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4 International review of economic analyses In addition to reviewing the evidence for the efficacy and safety of the technologies (2-7), a study was carried out on their cost-effectiveness. However, the cost-effectiveness of these technologies is less certain and is changing because the risks of HIV and hepatitis from allogeneic blood transfusion have decreased markedly during the last decade (226, 227). Some authorities have called for an increase in the use of technologies to minimize allogeneic blood transfusion (228-231), while others have suggested a more cautious approach, pointing out that the cost-effectiveness of some of these technologies appears unattractive (232-234). The purpose of the study was two-fold: 1) to review and compare current knowledge about the cost-effectiveness of these technologies, and 2) to assess the methodological quality of the economic evaluations using explicit, published criteria. This information can be used to design future studies that will determine the most costeffective methods of using these technologies. 4.1 Search strategy and data collection An economic evaluation was a priori defined as a study in which the cost of a technology for decreasing the use of perioperative allogeneic blood was compared with a control group receiving allo- TECHNOLOGIES: Aprotinin Desmopressin TXA = Tranexamic acid EPO = Erythropoietin ANH = Acute normovolemic hemodilution Autotransfusion/CS = Autotransfusion/cell salvage PAD = Preoperative autologous donation 49
50 geneic blood alone. To identify studies, the MEDLINE database from 1966 to March 1998 was searched using the following terms: aprotinin, tranexamic acid, desmopressin, DDAVP, erythropoietin, autologous blood transfusion (MeSH term used), isovolemic hemodilution, normovolemic hemodilution, cell salvage, and autotransfusion. The resulting articles were screened for economic evaluations using two published economic evaluation search “filters” published by Briggs and Sculpher (235) and Elixhauser et al (236). In addition, a key word search using the terms ECON* or COST* was conducted on a Reference Manager (Version 7.00) database of over 8500 MEDLINE references retrieved by the International Study of Perioperative Transfusion (ISPOT). A supplemental EMBASE search restricted to English language journal articles which provided an abstract was performed for the years 1980 to January 1998. For final inclusion into this review, retrieved studies had to: 1) compare the costs of at least two perioperative transfusion strategies; 2) include the use of allogeneic blood alone in one of the study arms; and 3) indicate that the economic evaluation of the technology was one of the main objectives of the paper. To meet the third criteria, papers had to present costing methodology in the “methods” section and the results of the economic evaluation in the “results” section. All economic evaluations were divided into one of four types, depending on how the outcome was measured: cost-comparison (only costs were compared), cost-effectiveness (outcomes were measured in “natural units” such as cost per allogeneic transfusion avoided), cost-utility (outcomes were measured as values or utilities), and cost-benefit (outcomes were converted into monetary units)(237). Studies were reviewed independently in an unblinded fashion by two investigators using forms developed for this review. The following was determined for each study: a) the methodology and outcomes used to determine effectiveness; b) the resources considered and their method of valuation; c) whether a transfusion threshold was used and adhered to and d) the author’s interpretation of the results. The quality of study reporting for all evaluations was then assessed using guidelines developed by the British Medical Journal Economic Evaluation Working Party (238). These guidelines were developed to increase the quality of economic evaluations submitted for publication and are grouped into three subject areas: study design,
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Medicinsk Teknologivurdering 2001;
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2 ALTERNATIVER TIL BLODTRANSFUSION
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4 teknologier til begrænsning af t
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6 6 Holdninger . . . . . . . . . .
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ii anvendelse af særligt udstyr og
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iv Teknologi Klinisk effekt 1) Bivi
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vi blødning efter hjerteoperation,
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viii ❖ For autotransfusion/CS var
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x Autotransfusion/CS Ud fra en klin
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xii
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xiv e.g. saline, and then reinfused
Page 23 and 24: xvi Effects and side effects of the
Page 25 and 26: xviii However, the number of studie
Page 27 and 28: xx ❖ Desmopressin, which was inef
Page 29 and 30: xxii effectiveness identified. Insu
Page 31 and 32: xxiv ❖ The use of blood-saving te
Page 33 and 34: 8 Udover den danske rapport findes
Page 35 and 36: 10 var igennem en alsidig vurdering
Page 37 and 38: 12 1.4 Blodforbrug og risici ved al
Page 39 and 40: 14 terspørges flere og større kli
Page 41 and 42: 16 nymitet mellem donor og patient,
Page 43 and 44: 18 FIGUR 1.1 Forarbejdning af donor
Page 45 and 46: 20 veau. Sundhedsstyrelsen udgav i
Page 47 and 48: 22 Samarbejdet skete dels via løbe
Page 49 and 50: 24 Den danske undersøgelse I Danma
Page 51 and 52: 26 2) Ikke-bruger-skemaer Der blev
Page 53 and 54: 28 sin; tranexamic acid; erythropoi
Page 55 and 56: 30 Aprotinin ISPOT-results (cardiac
Page 57 and 58: 32 Australian update (cardiac and o
Page 59 and 60: 34 ❖ In orthopedic surgery EPO re
Page 61 and 62: 36 Many studies of ANH reported an
Page 63 and 64: 38 PAD ◆ Analyses on the impact o
Page 65 and 66: 40 meta-analysis of ANH, and most o
Page 67 and 68: 42 about 1 to 2 units. Reductions w
Page 69 and 70: 44 such as nausea, diarrhea and abd
Page 71 and 72: 46 Autotransfusion/CS devices shoul
Page 73: 48 ❖ There was, on average, about
Page 77 and 78: 52 Autotransfusion/CS The 8 evaluat
Page 79 and 80: 54 sion, postoperative recovery of
Page 81 and 82: 56 tractive cost-utility ratios if
Page 84 and 85: 5 Anvendelsesmønstre Som led i pro
Page 86 and 87: FIGUR 5.1 Andel af afdelinger/sygeh
Page 88 and 89: Evidensbaseret anvendelse? Mønstre
Page 90 and 91: TABEL 5.2 Brugere og ikke-brugere a
Page 92 and 93: TABEL 5.3 Andel afdelinger inden fo
Page 94 and 95: lev anvendt “rutinemæssigt” el
Page 96 and 97: TABEL 5.6 Anvendelsesform af autotr
Page 98 and 99: Hvem beslutter? Ifølge tabel 5.8 e
Page 100 and 101: 6 Holdninger Ikke-brugeres holdning
Page 102 and 103: TABEL 6.2 Begrundelser for ikke-bru
Page 104 and 105: mærkninger omhandlede i flest tilf
Page 106 and 107: Med hensyn til fremtidig brug af PA
Page 108 and 109: 7 De samlede ISPOT-resultater i et
Page 110 and 111: ingen af omkostningseffektiviteten
Page 112 and 113: gevinst contra omkostninger og andr
Page 114 and 115: 8 Bilag 8.1 ISPOT-gruppen ISPOT-inv
Page 116: Dansk Selskab for Obstetrik og Gyn
Page 119 and 120: 94 (10) Georgsen J, Jensen F, Jeppe
Page 121 and 122: 96 (42) Chalmers TC, Celano P, Sack
Page 123 and 124: 98 (69) Rocha E, Hidalgo F, Llorens
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100 (94) Hardy JF, Belisle S, Coutu
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102 (119) de Andrade JR, Frei D, Yo
Page 129 and 130:
104 (144) Farag SS, Perkins A, Hamm
Page 131 and 132:
106 (172) Eng J, Kay PH, Murday AJ,
Page 133 and 134:
108 (199) Heiss MM, Fasol-Merten K,
Page 135 and 136:
110 (229) Practice Guidelines for b
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112 (259) Lægemiddelstatistik, 199
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