BACKGROUND: Anemia is common in patients presenting for elective surgery and is predictive of poor postoperative outcomes and increased resource utilization. Preoperative anemia is one of the strongest predictors of perioperative blood transfusion, which imposes a significant financial burden on health institutions. Costs associated with transfusion are estimated at $522 to $1183 per unit of packed red blood cells administered. Preoperative erythropoietin and/or iron therapy has been shown to reduce allogeneic blood transfusion (and its attendant costs) associated with major, predominantly orthopedic, surgical procedures. Herein we describe the financial implications of creating a preoperative anemia clinic (PAC) at an academic medical center. Costs associated with clinic implementation included purchasing a point of care hemoglobin monitor (HemoCue America, Brae, California) and test strips, laboratory costs (anemia diagnostic panel), mid-level provider costs (40 patients seen per week representing a full FTE), and costs of providing infusion therapy (venipuncture, infusion, erythropoietin acquisition, and monitoring laboratory tests). Positive cash flows generated by the PAC were defined as cost avoidance through transfusion reduction, and revenue generation through erythropoietin infusion. Costs of transfusion avoided on a per patient basis were determined by multiplying the cost of acquisition of a unit of packed red blood cells by the number of units transfused on average. Revenues per patient from erythropoietin infusion were determined by multiplying revenues per infusion visit by the number of infusion visits per patient.
METHODS: After selecting an orthopedic pilot population, we received IRB approval to perform a retrospective chart review of a random sample of 200 patients that had lower extremity total joint replacement in the previous calendar year to determine their rate of anemia. Conservative initial clinic volume projections were based on health system data describing total joint replacement cases done annually. These assumptions were then compared to existing experience in other PACs for financial evaluations.
RESULTS: Financial modeling of the clinic’s impact on institutional revenue expansion, expense reduction, and cost of implementation both in the first-year pilot population (100 patients) as well as over five years (increasing to 1,000 patients per year with service line expansion) demonstrated a positive net present value of > $100K over 1 year and > $2.5M over five years (range based on transfusion reduction of 25% to 90% of ~ $100K to ~ $200K over 1 year, and ~ $2M to ~ $4M over five years).
DISCUSSION: Improvement in perioperative outcomes in lower extremity total joint replacement is facilitated by reduction in blood product transfusion. As a result, development and implementation of a PAC is predicted to reduce morbidity and mortality in this patient population. Our analysis suggests that doing so will also result in a net institutional financial gain.
