Transfusion Preparedness Strategies for Obstetric Hemorrhage A Cost-Effectiveness Analysis
Transfusion Preparedness Strategies for Obstetric Hemorrhage A Cost-Effectiveness Analysis
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DOI：
10.1097/aog.0000000000002359
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发表时间：
2017-12-01
影响因子：
7.2
通讯作者：
Clark, Erin A. S.
中科院分区：
文献类型：
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作者：
Einerson, Brett D.;Stehlikova, Zuzana;Clark, Erin A. S.
目的：评估预防紧急释放输血的常见产科输血准备策略的成本效益。方法：决策分析模型比较了一般产科人群中五种常用的输血准备策略。患者被分为低、中或高输血风险。最充分的策略是针对高风险患者采用通用型和筛查加交叉配型的策略。其他策略仅使用通用型和筛查、对高危患者使用通用型凝块加交叉配血、仅在高危患者中使用选择性型和筛查，或者不进行常规入院检测。使用从患者水平数据和已发表文献中得出的输血相关成本和概率估计来比较策略。主要结果是每次预防紧急释放输血所增加的成本。如果经专家共识确定，每次避免紧急释放输血的成本低于 1,500 美元，则该策略被认为具有成本效益。紧急释放输血包括通用供体或未与受体交叉配型的特定类型浓缩红细胞。除了基本情况分析之外，我们还使用二阶蒙特卡罗模拟进行了单向和双向敏感性分析以及概率敏感性分析。在成本效益可接受性分析中探讨了支付意愿阈值的变化。该模型是从医院的角度进行的。 结果：在基本案例分析中，与通用保留凝块策略相比，针对高风险患者的通用型和交叉配型筛查策略产生的每次紧急释放输血的增量成本为 115,541 美元。与不进行常规入院检测的策略相比，通用保留凝块策略每次避免紧急释放输血的成本为 2,878 美元。使用通用类型和屏幕的策略在 10,000 次模拟中零次具有成本效益，每次预防的紧急释放输血的支付意愿门槛为 1,500 美元。即使愿意支付超过 10,000 美元来防止紧急释放输血，通用型和筛查策略也不具有成本效益。结论：在各种假设和变量范围内，通用型和筛查的输血准备在一般产科人群中并不具有成本效益。
OBJECTIVE: To evaluate the cost-effectiveness of common obstetric transfusion preparedness strategies to prevent emergency-release transfusions.METHODS: A decision analytic model compared five commonly used transfusion preparedness strategies in a general obstetric population. Patients were classified as being at low, moderate, or high risk for transfusion. The most prepared strategy used a policy of universal type and screen plus crossmatch for high-risk patients. Other strategies used universal type and screen only, universal hold clot plus crossmatch for high-risk patients, selective type and screen only in high-risk patients, or no routine admission testing. Strategies were compared using transfusion-related cost and probability estimates derived from patient-level data and from the published literature. The primary outcome was incremental cost per emergency-release transfusion prevented. A strategy was considered cost-effective if the cost was less than $1,500 per emergency-release transfusion avoided as determined by expert consensus. Emergency-release transfusion included universal donor or type-specific packed red cells that are not crossmatched to the recipient. Along with the base-case analyses, we also conducted one-and two-way sensitivity analyses and probabilistic sensitivity analyses using second-order Monte Carlo simulation. Variability in the willingness-to-pay threshold was explored in a cost-effectiveness acceptability analysis. The model was conducted from a hospital perspective.RESULTS: In the base-case analysis, the strategy of universal type and screen with crossmatch for high-risk patients yielded an incremental cost of $115,541 per emergency-release transfusion prevented compared with a strategy of universal hold clot. The universal hold clot strategy yielded a cost of $2,878 per emergency-release transfusion prevented compared with a strategy of no routine admission testing. Strategies using universal type and screen were cost-effective in zero of the 10,000 simulations at a willingness-to-pay threshold of $1,500 per emergency-release transfusion prevented. Even at willingness to pay greater than $10,000 to prevent an emergency-release transfusion, universal type and screen strategies were not cost-effective.CONCLUSION: Transfusion preparedness with universal type and screen is not cost-effective in a general obstetric population across a wide range of assumptions and variable ranges.