SELECTIVE TYPE & SCREEN FOR ELECTIVE COLECTOMY BASED ON A TRANSFUSION RISK SCORE MAY GENERATE SUBSTANTIAL COST SAVINGS
Thomas Curran*1, Vlad V. Simianu2, Christine C. Jensen3, Shelby Allen1, Marc L. Schermerhorn4, Virgilio V. George1
1Surgery, Medical University of South Carolina, Charleston, SC; 2Surgery, Virginia Mason, Seattle, WA; 3Surgery, University of Minnesota, Minneapolis, MN; 4Surgery, Beth Israel Deaconess Medical Center, Boston, MA
Background: Preoperative type and screen is currently recommended for all patients undergoing colectomy, yet transfusion risk at the time of colectomy is low. We aimed to identify risk factors for transfusion such that we may define a cohort of patients undergoing colectomy in whom type and screen may be safely avoided which would create an opportunity for cost savings.
Methods: We identified all patients undergoing elective colectomy in the National Surgical Quality Improvement Project (NSQIP) 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 that did not with respect to preoperative characteristics, operative procedure and operative approach. Half of the patients were 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 half of the cohort.
Results: Of 62,061 patients undergoing colectomy, 3,128 (5%) patients were transfused with 41% of transfusions (N = 1,290) occurring on day of surgery. Significant factors in the points-based risk prediction model are shown in the table. This model produced a c-statistic of 0.855 in the derivation set and 0.777 in the validation set. A score of 25 corresponded to an actual and predicted transfusion risk less than 5% with 91% of patients at or below this score (Figure). Among patients with hematocrit > 35, day of surgery transfusion risk was 0.8%; 99% of patients with hematocrit > 35 had a score 25 or less. Selective type and screen for patients with transfusion score < 25 or hematocrit >35 would avoid type and screen in 91% and 81% of patients, respectively. At $100 USD per type and screen, employing these criteria would have the potential to save $5.0 - 5.5 million USD over the study period.
Conclusions: Transfusion following colectomy is rare and can be accurately predicted by preoperative patient and operative characteristics. Selective type and screen based on these parameters has the potential to generate substantial cost savings.
Transfusion risk score
| Points | Points | ||
| Age (years) - 18-42 - 43-68 - > 69 | . 0 2 4 | Wound class - II - III - IV | . 3 7 9 |
| Chronic nursing home | 5 | Open procedure (intent to treat) | 6 |
| ASA class 3+ | 5 | Lysis of adhesions | 3 |
| Preoperative chronic kidney disease | 2 | Preoperative hematocrit - <25 - 25-30 - >30-35 - >35 | . 23 17 8 0 |
| Cancer diagnosis | 4 |
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