Preoperative Anemia Screening and Treatment: Is It Worth the Return on Investment?

See Article, p 344 The evaluation and targeted treatment of anemia and iron deficiency before elective surgery is considered a pillar of patient blood management (PBM).1,2 Preoperative anemia is the leading risk factor for perioperative blood product transfusion and is strongly and independently associated with adverse perioperative outcomes in children and adults including acute kidney injury, increased hospital length of stay, and higher mortality.3–6 Approximately 40% of patients presenting for major elective surgery are anemic, with substantial variation in anemia prevalence by surgery type. Hence, it is an obvious problem with a straightforward solution. Clinical trials have shown that targeted preoperative treatment of iron deficiency anemia, the leading cause of anemia globally, successfully augments hemoglobin concentrations and reduces perioperative transfusions.7,8 Despite these benefits, data regarding the impact of preoperative anemia screening and treatment on hospital costs and reimbursement remain limited. In the absence of such data, most patients do not receive comprehensive anemia evaluation and treatment before elective surgery,9 despite potential risks associated with substandard preoperative optimization. Having these data would corroborate the return on investment of a comprehensive preoperative anemia program within a hospital-based PBM program. In this issue of Anesthesia& Analgesia, Trentino et al10 present an analysis of changes in hospital costs and reimbursement over a 2-year period following the implementation of a preoperative anemia and suboptimal iron stores clinic for patients undergoing elective colorectal surgery. The authors note several important findings and should be commended for their efforts. First, the implementation of a formal preoperative anemia clinic improved the proportion of patients evaluated for preoperative anemia from 13% to 73% over the study period. Approximately one-third of surgical patients in the postimplementation period were treated with iron replacement therapy for iron deficiency, with a mean posttreatment hemoglobin increment of approximately 1.0 g/dL. This confirms that iron deficiency is common in patients undergoing colorectal surgery and can be addressed with a simple treatment; yet without a dedicated program designed to specifically screen for this condition, many patients proceed to surgery without hematologic optimization. Second, the implementation of a preoperative anemia clinic was associated with a reduction in red blood cell (RBC) transfusion by half, which is consistent with previous literature. Third, anemia screening was associated with downstream cost savings, including improvements in mean net hospital costs (ie, hospital costs minus hospital reimbursement) for rectal surgeries ($7619; 95% confidence interval [CI], $4230-$11,008 Australian Dollar [AUD]) and small and large bowel procedures ($6744;[95% CI, $2430-$11,057 AUD). Notably, a primary strength of this investigation is related to the capture and analysis of actual admission-level hospital costs and associated hospital reimbursement from the Australian national activity-based funding framework rather than cost estimates derived from institutional economic models. This is a welcome addition to the literature because it provides empirical data of changes in hospital costs and reimbursement after preoperative anemia clinic implementation in a tertiary care medical center. To that end, these data suggest that the creation and implementation of a preoperative anemia treatment program may be associated with downstream hospital cost savings in addition to improving the quality of patient care as evidenced by improvement in hemoglobin concentrations, transfusion reductions, and shorter lengths of stay. Despite the new knowledge gained regarding downstream hospital cost savings, substantial gaps remain in our understanding of the cost-effectiveness of preoperative anemia evaluation and treatment programs. One limitation of this work relates to the absence of data on anemia screening, treatment, and administration costs, which impairs our ability to truly determine if preoperative anemia management is cost-effective over the entire episode of care. Fortunately, the authors provide previously published cost estimates for anemia screening. At just over $300 AUD per screened patient, it is likely that the associated decreases in net hospital costs with preoperative anemia evaluation do indeed outweigh the costs of the intervention, which is consistent with previous literature using cost estimates and economic modeling.11 Additionally, the cost savings associated with reductions in the number of transfused blood products were not captured in this investigation; transfusion reductions bringing even greater cost savings.12–14 Second, it is unclear exactly at what point in the patient’s hospital course that savings were experienced. While the authors captured actual admission-level costs for each patient, there was no breakdown for individual costs and reimbursements associated with the hospital admission of interest. As such, it is unclear if cost savings may be secondary to avoidance of downstream complications of anemia, avoidance of increased care complexity in those with perioperative anemia, sequelae of transfusion, shorter hospital stays, or other causes. Third, this study presents data for a limited number of patients with relatively low baseline transfusion rates. It is quite possible that the beneficial effects of anemia treatment, transfusion avoidance, and downstream cost reductions are even greater in high-risk patients. Finally, the study uses a before-after retrospective study design in a single medical center in Western Australia with only a single year of preintervention assessment. Hence, there is a risk for incomplete assessment of baseline hospital costs, unclear generalizability to other health care settings, and the potential for residual confounding in the postimplementation period, which may influence observed changes in hospital costs and reimbursement. While the authors report no substantial changes in clinical practice over the study time frame, the risk for bias is heightened given the observational study design. Despite these limitations, the work by Trentino et al10 highlights the fact that preoperative anemia evaluation and management is feasible and is associated with financial benefits secondary to reduced costs associated with postoperative hospitalization. This information may be particularly useful for institutional stakeholders and hospital leaders whose hospitals have yet to implement evidence-based preoperative anemia evaluation and treatment programs for elective surgery, perhaps dissuaded by the limited data to suggest a financial incentive in doing so. It is important to note that while most of the literature supports the efficacy and effectiveness of preoperative anemia screening and targeted treatment, a recent randomized placebo-controlled trial did not find significant transfusion reduction in all anemic patients randomly assigned to a single dose of intravenous (IV) iron before major abdominal surgery15; however, several limitations should be highlighted: (1) iron therapy was not targeted to iron deficiency; (2) most patients were administered iron 2 weeks before surgery, which may not allow sufficient time for erythropoiesis as evidenced by only 1 of 5 of treated patients achieving anemia resolution; (3) 20% of patients in both arms were already receiving oral iron before randomization; (4) a formal transfusion protocol was not utilized, which complicates the interpretation of a transfusion-based primary outcome; and (5) pretransfusion hemoglobin values were not reported, with concern for liberal transfusions in both arms (ie, approximately 30% transfusion rate). Interestingly, despite these limitations, patients receiving IV iron in this trial had improved hemoglobin recovery through 6 months after surgery and also experienced lower hospital readmission rates for the management of postoperative complications (13% vs 22%). In light of these findings and abundant clinical data showing a clear relationship between preoperative anemia and inferior patient outcomes, optimization of hematologic status with diagnostic evaluations and treatments specifically directed to the underlying cause(s) of anemia before, during, and after elective surgery is clearly the right thing to do for our patients, even if one were to assume a budget neutral effect of preoperative evaluation and treatment. Fortunately, there is an abundance of literature available to guide clinicians and hospital administrators through such anemia optimization efforts.1,16 Future investigations are necessary to fully capture the costs of preoperative anemia screening and treatment and to identify exactly where hospital savings are encountered. Additionally, it is essential that we capture outcomes extending beyond those of hemoglobin optimization and transfusion avoidance, including improvements in patient-centered outcomes and enhanced postoperative recovery. In doing so, we can further optimize the perioperative blood health of our patients to improve clinical outcomes and enhance the long-term financial sustainability of these efforts. So, are preoperative anemia screening and targeted treatment programs worth the return on investment? The answer is a resounding “yes.” DISCLOSURES Name: Matthew A. Warner, MD. Contribution: This author helped write the manuscript. Name: Susan M. Goobie, MD, FRCPC. Contribution: This author helped write the manuscript. This manuscript was handled by: Thomas R. Vetter, MD, MPH.