title: Improving decision making for massive transfusions in a resource poor setting: a preliminary study in Kenya.
abstract: BACKGROUND
  The reality of finite resources has a real-world impact on a patient's ability to receive life-saving care in resource-poor settings. Blood for transfusion is an example of a scarce resource. Very few studies have looked at predictors of survival in patients requiring massive transfusion. We used data from a rural hospital in Kenya to develop a prediction model of survival among patients receiving massive transfusion.
  
  
  METHODS
  Patients who received five or more units of whole blood within 48 hours between 2004 and 2010 were identified from a blood registry in a rural hospital in Kenya. Presenting characteristics and in-hospital survival were collected from charts. Using stepwise selection, a logistic model was developed to predict who would survive with massive transfusion versus those who would die despite transfusion. An ROC curve was created from this model to quantify its predictive power.
  
  
  RESULTS
  Ninety-five patients with data available met inclusion criteria, and 74% survived to discharge. The number of units transfused was not a predictor of mortality, and no threshold for futility could be identified. Preliminary results suggest that initial blood pressure, lack of comorbidities, and indication for transfusion are the most important predictors of survival. The ROC curve derived from our model demonstrates an area under the curve (AUC) equal to 0.757, with optimism of 0.023 based on a bootstrap validation.
  
  
  CONCLUSIONS
  This study provides a framework for making prioritization decisions for the use of whole blood in the setting of massive bleeding. Our analysis demonstrated an overall survival rate for patients receiving massive transfusion that was higher than clinical perception. Our analysis also produced a preliminary model to predict survival in patients with massive bleeding. Prediction analyses can contribute to more efficient prioritization decisions; these decisions must also include other considerations such as equity, acceptability, affordability and sustainability.
authors.affiliation: Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: Elisabeth D
authors.initials: ED
authors.lastname: Riviello
authors.affiliation: Africa Inland Church Kijabe Hospital, Kijabe, Kenya.
authors.forename: Stephen
authors.initials: S
authors.lastname: Letchford
authors.affiliation: Harvard School of Public Health, Boston, Massachusetts, United States of America.
authors.forename: Earl Francis
authors.initials: EF
authors.lastname: Cook
authors.affiliation: Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: Aaron B
authors.initials: AB
authors.lastname: Waxman
authors.affiliation: Harvard School of Public Health, Boston, Massachusetts, United States of America; Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: Thomas
authors.initials: T
authors.lastname: Gaziano
mesh_terms: D001803:Blood Transfusion; D003657:Decision Making; D018572:Disease-Free Survival; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D008297:Male; D008954:Models, Biological; D012042:Registries; D015996:Survival Rate; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy