ArticlePDF Available

Characterising differences in red blood cell usage patterns between healthcare sectors in South Africa: 2014-2019

Authors:

Abstract and Figures

Background - South Africa aims to transition from a two-tiered healthcare system (public and private) to universal health coverage. Data on red blood cell (RBC) product usage reveal disparities between the sectors. Blood transfusion services further need to understand differing disease profiles and transfusion prescribing practices between the sectors to ensure blood security should the transition to a two-tiered health system come to fruition. Materials and methods - Operational data for public and private healthcare RBC requests between 1 January 2014 and 31 March 2019, obtained from the South African National Blood Service (SANBS), were retrospectively analysed. Sector-specific demographic and utilisation trends were compared for the dominant clinical disciplines. Pre-transfusion haemoglobin (Hb) patterns were also delineated for 2018. Results - Between 2014 and 2019, 2,356,411 public and private sector RBC transfusion events resulted in the issue of 4,020,094 RBC units (1,553,159 transfusion events and 2,495,054 units within the public sector versus 803,282 transfusion events and 1,525,040 units in private). The dominant clinical disciplines within the public sector were Medical (32.9%), Gynaecology/Obstetrics (27.3%), General Surgery (13.6%), and Paediatrics (including Paediatric Surgery) (6.5%), compared to Intensive Care Units (33.2%), Medical (28.3%), General Surgery (10.4%), and Haematology/Oncology (8.3%) in the private sector. Median pre-transfusion Hb values for 2018 were lower in the public than in the private sector: 6.9 g/dL public sector versus 8 g/dL private sector. Discussion - Clinical drivers of RBC usage within the public and private healthcare sectors in South Africa differ significantly. Disparate pre-transfusion Hb between the sectors are likely due to differing disease profiles and severity, as well as differences in practice in prescribing transfusions. Implementation of a nationally co-ordinated Patient Blood Management programme may help to address these disparities and help ensure a sustainable blood transfusion system.
Content may be subject to copyright.
1
Blood Transfus 2021; DOI 10.2450/2021.0209-21
© SIMTIPRO Srl
Background - South Africa aims to transition from a two-tiered healthcare
system (public and private) to universal health coverage. Data on red blood cell
(RBC) product usage reveal disparities between the sectors. Blood transfusion
services further need to understand diering disease proles and transfusion
prescribing practices between the sectors to ensure blood security should the
transition to a two-tiered health system come to fruition.
Materials and methods - Operational data for public and private healthcare
RBC requests between 1 January 2014 and 31 March 2019, obtained from the
South African National Blood Service (SANBS), were retrospectively analysed.
Sector-specic demographic and utilisation trends were compared for the
dominant clinical disciplines. Pre-transfusion haemoglobin (Hb) patterns
were also delineated for 2018.
Results - Between 2014 and 2019, 2,356,411 public and private sector RBC
transfusion events resulted in the issue of 4,020,094 RBC units (1,553,159
transfusion events and 2,495,054 units within the public sector versus 803,282
transfusion events and 1,525,040 units in private). The dominant clinical
disciplines within the public sector were Medical (32.9%), Gynaecology/Obstetrics
(27.3%), General Surgery (13.6%), and Paediatrics (including Paediatric Surgery)
(6.5%), compared to Intensive Care Units (33.2%), Medical (28.3%), General
Surgery (10.4%), and Haematology/Oncology (8.3%) in the private sector. Median
pre-transfusion Hb values for 2018 were lower in the public than in the private
sector: 6.9 g/dL public sector versus 8 g/dL private sector.
Discussion - Clinical drivers of RBC usage within the public and private healthcare
sectors in South Africa dier signicantly. Disparate pre-transfusion Hb between
the sectors are likely due to diering disease proles and severity, as well as
dierences in practice in prescribing transfusions. Implementation of a nationally
co-ordinated Patient Blood Management programme may help to address these
disparities and help ensure a sustainable blood transfusion system.
Keywords: healthcare sectors, public health policy, transfusion prescribing practices,
pre-transfusion haemoglobin, patient blood management.
Characterising dierences in red
blood cell usage patterns between
healthcare sectors in South Africa:
2014-2019
Larisse Bolton1, Karin van den Berg2,3,4, Ronél Swanevelder2, Juliet R.C. Pulliam1
Original article
TRANSFUSION MEDICINE
Arrived: 23 July 2021
Revision accepted: 19 October 2021
Correspondence:
Larisse Bolton
e-mail: lbolton@sun.ac.za
1South African DSI-NRF Centre
of Excellence in Epidemiological
Modelling and Analysis (SACEMA),
Stellenbosch University,
Stellenbosch, South Afr ica;
2Translational Research, Medical
Division, South African National
Blood Service, Roodepoort,
South Africa;
3Division of Clinical Haematology,
Department of Medicine, Faculty of
Health Sciences, Universit y of Cape
Town, South Africa;
4Division of Clinical Haematology,
University of the Free State,
Bloemfontein, South Africa
INTRODUCTION
In 2019, the population of Sub-Saharan Africa populat ion reached 1.107 billion individuals 1.
             
© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
2
Bolton L et al
Blood Transfus 2021; DOI 10.2450/2021.0209-21
accounts for 68% of all worldwide maternal deaths2.
      
obstetric haemorrhage is essential to avert the death of
the patient. However, in Sub-Saharan African countries
      
.
        
two distinct sectors: public and private7   
      
       
        
        
      

11.02 RBC units per 1,000 of the population8,9
       10
       7,
equipment, and medicines11
        
scheme contributions12
than the public healthcare sector7   
 

 
vs
public sector

public healthcare sector, healthcare across both sectors
is still considered “pro-rich”   
between the two healthcare sectors, the blood product


 

9. Under
      
        
    16,17  
product providers need to understand the disease
spectrums and prescribing practices driving usage within

    
2021, the bill is still going through public hearings18.
According to South African guidelines, the haemoglobin
      
19,20 .
  
each case and to compare the advantage of administering
a transfusion with the possible risks associated with
the transfusion procedure itself21. However, despite
these guidelines, there is substantial inter-hospital and
22.
A previous evaluation of RBC products had found that the
 
between the public and private healthcare sectors of
South Africa9      
transfusion rates at an average 11.6 units per 1,000
of the population, while the private sector had rates
comparable to high income countries at an average
      9 
      
       
 9 
build upon the prior investigation into RBC utilisation9,
       
transfusion prescribing practices underpinning the
disparate RBC usage between the healthcare sectors.
       


MATERIAL AND METHODS
    
blood product and serv ice provider for eight out of the nine
provinces in South Africa. As the dominant transfusion
       
        via its
   All RBC product requests submitted to
  


  
       

requisition number representing a unique transfusion event.
Data collection
     
       
     
   
© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
3
Blood Transfus 2021; DOI 10.2450/2021.0209-21
RBC usage patterns in South African healthcare sectors
 

demographic information of the blood recipients such as

        
       
  
for a particular blood requisition event based on either the
main clinical discipline into which the patient is admitted
or the discipline of the clinician ordering the transfusion.
        
         

        


   
    
     




  
        


of cancellation, was also collected.
Data analysis
         ,
. Descriptive
statistics were used to characterise demographic trends
 
      
       
calculating the percentage of the respective sector RBC
units that were issued to a particular discipline within the
       
  

healthcare sector population as estimated from General
 and expressing
the outcome per 1,000 of the respective population.
    
practices between the public and private healthcare sectors
   
pre-transfusion Hb values for requisitions during 2018.



latter investigation as the pre-transfusion Hb values were

     
        
  

In addition to the missing values, the Hb dataset
       

 
       in R
 under the assumption of missing at
randomOnline Supplementar y Content
for imputation contained the pre-transfusion Hb values
along with the variables age, gender, clinical discipline,
        
were considered to be possible predictors for the missing
pre-transfusion Hb values due to their expected association

Hb values or as contributing factors for the values being
missing       
a predictor matrix and applied to the imputation set to
impute the missing pre-transfusion Hb values.
Data considerations
Since this investigation extends a prior investigation
et al.9 of blood usage patterns in South Africa,
        
     
       
However, the size of the dataset, as well as the required
     
addition, the number of units of blood products issued
        
       

imputed as described in the Online Supplementary Content,
and although on average patient age was well-captured,



© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
4
Bolton L et al
Blood Transfus 2021; DOI 10.2450/2021.0209-21
  
   
    Online Supplementary
Content        
       
     
         
       
        

       
      
forms is independent of age, the demographic and

     
      
   
were considered to determine the demographic and
utilisation trends within this clinical discipline. However,
      
       

      

    
       
        

       
     

of a small number of men registered in this clinical
discipline due to a shortage of beds at the respective
   Supplementary Online Content  



assumed to occur in settings where there is a shortage of
 
patient to be treated as a paediatric patient.
       
      
       
terms of RBC transfusion events or usage were selected
for discussion.
Ethical considerations and data sharing

    

     
allow for the sharing of    
        
appropriate contractual or non-disclosure agreements.
RESULTS
Trends in public and private healthcare sector
transfusion events by clinical discipline


         
Table I
      
     .
       
transfusion events across the domina nt clinical disciplines
    

    
      
        
     
       
     
disciplines, where the private sector patients accounted
       
        
      
     
      
    . Across both
sectors, females accounted for most of the transfusion
      
   
 
       
ratio of female to male transfusion events was 1.6 in the
public sector vs
 vs the
 vs

© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
5
Blood Transfus 2021; DOI 10.2450/2021.0209-21
RBC usage patterns in South African healthcare sectors
Table I - Demographic characteristics of the public and private sector red blood cell transfusion events
by dominant clinical disciplines: 2014-2019*
Clinical Discipline Public Sector Private Sector Total
TRANSFUSION EVENTS 1,553,159 (65.9%) 803,282 (34.1%) 2,356,441
GENERAL SURGERY 193,139 (70.4%) 81,080 (29.6%) 274,219 (11.6%)
Age (years) 48 (33-63) 57 (43-70)
Gender
Female 96,506 (50.0%) 43,294 (53.4%)
Male 96,379 (49.9%) 37,753 (46.6%)
Unknown 254 (0.1%) 33 (0.0%)
GYNAECOLOGY/OBSTETRICS 384,047 (90.3%) 41,435 (9.7%) 425,482 (18.1%)
Age (years) 29 (23-37) 34 (28-41)
Gender
Female 379,713 (98.9%) 40,322 (97.3%)
Male 3,997 (1.0%) 1,108 (2.7%)
Unknown 337 (0.1%) 5 (0.0%)
HAEMATOLOGY/ONCOLOGY 59,499 (46.1%) 69,641 (53.9%) 129,140 (5.5%)
Age (years) 39 (23-55) 57 (41-68)
Gender
Female 34,829 (58.5%) 35,063 (50.3%)
Male 24,577 (41.3%) 34,408 (49.4%)
Unknown 93 (0.2%) 170 (0.2%)
INTENSIVE CARE UNIT 62,832 (19.3%) 263,292 (80.7%) 326,124 (13.8%)
Age (years) 33 (20-49) 56 (39-69)
Gender
Female 31,145 (49.6%) 126,840 (48.2%)
Male 31,577 (50.3%) 136,356 (51.8%)
Unknown 110 (0.2%) 96 (0.0%)
MEDICAL 499,163 (69.8%) 216,120 (30.2%) 715,283 (30.4%)
Age (years) 40 (29-56) 56 (42-70)
Gender
Female 310,046 (62.1%) 119,365 (55.2%)
Male 188,356 (37.7%) 96,660 (44.7%)
Unknown 761 (0.2%) 95 (0.0%)
PAEDIATRICS† 157 071 (86.4%) 24 824 (13.7%) 181 895 (7.7%)
Age (years) 0 (0-1) 0 (0-3)
Gender
Female 72,309 (46.0%) 11,716 (47.2%)
Male 83,896 (53.4%) 13,099 (52.8%)
Unknown 866 (0.6%) 9 (0.0%)
*Data reported as median (interquartile range) or number of transfusion events (%). † Includes paediatric surgery.
© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
6
Bolton L et al
Blood Transfus 2021; DOI 10.2450/2021.0209-21
male to female relationship is more comparable between
    vs     
     vs    
       
towards an older demographic in the private sector, with
vs
Trends in public and private healthcare sector red
blood cell utilisation according to clinical discipline
         
        
        
  
        
disciplines used the greatest number of RBC units
       
comparative per capita usage for the medical discipline
       vs
      

      

   
dominant clinical disciplines in terms of percentage


       

Figure 1
Trends in pre-transfusion haemoglobin levels
between public and private healthcare sector
according to clinical discipline
       
       
       
       

         
private sector. Table II presents the median pre-transfusion
Hb values for men and women per healthcare sector for the
dominant clinical disciplines. Across all the disciplines,
the median private sector pre-transfusion Hb values were
higher than those in the public sector. Figure 2 shows the
comparative median healthcare sector pre-transfusion
Figure 1 - The percentage of red blood cell (RBC) units issued by clinical discipline in the public and private healthcare
sectors
(Paediatrics include paediatric surgery). (N= 4,020,094)
© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
7
Blood Transfus 2021; DOI 10.2450/2021.0209-21
RBC usage patterns in South African healthcare sectors
Table II - Median (interquartile range) haemoglobin in g/dL for male and female patients by dominant clinical discipline
and healthcare sector for 2018
Clinical discipline Public sector Private sector
Overall Males Females Overall Males Females
General surgery 7.0
(5.9-8.0)
7.0
(5.9-8.0)
7.0
(5.8-8.0)
8.0
(7.3-8.7)
8.0
(7.3-8.7)
8.0
(7.3-8.7)
Gynaecology/Obstetrics 7.0
(5.9-7.7)
7.0
(5.9-7.7)
8.0
(7.0-8.5)
8.0
(7.0-8.5)
Haematology/Oncology 7.0
(6.0-7.7)
7.0
(6.0-7.5)
6.9
(6.0-7.8)
7.9
(7.0-8.3)
7.8
(7.0-8.2)
7.9
(7.2-8.4)
Intensive care unit 7.0
(6.4-8.0)
7.1
(6.5-8.1)
7.0
(6.3-8.0)
8.0
(7.4-8.8)
8.0
(7.4-8.8)
8.0
(7.4-8.8)
Medical 6.0
(4.9-6.8)
6.0
(5.0-6.9)
6.0
(4.9-6.8)
7.5
(7.0-8.5)
7.6
(7.0-8.5)
7.5
(7.0-8.5)
Paediatrics 8.0
(7.0-9.1)
8.0
(7.0-9.1)
8.0
(7.0-9.2)
9.0
(8.0-10.0)
9.0
(8.0-10.0)
9.2
(8.0-10.0)
Figure 2 - The comparative median pre-transfusion haemoglobin (Hb) levels (g/dL) of public and private healthcare sector
red blood cell (RBC) requisitions for 2018
Requisitions were stratied by age, gender, and clinical discipline (Medical, Intensive Care Unit, General Surgery and Haematology/Oncology,
Gynaecology/Obstetrics and Paediatrics [including Paediatric Surgery]).
© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
8
Bolton L et al
Blood Transfus 2021; DOI 10.2450/2021.0209-21
        

Hb was consistent across the age groups for all except one

Figure 2
DISCUSSION
       
      
disease spectrums. Although clinical discipline is not a
      
broad indication of the spectrum of diseases that could be
associated with the greatest RBC utilisation.
    
       
utilisation between the public and private healthcare
 
the public healthcare sector are comparable to patterns
in other middle-income countries, with paediatrics and
   , while the
trends in the private sector resemble patterns observed

  .
 
       . RBC utilisation
 
        
2008, Shortt et al.      
utilisation trends of RBC products produced and
       
      
         
  
    
    
     

Australia and the South African private healthcare sector
      

diseases and chronic conditions, and treatment of
malignancies
utilisation patterns, the comparable utilisation trends
      
South African public healthcare sector is remarkable.
   
   personal communication, 2020   
leading clinical discipline for RBC usage to be Internal

     

       


       
between the public and private healthcare sectors, with a

  
 
     
the median Hb values for this discipline has multiple

      
of both haematologic and oncological patients created
         
diseases, each with unique treatment guidelines and
modalities , and within this broad range of diseases,
   
course of the disease which would further impact the
transfusion requirements of the individual patient. It
is evident that combining these two categories of patients
  
 
their pre-transfusion Hb values.
        
pre-transfusion Hb values between the healthcare sectors
  

individuals are, for the most part, dependent on the public
sector
    
facilities could all contribute to these patients arriving at the
 
condition compared to those with the means to seek medical
          
          
prescribing practices through the actual application of
    
        
within the private healthcare sector.
© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
9
Blood Transfus 2021; DOI 10.2450/2021.0209-21
RBC usage patterns in South African healthcare sectors


related to blood transfusions. Barrett et al. investigated
the level of transfusion knowledge and training at the
Universitas Academic hospital complex in Bloemfontein,

 et al. acknowledged
a lack of training in transfusion medicine, and reported
      
transfusions without a clear clinical indication for the
procedure      
        

applied, even though it is well known that Hb thresholds
         
transfusion. RBC transfusion should involve a careful
balance between administering the required amount of
product to ensure optimal patient outcomes while limiting


implications19.
       



        
           
       
         
        
         

based on out-dated practices or the lack of onsite blood
       
more restrictive transfusion practice in the public sectors
        
     



decision makers could be attempting to reduce costs
      


in pre-transfusion Hb values between the healthcare
sectors, but rather a combination of possible factors.
Achieving a balance in utilisation between the sectors
would require addressing multiple aspects of the
management of these procedures. Both healthcare sectors

for clinicians and nurses, with a particular emphasis
        



be better management of transfusion practices within
       

      

product providers to appropriate forums within the private
      
Africa either lack such an oversight, or do not provide
access to those who operate in the transfusion services
        
    
       
transfusion practice, disseminate transfusion guidelines
and monitor the implementation of programs related to
transfusion medicine in the hospital”, and also be a driving
force for the application of patient blood management
within their facilities.
CONCLUSION
South Africa plans to transition from a two-tiered
      
a donor pool of less than 1% of the South African
population, it is evident that this scarce resource
      

       
addressed to ensure an equitable and sustainable blood

    
     
were found to underpin the disparate utilisation trends
       
healthcare access remains of paramount importance,
     
between the sectors should be considered. Although the
© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
10
Bolton L et al
Blood Transfus 2021; DOI 10.2450/2021.0209-21
disease spectrums are population-dependent and for the
most part unavoidable, ensuring oversight of transfusion
        
        
transfusion training programme for clinicians, as well as
functioning and transparent transfusion committees and

aspects could bring about a more uniform approach to
blood transfusions across the healthcare sectors, as well
     
procedures.
ACKNOWLEDGMENT
        
 
   

        
       

or recommendation expressed in this material is that of
   
this regard.
FUNDING AND RESOURCES
       
     
      
          
      
  
     

AUTHORSHIP CONTRIBUTIONS
     
   
visualization, writing-original, writing-review
    

    
    
   
funding acquisition, writing-review and editing.
 
REFERENCES
1. The World B ank. Sub-Saharan Afric a. Data. 2021. Available at: ht tps://
data.worldbank.org/country/ZG. Accesse d on 17/02/2021.
2. UNICEF. Maternal mortality. 2019 Sep. Available at: https://data.unicef.
org/topic/maternal-health/maternal-mor tality/. Accessed 9/02/2021.
3. Bates I, Chapotera GK, McKew S, Van Den Broek N. Maternal mortalit y
in sub-Saharan Africa: The contribution of ineective blood transfusion
serv ices. BJOG 20 08; 115: 133 1-9.
4. Waters JH , Bonnet MP. When and how sh ould I transfu se during obste tric
hemorr hage? Int J Obstet An esth 2021; 46: 102973 .
5. As ante A, Pri ce J, Ha yen A , et al. Equ ity i n heal th car e nan cing in lo w-an d
middle-income countr ies: a systematic review of evidence from studies
using bene t and nancing incidence analyses. PLoS ONE 2016; 11: 1-2 0.
6. Mills A, Atagub a JE, Aka zili J, et al. Equit y in nanc ing and us e of healt h
care in Ghana, South Afr ica, and Tanzania: Implications for paths to
univers al coverage. The L ancet 2012; 380: 126-33.
7. Mc intyre D, Thiede M, Nkosi M, Mutyambizi V. A Critical Analysis of th e
current S outh African Health System. Cape Town: Health Economics
Unit, University of Ca pe Town, and Centre of Health Policy, University of
the Witwatersrand; 2007. Available at: http://web.uct.ac .za/depts/heu//
SHIELD/reports/SouthAfrica1.pdf. Accessed on 21/02/2020.
8. Statistics Sou th Africa. General Household Surve y 2018. Statist ical Release:
P0318. 2018 . Available on: w ww.stat ssa.gov.z a. Accesse d on 7/01/2020.
9. Bolton L, van Den Berg K, Swanevelder R , Pulliam JR. Mind the gap:
patter ns of red blood ce ll product us age in South Afr ica, 2014-2019. SA MJ
2021; 111: 985-90.
10. Gilson L , McIntyre D. Post-apartheid challenges: household access and
use of heal th care in South Af rica. Int J Healt h Serv 2007; 37: 673-91.
11. Macha J, Harris B, Garshong B, et al. Factors inuencing the burden of
heal th care na ncing an d the dist ributi on of healt h care ben ets in G hana,
Tanzania and So uth Africa. H ealth Policy Pla n 2012; 27(Suppl 1): 46- 54.
12. Ata guba JE , McInt yre D. Th e incid ence of hea lth na ncing in South A frica :
ndings fr om a recent dat a set. Hea lth Econ Policy Law 2018; 13: 68 -91.
13. South Af rican National Treasury. Summar y of the Provincial Budgets
and Expenditure Review. Pretoria: National Treasury; 2 015. Available at:
https://www.gov.za/provincial-budget-and-expenditure-review- 201011
-201616. Access ed on 10/10/2021.
14. Da y C, Gray A, Ndl ovu N. Health and R elated Indica tors 2018. In: South African
Health Rev iew 2018. Durban: H ealth Systems Trus t; 2018. p. 139 -250.
15. Ataguba JE, McInt yre D. Paying for and receivin g ben ets from health
serv ices in South Af rica: Is the health system e quitable? Health Policy
Plan 2012; 27 (Su ppl 1): 35-45 .
16. South Africa Depar tment of Health. National Health insurance for South
Africa. National Health Act, 200 3. 27 Jul 2017. Available at: ht tp://www.
health. gov.za/index .php/nhi#. Accesse d on 7/10/2019.
17. South Af rica Ministe r of Health. National Health Insurance Bill: B11-
2019. 2019. Available at: https://www.gov.za/sites/default/les/
gcis_document/201908/national-h ealth-insurance-bill-b-11-2019.pdf.
Access ed on 16/09/2021.
18. Parliamentary Monitoring Group. National health insurance bill (B11-
2019). Section 76: Ordinary Bills aecting the provinces. National Health
Insurance Bill B11-2019. 2019. Available at: https://pmg.org.za/bill/886/.
Access ed on 16/09/2021.
19. South Af rican National Blood Ser vice (SANBS), Western Cape Blood
Serv ice (WCBS). Clinical guideline s for use of blood p roducts in S outh
Africa. 5th ed. SANBS/ WCBS; 2014. Avai lable at: http s://www.wcbs.o rg.za.
Access ed on 17/03/2020.
20. Wise R, Bishop D, Gibbs M, et al. South Afr ican Societ y of
Anaesthesiologist s Perioperative Patient Blood Management Guidelines
2020. SAJAA 2020; 26: S1-59.
21. Szczepiorkowski ZM, Dunbar NM. Transfusion guidelines: when
to transfuse. Hematology Am Soc Hematol Educ Program 2013;
2013: 63 8-44.
22. Thomson A, Farmer S, Hof mann A, et al. Patient Blood Management -
a new paradigm for transfusion medicine? ISBT Science Series 2009;
4: 423-3 5.
© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
11
Blood Transfus 2021; DOI 10.2450/2021.0209-21
RBC usage patterns in South African healthcare sectors
23. RStudio Team. RStudio: Integra ted Developme nt Environment for R.
Boston: R studio c2021. Available at : https://rstu dio.com/. Accessed on
19/07/2021.
24. R Core Team. R: A langauge environment for statis tical computing . 2019.
Availabl e at: https://ww w.r-project .org/. Accessed o n 19/07/2021.
25. Statistics South Africa. Gene ral Househo ld Survey 2014. St atistical
Release: P0318. 2014:1–173. Available at: www.statssa.gov.za. Accessed
on 9/01/ 2020.
26. Statistics South Africa. Gene ral Househo ld Survey 2015 . Statistic al
Release: P0318. 2015;1-195. Available at: www.statssa.gov.za. Accessed
on 9/01/ 2020.
27. Statistics South Africa. Gene ral Househo ld Survey 2016. Statistical
Release: P0318. 2016:1-177. Available at: w ww.stat ssa.gov.z a. Accessed
on 9/01/ 2020.
28. Statistics South Africa. Gene ral Househo ld Survey 2017. Statist ical
Release: P0318. 2017:1-180. Available at: www.st atssa.gov.za. Access ed
on 7/01/2020.
29. Statistics South Africa. Gene ral househo ld survey 2019. Statistical
Release: P0318. 2019;1-183. Available at: w ww.stat ssa.gov.za . Accessed
on 11/10/2021 .
30. van Buure n S, Groothuis- Oudshoorn K . mice: multivar iate imputation b y
chained equations in R. J Stat Sow 2011;45: 1-6 7. Available at: https://
www.js tatso.org /v45/i03/. Accesse d on 26/11/2019.
31. Hanafus a N, Nomura T, Hasegawa T, Nangaku M. Age and anemia
management: Relationship of hemoglobin levels with mortality might
dier betwe en eld erly and nonelderly hemodial ysis p atients. Nephrol
Dial Transpla nt 2014; 29: 2316-26.
32. World Health Organization (WHO). Haemoglobin concent rations for the
diagnosis of anaemia and assessment of severity. Geneva: Vitamin and
Mineral Nutrition Information System; 2011. Available at: http://ww w.
who.int/vmnis/indica tors/haemoglobin. Accessed on 23/11/2020.
33. Van Buuren S , Boshuizen HC , Knook DL. Multiple imputat ion of missing
blood pre ssure covaria tes in surviv al analysis. St at Med 1999; 18: 6 81-94.
34. World Hea lth Org aniza tion ( WHO). Glo bal st atus re por t on bloo d safe ty an d
availabil ity 2016. Lice nce: CC BY-NC-SA 3 .0 IGO. 2017. Available at: h ttps://
apps.who.int/iris/bitstream/handle/10665/254987/9789241565431-eng.
pdf. Acces sed on 17/09/2019.
35. The World B ank. World Ba nk list of econom ies. 2020. Ava ilable at: htt ps://
datahelpdesk.worldbank.org/knowledgebase/articles/906519-world -
bank-co untry-and -lending-gr oups. Accesse d on 19/10/2020.
36. Australian Bureau of Statistics . National, st ate and territory population
tables. 2020. Available at: https://www.abs.gov.au/statistics/people/
population/national-state-and-territory-population/mar-2020#data-
download s-data- cubes. Access ed on 24/11/2020.
37. National Blood Authority Australia. Australian Haemovigilance report:
Data for 20 09-10 and 2010-11. National Blood Authority Australia; 2013.
Available at: https://www.blood.gov.au/haemovigilance-reporting.
Access ed on 5/10/2020.
38. Wood EM, Shortt J, Poliz zotto MN, et al . Assess ment of the urgency
and deferability of tr ansfusion to inform emerge ncy blood planning
and triage: The Bloodhound prospective audit of red blood cell use.
Transfusion 2009; 49: 2296 -303.
39. Liu C, Gro ssman BJ. Re d blood cell tr ansfusion f or hematolog ic disorder s.
Hematolo gy Am Soc Hemat ol Educ Program 2015 ; 2015: 454- 61.
40. Freshwate r D, Maslin-Pr othero SE, ed itors. Blackwell’s Nursing dictionary.
2nd ed. Lans downe: Juta & Compa ny Ltd; 1994.
41. Ho brand AV, Moss PAH. Essential Haematology. 6th ed. West Sussex:
Wiley/Blackwell; 2011.
42. Jelovac D, A rmstrong D K. Recent pro gress in the di agnosis and tr eatment
of ovaria n cancer. CA Cancer J C lin 2011; 61: 183-203.
43. Harris B , Goudge J, Atagu ba JE, et al. Ine quities in acces s to health care i n
South Af rica. J Public He alth Policy 2011; 32: 102-2 3.
44. Carson JL, Stanwor th SJ, Roubinian N, et al. Transfusion thresholds
and other s trategies for guiding allogeneic red blood cell transfusion.
Cochra ne Database Syst R ev 2016; 10: CD002042.
45. Shander A , Gross I, Hill S, et al. A new per spective on best trans fusion
pract ices. Blood Trans fus 2013; 11: 193-202 .
46. Barret t C, Mphahlele K, Khunou I, et al. The knowledge of transfusion
and relate d practice s among doctor s at Universit as Academic Complex,
Bloemfo ntein, South Af rica. Transfus Ap her Sci 2020; 59: 1027 39.
47. Ogunbanjo GA, van Bogaert KD. Ethic s in health care: the practi ce of
defensi ve medicine. S Afr Fam P ract 2014; 56: 6-8 .
48. Orkuma JA , Ayia ON. Ethico -legal asp ects of hospital-based blood
transf usion practice; implications of professional negligence to medical
pract itioners: a re view. Int J Med Biome d Res 2014; 3: 219-35.
49. Thakkar R N, Lee KHK, Ness PM, et al. Relative impact of a patient
blood management program on utilization of all three majo r blood
components. Transfusion 2016; 56: 2212-20.
50. Kasere r A, Rössle r J, Braun J, et al . Impact of a Pat ient Blood Ma nagement
monitoring and feedbac k programme on allogeneic bloo d transfusions
and relate d costs. Ana esthesia 2019; 74 : 1534- 41.
51. Nationa l Treasury: Republic of South Africa. Budget Review. Pretoria:
National Treas ury: Republic of South Afr ica; 2019. Availab le at: http://
www.treasury.gov.za/documents/national budget/2018/review/FullBR.
pdf. Acces sed on 9/12/2020 .
52. Spahn DR. Patient Blood Management: what else? Ann. Surg. 2019; 269:
80 5-7.
53. Yazer MH, Lozano M, Fung M, et al. An inter national sur vey on the role of
the hospital transfusion committee. Transfusion 2017; 57:128 0-7.
54. South Af rican Nationa l Blood Serv ice (SANBS). Annual I ntegrated Rep ort
2020. Roodepoort : South Afric an National Blood Service (SANBS); 2020.
Available at: https://sanbs.org.za/wp- content/uploads/2021/02/Annual-
Report-21-December-2020.pdf. Accessed on 20/09/2021.
© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
12
Bolton L et al
Blood Transfus 2021; DOI 10.2450/2021.0209-21
ONLINE SUPPLEMENTARY CONTENT
IMPUTATION OF MISSING HB VALUES FOR 2018
        
and private healthcare RBC requests for 2018 and the
variables: pre-transfusion Hb, agess1, genders2 ,
       
    
       
missingness of the pre-transfusion Hb values
was transformed to categorical age groups in intervals
 

        
     s6 to generate
       norm.boot
   

       
values were then replaced.
        
      
Hb values were drawn from the subset and the recorded
       Table SI
Recorded Hb values refer to Hb values that were not
missing within the pre-imputed data set and could be
used for comparison to predicted Hb values.
      
recorded pre-transfusion Hb values were compared to the
complete subset following imputation in terms of overall
minimum, maximum, standard deviation, mean, median
and interquartile range of pre-transfusion Hb values
         
private healthcare to determine the whether the imputed
         
Table SII
        
        
 
Table SII - Comparison of summary statistics to evaluate imputations
Min Hb
(g/dL)
Max Hb
(g/dL)
Mean Hb
(g/dL)
Median Hb
(g/dL)
SD
(g/dL)
IR
(g/dL)
RECORDED
Public sector 1 20 6.767 6.7 2.0972 5.4-8.0
Private sector 1 20 8.069 8.0 1.7545 7.1-8.8
Overall 1 20 7.223 7.2 2.0789 6.0-8.4
IMPUTED
Public sector 1 20 6.804 6.9 1.9773 5.7-8.0
Private sector 1 20 8.079 8.0 1.6708 7.1-8.8
Overall 1 20 7.252 7.1 1.9717 6.0-8.3
Hb: haemoglobin; SD: standard deviation; IR: interquartile range.
Table SI - Percentage difference in recorded and predicted
pre-transfusion Hb values for 50 selected requisitions
Difference between recorded and predicted
pre-transfusion Hb value (g/dL)
Number of requisitions (%)
0-1 24 (48%)
1-2 13 (26%)
2-3 9 (18%)
3 or more 4 (8%)
Hb: haemoglobin.
© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
13
Blood Transfus 2021; DOI 10.2450/2021.0209-21
RBC usage patterns in South African healthcare sectors
       
  
requisitions with recorded Hb values and the full set
  
      
that the imputations did not alter the general Hb trend of

were reasonable.
DATA CONSIDER ATIONS
     
     
      
      
diagnoses associated and can therefore also be assumed
to be erroneous.
REFERENCES
s1. Hanafusa N, Nomura T, Hasegawa T, Nangaku M. Age and anemia
management: Relationship of hemoglobin levels with mortality might
dier bet ween elderly and nonelde rly hemodialysis pati ents. Nephrol Dial
Transplant 2014; 29: 2 316-26.
s2. World Health Organization (WHO). Haemoglobin concent rations for the
diagnosis of anaemia and assessment of severity. Geneva: Vitamin and
Mineral Nutrition Information System; 2011. Available at: http://ww w.
who.int/vmnis/indica tors/haemoglobin. Accessed on 23/11/2020.
s3. Do ng XQ, De Leon CM, A rtz A, e t al. A population-based s tudy of
hemoglobin, race, and mortality in elderly per sons. J Gerontol A Biol Sci
Med Sci 20 08; 63: 873-8 .
s4. Van Buuren S, Boshuizen H C, Knook DL. Multiple imputation of missing
blood pre ssure covariat es in surviva l analysis. Stat M ed 1999; 18: 681-9 4.
s5. van Buuren S, Groothuis-Oudshoorn K. mice: Multivariate Imputation by
Chained Equations in R . J Stat So w 2011; 45: 1-67. Available at: https://
www.js tatso.org /v45/i03/. Accesse d on 26/11/2019.
s6. R Core Team. R: A langauge environm ent for statistical computing. 2019.
Availabl e at: https://ww w.r-project .org/. Accessed o n 19/07/2021.
© SIMTIPRO Srl
All rights reserved - For personal use only
No other use without premission
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Background: A key component of any successful healthcare system is the availability of sufficient, safe blood products delivered in an equitable manner. South Africa (SA) has a two-tiered healthcare system with public and privately funded sectors. Blood utilisation data for both sectors are lacking. Evaluation of blood utilisation patterns in each healthcare sector will enable implementation of systems to bring about more equality. Objectives: To conduct a critical evaluation of red blood cell (RBC) product utilisation patterns at the South African National Blood Service (SANBS). Methods: Operationally collected data from RBC requests submitted to SANBS blood banks for the period 1 January 2014 - 31 March 2019 were used to determine temporal RBC product utilisation patterns by healthcare sector. Demographic patterns were determined, and per capita RBC utilisation trends calculated. Results: Of the 2 356 441 transfusion events, 65.9% occurred in the public and 34.1% in the private sector. Public sector patients were younger (median (interquartile range (IQR)) 33 (22 - 49) years) than in the private sector (median (IQR) 54 (37 - 68) years), and mainly female in both sectors (66.2% in the public sector and 53.4% in the private sector). Between 2014 and 2018, per capita RBC utilisation decreased from 11.9 to 11.0/1 000 population in the public sector, but increased from 34.8 to 38.2/1 000 population in the private sector. Conclusions: We confirmed distinctly different RBC utilisation patterns between the healthcare sectors in SA. Possible drivers for these differences may be healthcare access, differing patient populations and prescriber habits. Better understanding of these drivers may help inform equitable public health policy.
Article
Full-text available
Anaesthesiologists regularly request and administer blood components to their patients, a potentially life-saving intervention. All anaesthesiologists must be familiar with the indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematologists and their local haematology blood sciences laboratory is encouraged. In the last decade, there have been considerable changes in approaches to optimal use of blood components, together with the use of alternative products, with a need to update previous guidelines and adapt them for anaesthesiologists working throughout the hospital system.
Article
The incidence of maternal hemorrhage and blood transfusion has increased over time. Causes of massive hemorrhage, defined as a transfusion greater than 10 units of erythrocytes, include abnormal placental insertion, preeclampsia, and placental abruption. Although ratio-based transfusion has been described for managing massive hemorrhage, a goal-directed approach using laboratory or point-of-care data may lead to better outcomes. Autotransfusion, which involves the collection, washing, and filtration of maternal shed blood, avoids many of the complications associated with allogeneic blood transfusion. In this review, we provide an overview of transfusion practices related to the management of obstetric hemorrhage.
Article
A Patient Blood Management programme was established at the University Hospital of Zurich, along with a monitoring and feedback programme, at the beginning of 2014 with a first analysis reported in 2015. Our study aimed to investigate the further impact of this Patient Blood Management monitoring and feedback programme on transfusion requirements and related costs. We included adult patients discharged between 2012 and 2017. A total of 213,882 patients underwent analysis: 66,659 patients in the baseline period (2012–2013); 35,309 patients in the year after the introduction of the Patient Blood Management monitoring and feedback programme (2014) and 111,914 patients in the continued sustainability period (2015–2017). The introduction of the Patient Blood Management monitoring and feedback programme reduced allogeneic blood product transfusions by 35%, from 825 units per 1000 hospital discharges in 2012 to 536 units in 2017. The most sustained effect was an approximately 40% reduction in red blood cell transfusions, from 535 per 1000 discharges to 319 units. Fewer patients were transfused in the periods after the introduction of the Patient Blood Management monitoring and feedback programme (6251 (9.4%) vs. 2932 (8.3%) vs. 8196 (7.3%); p < 0.001). Compared with 2012, the yearly OR for being exposed to any blood transfusion declined steadily after the introduction of the Patient Blood Management monitoring and feedback programme to 0.64 (95%CI 0.61–0.68; p < 0.001) in 2017. For patients requiring extracorporeal membrane oxygenation, transfusion requirements were also sustainably reduced. This reduction in allogeneic blood transfusions led to savings of 12,713,754 Swiss francs (£ 9,497,000 sterling; EUR 11,100,000; US$ 12,440,000) in blood product acquisition costs over 4 years. In‐hospital mortality was not affected by the programme. The Patient Blood Management monitoring and feedback programme sustainably reduced transfusion requirements and related costs, without affecting in‐hospital mortality.
Article
There is an international call for countries to ensure universal health coverage. This call has been embraced in South Africa (SA) in the form of a National Health Insurance (NHI). This is expected to be financed through general tax revenue with the possibility of additional earmarked taxes including a surcharge on personal income and/or a payroll tax for employers. Currently, health services are financed in SA through allocations from general tax revenue, direct out-of-pocket payments, and contributions to medical scheme. This paper uses the most recent data set to assess the progressivity of each health financing mechanism and overall financing system in SA. Applying standard and innovative methodologies for assessing progressivity, the study finds that general taxes and medical scheme contributions remain progressive, and direct out-of-pocket payments and indirect taxes are regressive. However, private health insurance contributions, across only the insured, are regressive. The policy implications of these findings are discussed in the context of the NHI.
Article
Background: Hospital transfusion committees (HTCs) can oversee all aspects of transfusion practice at a hospital. This survey sought to identify which quality variables were being reported at HTCs around the world. Study design and methods: A working party composed of members of the Biomedical Excellence for Safer Transfusion (BEST) collaborative developed a survey of quality variables that could be potentially presented at HTC meetings. The survey was electronically sent to all BEST members who were encouraged to complete it if they were active on an HTC and to send it to other colleagues with similar experience. An expert panel was convened to determine which quality variables are the most important for review at HTC meetings. Results: There were 121 respondents; the majority were from Europe (52%), Asia (19%), or North America (19%). Most respondents (68%) were at university hospitals. Of the 117 (97%) respondents with an HTC, the committee most often met quarterly (42%) and reviewed transfusion reactions (79%) and risk management-reported events (52%). The HTCs most commonly included transfusion medicine physicians, anesthesiologists, and other physicians who regularly transfuse blood products. Some of the most commonly reported quality variables included number of blood products transfused, wasted, and expired and the number of improperly labeled specimens. The expert panel analysis revealed that some variables that were deemed important were not being frequently reported at HTCs. Conclusion: There is variability in the variables being reported at HTCs around the world with some important variables not frequently reported.
Article
Background: There is considerable uncertainty regarding the optimal haemoglobin threshold for the use of red blood cell (RBC) transfusions in anaemic patients. Blood is a scarce resource, and in some countries, transfusions are less safe than others because of a lack of testing for viral pathogens. Therefore, reducing the number and volume of transfusions would benefit patients. Objectives: The aim of this review was to compare 30-day mortality and other clinical outcomes in participants randomized to restrictive versus liberal red blood cell (RBC) transfusion thresholds (triggers) for all conditions. The restrictive transfusion threshold uses a lower haemoglobin level to trigger transfusion (most commonly 7 g/dL or 8 g/dL), and the liberal transfusion threshold uses a higher haemoglobin level to trigger transfusion (most commonly 9 g/dL to 10 g/dL). Search methods: We identified trials by searching CENTRAL (2016, Issue 4), MEDLINE (1946 to May 2016), Embase (1974 to May 2016), the Transfusion Evidence Library (1950 to May 2016), the Web of Science Conference Proceedings Citation Index (1990 to May 2016), and ongoing trial registries (27 May 2016). We also checked reference lists of other published reviews and relevant papers to identify any additional trials. Selection criteria: We included randomized trials where intervention groups were assigned on the basis of a clear transfusion 'trigger', described as a haemoglobin (Hb) or haematocrit (Hct) level below which a red blood cell (RBC) transfusion was to be administered. Data collection and analysis: We pooled risk ratios of clinical outcomes across trials using a random-effects model. Two people extracted the data and assessed the risk of bias. We conducted predefined analyses by clinical subgroups. We defined participants randomly allocated to the lower transfusion threshold as 'restrictive transfusion' and to the higher transfusion threshold as 'liberal transfusion'. Main results: A total of 31 trials, involving 12,587 participants, across a range of clinical specialities (e.g. surgery, critical care) met the eligibility criteria. The trial interventions were split fairly equally with regard to the haemoglobin concentration used to define the restrictive transfusion group. About half of them used a 7 g/dL threshold, and the other half used a restrictive transfusion threshold of 8 g/dL to 9 g/dL. The trials were generally at low risk of bias .Some items of methodological quality were unclear, including definitions and blinding for secondary outcomes.Restrictive transfusion strategies reduced the risk of receiving a RBC transfusion by 43% across a broad range of clinical specialties (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.49 to 0.65; 12,587 participants, 31 trials; high-quality evidence), with a large amount of heterogeneity between trials (I² = 97%). Overall, restrictive transfusion strategies did not increase or decrease the risk of 30-day mortality compared with liberal transfusion strategies (RR 0.97, 95% CI 0.81 to 1.16, I² = 37%; N = 10,537; 23 trials; moderate-quality evidence) or any of the other outcomes assessed (i.e. cardiac events (low-quality evidence), myocardial infarction, stroke, thromboembolism (high-quality evidence)). Liberal transfusion did not affect the risk of infection (pneumonia, wound, or bacteraemia). Authors' conclusions: Transfusing at a restrictive haemoglobin concentration of between 7 g/dL to 8 g/dL decreased the proportion of participants exposed to RBC transfusion by 43% across a broad range of clinical specialities. There was no evidence that a restrictive transfusion strategy impacts 30-day mortality or morbidity (i.e. mortality at other points, cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism, infection) compared with a liberal transfusion strategy. There were insufficient data to inform the safety of transfusion policies in certain clinical subgroups, including acute coronary syndrome, myocardial infarction, neurological injury/traumatic brain injury, acute neurological disorders, stroke, thrombocytopenia, cancer, haematological malignancies, and bone marrow failure. The findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds above 7 g/dL to 8 g/dL.