Preoperative Erythropoietin Alpha Reduces Postoperative Transfusions in THA and TKA but May Not Be Cost-effective
Background Preoperative erythropoietin alpha (EPO) has been shown to be effective at reducing postoperative blood transfusions in total hip arthroplasty (THA) and total knee arthroplasty (TKA); however, treatment with EPO is associated with additional costs, and it is not known whether these costs c...
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| description | Background
Preoperative erythropoietin alpha (EPO) has been shown to be effective at reducing postoperative blood transfusions in total hip arthroplasty (THA) and total knee arthroplasty (TKA); however, treatment with EPO is associated with additional costs, and it is not known whether these costs can be justified when weighed against the transfusion reductions achieved in patients who receive the drug.
Questions/purposes
The purpose of this study is to investigate (1) efficacy of preoperative EPO in reducing postoperative transfusions in TKA and THA; (2) whether patients treated with EPO have reduced length of stay or a different discharge disposition; and (3) whether EPO use reduces overall blood management costs.
Methods
Patients undergoing primary THA or TKA over a 10-month period with preoperative hemoglobin 0.05). No transfusion triggers were used; rather, patients with postoperative hemoglobin |
| doi_str_mv | 10.1007/s11999-014-3819-z |
| format | Article |
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Preoperative erythropoietin alpha (EPO) has been shown to be effective at reducing postoperative blood transfusions in total hip arthroplasty (THA) and total knee arthroplasty (TKA); however, treatment with EPO is associated with additional costs, and it is not known whether these costs can be justified when weighed against the transfusion reductions achieved in patients who receive the drug.
Questions/purposes
The purpose of this study is to investigate (1) efficacy of preoperative EPO in reducing postoperative transfusions in TKA and THA; (2) whether patients treated with EPO have reduced length of stay or a different discharge disposition; and (3) whether EPO use reduces overall blood management costs.
Methods
Patients undergoing primary THA or TKA over a 10-month period with preoperative hemoglobin < 13 g/dL were recommended to be treated preoperatively with EPO. During that time, 80 of 286 (28%) patients met that inclusion criterion and the treating team recommended EPO to all of them; of that group, 24 (30%) opted to take EPO and 56 (70%) opted not to. Patients receiving at least one dose of EPO and those not receiving EPO were compared in terms of transfusion frequency, length of stay and discharge disposition, and overall blood management costs. Demographics, preoperative hemoglobin, and operative blood loss for both groups were similar (p > 0.05). No transfusion triggers were used; rather, patients with postoperative hemoglobin < 10 mg/dL and who were symptomatic despite fluid boluses were transfused. The clinician responsible for transfusing symptomatic patients was blinded to the patient’s EPO treatment status. Costs were defined as direct costs paid or incurred by our institution for EPO, allogeneic blood, and variable costs associated with patient care after THA/TKA. A decision-tree cost analysis was performed using the collected clinical data and cost data collected from our institution; the analysis considered total associated blood management cost for an EPO and a non-EPO strategy with sensitivity analysis of key cost variables.
Results
The proportion of patients receiving transfusions was lower in patients who received EPO than in patients who did not (0% [zero of 24] versus 41% [23 of 56]; p < 0.001). The mean length of inpatient hospital stay (EPO: 3.0 ± 0.4 versus control: 3.3 ± 0.8 days, p = 0.77) and discharge disposition also was not different between the groups. The cost analysis demonstrated that the EPO strategy was more costly compared with no EPO (USD 2632 versus USD 2284) and its cost would need to be less than USD 225/dose for this to change.
Conclusions
EPO reduced the need for postoperative transfusions in high-risk patients undergoing THA and TKA; however, it was not found to be cost-effective in our model. Our model could not consider relatively rare complications of blood transfusions, including disease transmission, deep periprosthetic infections, and transfusion reactions, but if surgeons or patients value avoiding these potential but rare factors highly, this could reasonably influence the decision of whether to use EPO despite our findings that it was not cost-effective.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.</description><identifier>ISSN: 0009-921X</identifier><identifier>EISSN: 1528-1132</identifier><identifier>DOI: 10.1007/s11999-014-3819-z</identifier><identifier>PMID: 25106796</identifier><language>eng</language><publisher>Boston: Springer US</publisher><subject>Aged ; Arthroplasty, Replacement, Hip ; Arthroplasty, Replacement, Knee ; Blood Transfusion - economics ; Blood Transfusion - statistics & numerical data ; Conservative Orthopedics ; Cost-Benefit Analysis ; Decision Trees ; Erythropoietin - economics ; Erythropoietin - therapeutic use ; Female ; Hip ; Humans ; Length of Stay ; Male ; Medicine ; Medicine & Public Health ; Middle Aged ; Orthopedics ; Postoperative Period ; Sports Medicine ; Surgery ; Surgical Orthopedics ; Symposium: 2014 Hip Society Proceedings</subject><ispartof>Clinical orthopaedics and related research, 2015-02, Vol.473 (2), p.590-596</ispartof><rights>The Association of Bone and Joint Surgeons® 2014</rights><rights>The Association of Bone and Joint Surgeons 2015</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c540t-d1ef09c4ae8f567a9490910074e677e57fd347e02cbe17ad6bf57dbb823fb1a43</citedby><cites>FETCH-LOGICAL-c540t-d1ef09c4ae8f567a9490910074e677e57fd347e02cbe17ad6bf57dbb823fb1a43</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4294940/pdf/$$EPDF$$P50$$Gpubmedcentral$$H</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4294940/$$EHTML$$P50$$Gpubmedcentral$$H</linktohtml><link.rule.ids>230,314,723,776,780,881,27901,27902,41464,42533,51294,53766,53768</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/25106796$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Bedair, Hany</creatorcontrib><creatorcontrib>Yang, Judy</creatorcontrib><creatorcontrib>Dwyer, Maureen K.</creatorcontrib><creatorcontrib>McCarthy, Joseph C.</creatorcontrib><title>Preoperative Erythropoietin Alpha Reduces Postoperative Transfusions in THA and TKA but May Not Be Cost-effective</title><title>Clinical orthopaedics and related research</title><addtitle>Clin Orthop Relat Res</addtitle><addtitle>Clin Orthop Relat Res</addtitle><description>Background
Preoperative erythropoietin alpha (EPO) has been shown to be effective at reducing postoperative blood transfusions in total hip arthroplasty (THA) and total knee arthroplasty (TKA); however, treatment with EPO is associated with additional costs, and it is not known whether these costs can be justified when weighed against the transfusion reductions achieved in patients who receive the drug.
Questions/purposes
The purpose of this study is to investigate (1) efficacy of preoperative EPO in reducing postoperative transfusions in TKA and THA; (2) whether patients treated with EPO have reduced length of stay or a different discharge disposition; and (3) whether EPO use reduces overall blood management costs.
Methods
Patients undergoing primary THA or TKA over a 10-month period with preoperative hemoglobin < 13 g/dL were recommended to be treated preoperatively with EPO. During that time, 80 of 286 (28%) patients met that inclusion criterion and the treating team recommended EPO to all of them; of that group, 24 (30%) opted to take EPO and 56 (70%) opted not to. Patients receiving at least one dose of EPO and those not receiving EPO were compared in terms of transfusion frequency, length of stay and discharge disposition, and overall blood management costs. Demographics, preoperative hemoglobin, and operative blood loss for both groups were similar (p > 0.05). No transfusion triggers were used; rather, patients with postoperative hemoglobin < 10 mg/dL and who were symptomatic despite fluid boluses were transfused. The clinician responsible for transfusing symptomatic patients was blinded to the patient’s EPO treatment status. Costs were defined as direct costs paid or incurred by our institution for EPO, allogeneic blood, and variable costs associated with patient care after THA/TKA. A decision-tree cost analysis was performed using the collected clinical data and cost data collected from our institution; the analysis considered total associated blood management cost for an EPO and a non-EPO strategy with sensitivity analysis of key cost variables.
Results
The proportion of patients receiving transfusions was lower in patients who received EPO than in patients who did not (0% [zero of 24] versus 41% [23 of 56]; p < 0.001). The mean length of inpatient hospital stay (EPO: 3.0 ± 0.4 versus control: 3.3 ± 0.8 days, p = 0.77) and discharge disposition also was not different between the groups. The cost analysis demonstrated that the EPO strategy was more costly compared with no EPO (USD 2632 versus USD 2284) and its cost would need to be less than USD 225/dose for this to change.
Conclusions
EPO reduced the need for postoperative transfusions in high-risk patients undergoing THA and TKA; however, it was not found to be cost-effective in our model. Our model could not consider relatively rare complications of blood transfusions, including disease transmission, deep periprosthetic infections, and transfusion reactions, but if surgeons or patients value avoiding these potential but rare factors highly, this could reasonably influence the decision of whether to use EPO despite our findings that it was not cost-effective.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.</description><subject>Aged</subject><subject>Arthroplasty, Replacement, Hip</subject><subject>Arthroplasty, Replacement, Knee</subject><subject>Blood Transfusion - economics</subject><subject>Blood Transfusion - statistics & numerical data</subject><subject>Conservative Orthopedics</subject><subject>Cost-Benefit Analysis</subject><subject>Decision Trees</subject><subject>Erythropoietin - economics</subject><subject>Erythropoietin - therapeutic use</subject><subject>Female</subject><subject>Hip</subject><subject>Humans</subject><subject>Length of Stay</subject><subject>Male</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Middle Aged</subject><subject>Orthopedics</subject><subject>Postoperative Period</subject><subject>Sports Medicine</subject><subject>Surgery</subject><subject>Surgical Orthopedics</subject><subject>Symposium: 2014 Hip Society Proceedings</subject><issn>0009-921X</issn><issn>1528-1132</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2015</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>BENPR</sourceid><recordid>eNp1kVFvFCEUhYnR2LX6A3wxJL74ggIDw_Bist1Ua6zamDXxjTAzl-40szAFpsn218tma60mPhFyv3Muh4PQS0bfMkrVu8SY1ppQJkjVME1uH6EFk7whjFX8MVpQSjXRnP08Qs9SuirXSkj-FB1xyWitdL1A1xcRwgTR5uEG8Gnc5U0MUxggDx4vx2lj8Xfo5w4Svggp_0HX0frk5jQEn3Bh12dLbH2P15-XuJ0z_mJ3-GvI-ATwqggJOAfdXvkcPXF2TPDi7jxGPz6crldn5Pzbx0-r5TnppKCZ9Awc1Z2w0DhZK6uFpnqfWkCtFEjl-koooLxrgSnb162Tqm_bhleuZVZUx-j9wXea2y30Hfgc7WimOGxt3JlgB_P3xA8bcxlujOBll6DF4M2dQQzXM6RstkPqYBythzAnw2rJy7erShb09T_oVZijL_EKJaSsimFTKHaguhhSiuDuH8Oo2Uczh0JNKdTsCzW3RfPqYYp7xe8GC8APQCojfwnxwer_uv4CIA-t4w</recordid><startdate>20150201</startdate><enddate>20150201</enddate><creator>Bedair, Hany</creator><creator>Yang, Judy</creator><creator>Dwyer, Maureen K.</creator><creator>McCarthy, Joseph C.</creator><general>Springer US</general><general>Lippincott Williams & Wilkins Ovid Technologies</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7QP</scope><scope>7RV</scope><scope>7T5</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8AO</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>H94</scope><scope>K9.</scope><scope>KB0</scope><scope>M0S</scope><scope>M1P</scope><scope>NAPCQ</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20150201</creationdate><title>Preoperative Erythropoietin Alpha Reduces Postoperative Transfusions in THA and TKA but May Not Be Cost-effective</title><author>Bedair, Hany ; Yang, Judy ; Dwyer, Maureen K. ; McCarthy, Joseph C.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c540t-d1ef09c4ae8f567a9490910074e677e57fd347e02cbe17ad6bf57dbb823fb1a43</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2015</creationdate><topic>Aged</topic><topic>Arthroplasty, Replacement, Hip</topic><topic>Arthroplasty, Replacement, Knee</topic><topic>Blood Transfusion - economics</topic><topic>Blood Transfusion - statistics & numerical data</topic><topic>Conservative Orthopedics</topic><topic>Cost-Benefit Analysis</topic><topic>Decision Trees</topic><topic>Erythropoietin - economics</topic><topic>Erythropoietin - therapeutic use</topic><topic>Female</topic><topic>Hip</topic><topic>Humans</topic><topic>Length of Stay</topic><topic>Male</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Middle Aged</topic><topic>Orthopedics</topic><topic>Postoperative Period</topic><topic>Sports Medicine</topic><topic>Surgery</topic><topic>Surgical Orthopedics</topic><topic>Symposium: 2014 Hip Society Proceedings</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Bedair, Hany</creatorcontrib><creatorcontrib>Yang, Judy</creatorcontrib><creatorcontrib>Dwyer, Maureen K.</creatorcontrib><creatorcontrib>McCarthy, Joseph C.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Calcium & Calcified Tissue Abstracts</collection><collection>Nursing & Allied Health Database</collection><collection>Immunology Abstracts</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>ProQuest Pharma Collection</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Nursing & Allied Health Premium</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Clinical orthopaedics and related research</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Bedair, Hany</au><au>Yang, Judy</au><au>Dwyer, Maureen K.</au><au>McCarthy, Joseph C.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Preoperative Erythropoietin Alpha Reduces Postoperative Transfusions in THA and TKA but May Not Be Cost-effective</atitle><jtitle>Clinical orthopaedics and related research</jtitle><stitle>Clin Orthop Relat Res</stitle><addtitle>Clin Orthop Relat Res</addtitle><date>2015-02-01</date><risdate>2015</risdate><volume>473</volume><issue>2</issue><spage>590</spage><epage>596</epage><pages>590-596</pages><issn>0009-921X</issn><eissn>1528-1132</eissn><abstract>Background
Preoperative erythropoietin alpha (EPO) has been shown to be effective at reducing postoperative blood transfusions in total hip arthroplasty (THA) and total knee arthroplasty (TKA); however, treatment with EPO is associated with additional costs, and it is not known whether these costs can be justified when weighed against the transfusion reductions achieved in patients who receive the drug.
Questions/purposes
The purpose of this study is to investigate (1) efficacy of preoperative EPO in reducing postoperative transfusions in TKA and THA; (2) whether patients treated with EPO have reduced length of stay or a different discharge disposition; and (3) whether EPO use reduces overall blood management costs.
Methods
Patients undergoing primary THA or TKA over a 10-month period with preoperative hemoglobin < 13 g/dL were recommended to be treated preoperatively with EPO. During that time, 80 of 286 (28%) patients met that inclusion criterion and the treating team recommended EPO to all of them; of that group, 24 (30%) opted to take EPO and 56 (70%) opted not to. Patients receiving at least one dose of EPO and those not receiving EPO were compared in terms of transfusion frequency, length of stay and discharge disposition, and overall blood management costs. Demographics, preoperative hemoglobin, and operative blood loss for both groups were similar (p > 0.05). No transfusion triggers were used; rather, patients with postoperative hemoglobin < 10 mg/dL and who were symptomatic despite fluid boluses were transfused. The clinician responsible for transfusing symptomatic patients was blinded to the patient’s EPO treatment status. Costs were defined as direct costs paid or incurred by our institution for EPO, allogeneic blood, and variable costs associated with patient care after THA/TKA. A decision-tree cost analysis was performed using the collected clinical data and cost data collected from our institution; the analysis considered total associated blood management cost for an EPO and a non-EPO strategy with sensitivity analysis of key cost variables.
Results
The proportion of patients receiving transfusions was lower in patients who received EPO than in patients who did not (0% [zero of 24] versus 41% [23 of 56]; p < 0.001). The mean length of inpatient hospital stay (EPO: 3.0 ± 0.4 versus control: 3.3 ± 0.8 days, p = 0.77) and discharge disposition also was not different between the groups. The cost analysis demonstrated that the EPO strategy was more costly compared with no EPO (USD 2632 versus USD 2284) and its cost would need to be less than USD 225/dose for this to change.
Conclusions
EPO reduced the need for postoperative transfusions in high-risk patients undergoing THA and TKA; however, it was not found to be cost-effective in our model. Our model could not consider relatively rare complications of blood transfusions, including disease transmission, deep periprosthetic infections, and transfusion reactions, but if surgeons or patients value avoiding these potential but rare factors highly, this could reasonably influence the decision of whether to use EPO despite our findings that it was not cost-effective.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.</abstract><cop>Boston</cop><pub>Springer US</pub><pmid>25106796</pmid><doi>10.1007/s11999-014-3819-z</doi><tpages>7</tpages><oa>free_for_read</oa></addata></record> |
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| source | MEDLINE; SpringerLink Journals; Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals; PubMed Central |
| subjects | Aged Arthroplasty, Replacement, Hip Arthroplasty, Replacement, Knee Blood Transfusion - economics Blood Transfusion - statistics & numerical data Conservative Orthopedics Cost-Benefit Analysis Decision Trees Erythropoietin - economics Erythropoietin - therapeutic use Female Hip Humans Length of Stay Male Medicine Medicine & Public Health Middle Aged Orthopedics Postoperative Period Sports Medicine Surgery Surgical Orthopedics Symposium: 2014 Hip Society Proceedings |
| title | Preoperative Erythropoietin Alpha Reduces Postoperative Transfusions in THA and TKA but May Not Be Cost-effective |
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