patients with sickle cell disease using evidence from the TAPS trial. Eur J Haematol. 2014;92(3):249–55.
Vamvakas EC, Blajchman MA. Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention. Blood. 2009;113(15):3406–17.
Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness—the curious resilience of the $50,000-per-QALY threshold. N Engl J Med. 2014;371(9):796–7.
Fenwick E, Byford S. A guide to cost-effectiveness acceptability curves. Br J Psychiatry. 2005;187:106–8.
Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522–38.
Frank SM, Oleyar MJ, Ness PM, Tobian AA. Reducing unnecessary preoperative blood orders and costs by implementing an updated institution-specific maximum surgical blood order schedule and a remote electronic blood release system. Anesthesiology. 2014;121(3):501–9.
Stanhiser J, Chagin K, Jelovsek JE. A model to predict risk of blood transfusion after gynecologic surgery. Am J Obstet Gynecol. 2017;216(5):506.e1–e14.
Kirschen GW, Dayton SM, Blakey-Cheung S, Pearl ML. Which patients on a gynecologic oncology service will require perioperative transfusion? A single-center retrospective cohort study. Clin Exp Obstet Gynecol. 2021;48(1):47–52.
Acknowledgements
The authors would like to thank Dr. Manish Dave, who provided insight into management for transfusion reactions, which was used to generate the base case.
Authors’ contributions
K.E. Husk: protocol/project development, manuscript writing/editing; R. Wang: protocol/project development, data analysis, manuscript writing/editing; R.G. Rogers: protocol/project development, manuscript writing/editing; H.S. Harvie: protocol/project development, manuscript writing/editing.
Financial disclaimers
The authors report no financial support for this research. R.G. Rogers receives royalties from UpToDate. K.E. Husk, R. Wang, and H.S. Harvie have no relevant financial relationships to disclose.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
None.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
ESM 1
(DOCX 20 kb)
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Husk, K.E., Wang, R., Rogers, R.G. et al. Is Preoperative Type and Screen High-value Care? A Cost-effectiveness Analysis of Performing Preoperative Type and Screen Prior to Urogynecological Surgery. Int Urogynecol J 35, 781–791 (2024). https://doi.org/10.1007/s00192-023-05696-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00192-023-05696-x