Are Type and Screen Samples Routinely Necessary Before Laparoscopic Cholecystectomy?

Cost-effectiveness of routine type and screens in select urological surgeries

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.

Reducing Unnecessary Type and Screens Prior to Thoracic Surgery: A Quality Improvement Initiative

INTRODUCTION

Previous work identified that routine preoperative type and screen (T&S) testing before elective thoracic surgery is overutilized. We hypothesized that instituting a quality improvement (QI) initiative to change practice would significantly reduce this unnecessary testing, reduce costs, and improve healthcare efficiency.

MATERIALS AND METHODS

A QI initiative was developed at a single, academic center to reduce empiric T&S ordering before elective anatomic lung resections. Two interventions were implemented: 1) education based on current institutional data and 2) an electronic medical record order set modification. Utilization of T&S testing, blood transfusion data, and perioperative outcomes were tracked and compared between a preintervention group (2015-2018) and a postintervention group (2020-2021). Cost data were derived from institutional charges and Centers for Medicare & Medicaid Services fee schedules.

RESULTS

Of the 553 patients included: 420 were in the preintervention group and 133 were in the postintervention group. The rate of routine T&Ss significantly dropped after implementing the QI initiative (97 versus 20%, P ≤ 0.001). Additionally, no difference in blood transfusion rate was observed (4.3 versus 2.3%, P = 0.29), and there were no differences noted in postoperative complications (P = 0.82), 30-day readmission (P = 0.29), or mortality (P = 0.96). Based on current volumes of ∼200 anatomic lung resections/year, estimated cost savings from reducing T&S testing from 97 to 20% would be at least $40,000 a year.

CONCLUSIONS

Our QI initiative significantly reduced the use of routine T&S testing. This practice change was achieved while maintaining excellent outcomes demonstrating routine preoperative T&S testing can be safely reduced in most elective thoracic surgery.

Selective type & screen for elective colectomy based on a transfusion risk score may generate substantial cost savings

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.

Cost-Effectiveness of Routine Type and Screens in Select Endonasal Skull Base Surgeries

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.