Purpose: To explore peri-operative bleeding and its relationship with patient morbidity, mortality and increased healthcare costs in India.
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-seven studies were included in this systematic review. The incidence of significant peri-operative bleeding events in India ranged from 1–6.4%. The median volume of blood loss per procedure was 601 mL (range: 133–7250 mL). The average transfusion volume ranged from 2.5–8.5 units/patient for red blood cells, 0.44–7 units/patient for fresh frozen plasma, and 0.46–6.6 units/patient for platelets. Peri-operative bleeding was associated with increased mortality, infection rates, re-operations, and conversion to open surgery. Studies found that approximately 10% of recipients develop transfusion transmitted infections (TTIs) such as HIV, hepatitis B and C. Patients with peri-operative bleeding had an increased hospital stay of 4–5 days, this equates to additional costs of US$320. Pre-operative over-ordering of blood further adds to the burden to the healthcare system. Studies in India reported cross-match to transfusion (C:T) ratio of 2.1–10, indicating that up to 90% of ordered blood are wasted.
Conclusion: This review has identified several areas in which peri-operative bleeding may be associated with increased patient morbidity, mortality and costs to the Indian healthcare system. This includes the increased need for transfusions, risk of complications and extended hospital stay. TTIs such as HIV have severe implications for the patient and result in substantial lifetime costs to the health care system. The high rate of TTIs in India has been attributed to the high proportion of donated blood from replacement donors, where the prevalence of infections is higher, compared to non-remunerated voluntary donors. The over-ordering of blood was also found to be common practice in India and represents a costly waste of a scarce resource. Consequently, strategies and interventions that reduce bleeding-related complications and the use of blood products may improve resource utilisation and the efficiency of the healthcare system in India.
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