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Understanding and predicting transfusion practice in Australia: use and linkage of existing data to investigate transfusion recipient epidemiology and model blood product demand
thesisposted on 22.05.2017, 04:15 by McQuilten, Zoe Kathleen
Transfusion of blood components is a common and essential part of clinical care; however it is also an area in which evidence to inform practice is lacking, where understanding of current practice is limited and where effects on patient outcomes remain unclear. Transfusion is different from other medical interventions in that its provision relies on donations by non-remunerated volunteers, and the short shelf life of blood products mean that supply must be closely aligned to clinical demand. For these reasons, improved understanding of transfusion practice is required to ensure both optimal use of this limited resource and our ongoing ability to meet clinical demand as our population changes. The research presented in this thesis was designed to explore whether existing sources of routinely and systematically collected data, if linked appropriately, could be used to inform health care policy. The work focused on three areas: cardiac surgery (CS), myelodysplastic syndrome (MDS) and overall clinical red blood cell (RBC) demand. CS was included due to its high use of blood products, the requirement for standardisation of practice, the need for data to inform clinical studies and the availability of an established national registry. MDS was included due to the need for improved population-level data on disease burden and transfusion requirements. Overall clinical RBC demand was selected, as there is a clear requirement for improved data and modelling to assist governments and blood services in clinical supply and contingency planning. The Australian and New Zealand Society of Cardiac and Thoracic Surgeons national CS registry was linked with laboratory information system data to identify predictors for bleeding and transfusion in CS, develop predictive models of RBC transfusion to monitor risk-adjusted transfusion rates, and to evaluate effects of universal leucodepletion in Australian CS patients. To investigate transfusion practice in MDS, the Victorian Admitted Episode Dataset, containing information on all hospital admissions within Victorian hospitals, was linked with the Victorian Cancer Registry. The main findings were a higher incidence of MDS compared with cancer registry reports alone, an increase in hospitalisations with RBC transfusion during the study period, and the association of end organ complications with chronic transfusion. The research highlighted the limitations of cancer registry data for monitoring disease burden in MDS, and the value in linking cancer registry with other population-level data to provide information on healthcare utilisation and patterns of blood use over time. Various data sources that contained information about the indication and urgency of requirement for transfusion were combined to develop a model of RBC clinical demand, which allowed exploration of how triage strategies in shortages of different durations may affect overall RBC use. In the scenario of a 21-day shortage, deferral of transfusion for the least urgent RBC category and elective surgery resulted in only an approximate 10% reduction in RBC demand. The findings of this research provide new information on current Australian transfusion practice, predictors for transfusion and clinical demand for RBCs. This methodology could also be applied to other clinical areas with established national clinical outcome registries or with population-level data.