SYSTEMATIC REVIEW OF THE ECONOMIC AND EPIDEMIOLOGICAL BURDEN OF BLEEDING-RELATED COMPLICATIONS IN AUSTRALIA

Purpose: To explore peri-operative bleeding and its relationship with patient morbidity, mortality and increased healthcare costs in Australia.

Method: The EMBASE and Medline databases were searched to identify relevant epidemiological and economic studies. To ensure pertinence of the data, only studies published between 1995–2010 were considered. Relevant studies were identified using a priori defined inclusion criteria relating to the patient population, setting and outcomes of interest.

Result: Forty-four studies were included in this systematic review. The incidence of significant bleeding was higher in cardiac surgery (5–16%), while hysterectomy and joint arthroplasty were associated with a lower incidence of bleeding (1.6–2.0%). The mean volume of blood loss ranged from 24–3357 mL. The volume of blood loss was lower following endoscopic and laparoscopic procedures (24–102 mL), while cardiovascular, liver and orthopaedic surgery were associated with greater blood loss (394–3357 mL). Similarly, transfusion volume was found to vary by surgical procedure. The average volume of transfusion was low during knee arthroplasty (0.35 units) compared to hemipelvectomy (7 units packed cells, 4 units fresh frozen plasma). Peri-operative transfusions were associated with an increased risk of medical complications (RR 1.3, p<0.001) and re-operation (RR 1.6, p<0.001). Pre-operative over-ordering and the inappropriate use of blood further adds to the burden of peri-operative bleeding to the healthcare system. Two studies found that between 13–37% of transfusions were inappropriate. One study reported a cross-match to transfusion ratio of 3.6, indicating that only 27% of cross-match blood was actually transfused.

Conclusion: This review has identified several areas in which peri-operative bleeding may increase the burden to the healthcare system. This includes the need for transfusions, risk of complications and higher re-operation rates. The over-ordering and inappropriate use of blood in Australia represents a costly waste of a scarce resource. This practice has been defended on the grounds that it provides a safety margin in the event of massive unexpected haemorrhages. Consequently, interventions that reliably reduce peri-operative bleeding may give clinicians the confidence to reduce over-ordering of blood products. Furthermore, strategies that decrease bleeding-related complications and the use of blood products would improve resource utilisation and the efficiency of the healthcare system in Australia.