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All, it seems, part of a growing trend towards multimodal travel websites that provide planning for a door-to-door itinerary with several transportation modes such as car, train, bus, and plane.

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Matteo Cellini, Head of Search at Rome-based metasearch Venere believes that going forward we could start to see existing meta players facilitating the building of such packages. He could have a point. Already, one of the biggest players — Skyscanner — is seeing success with flights, hotels and cars. But Nikhil Gupta, Skyscanner, Director of Hotels says going forward the aim is provide the lowest cost, most relevant end-to-end travel service, that could involve all areas of travel - that could include multimodal packages. After all, Skyscanner has already dipped its toe in the water with bus travel in India.

Multimodal travel is already happening in a limited fashion with a growing number startups providing metasearch to these segments. Newest on the block is Gopili , the recently launched European arm of French ticketing startup KelBillet.

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A search engine that enables users to find the best travel rates in one click for more than 80, journey options, Gopili starts its Western European expansion in the UK. By presenting all of the data in one search, Gopili enables a clear overview of the options and to simplify the process. What Gopili does is to compare all transportation modes including train, rideshare, coach and plane.

Just five years ago, travellers used their personal car, the train or low cost airline companies for their domestic journeys, says Morfoise-Gauthier. The assessment of methodological quality predominantly revealed low risk of bias for intervention measurement, outcome assessment, incomplete outcome data, and selective reporting. The main categories for high risk were selection of participants and confounding variables. Twelve out of 17 studies were judged with high risk of bias for selection of participants, even though all of them reported similar demographic data between the pre-PBM and PBM cohort.

However, patients were examined at different time points due to the before-after design of respective studies. Confounding variables including adjustment analysis for confounding, treatments that differ from initial study protocol, noncompliance with the PBM protocol, and indications for further factors that may have affected results, were graded as high risk in 11 studies. Because of the study design, blinding of outcome assessment was not performed in nonrandomized trials. Over the last decade, single interventions of PBM have been implemented into clinical practice 10 ; however, only few institutions adopted measures of all 3 pillars.

To the best of our knowledge, this is the first meta-analysis including studies that targeted at least 1 measure of each pillar. In total, 17 studies were included and analysis of , surgical patients suggests that a multidisciplinary, multimodal PBM program is highly effective in reducing RBC utilization and is associated with improved postoperative outcomes in various surgical disciplines. Recent clinical trials and meta-analyses only evaluated safety and efficacy of individual PBM pillars rather than all 3 pillars together. The prevalence of preoperative anemia varied between Iron supplementation is an effective therapeutic agent to treat iron deficiency anemia and to reduce RBC transfusion need.

However, it is noteworthy, that adequate preoperative anemia management is often hindered as elective surgery is scheduled in many hospitals on short notice.

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The use of allogeneic blood products and its potential side effects has been the focus of many discussions and whether a liberal transfusion strategy is superior to a restrictive one is still under debate. As we particularly focused on a PBM program that covered all 3 pillars of PBM, our data do not allow to reveal, which PBM measure was most effective in reducing transfusion and complication rate.

We hypothesize that the required minimum of 3 measures should address the most-widely researched and complementary PBM measures, including detection and treatment of anemia first pillar , any strategy to reduce blood loss and bleeding by perioperative autologous cell salvage, use of an antifibrinolytic agent, or hemostasis management second pillar , and compliance with restrictive transfusion thresholds third pillar. The successful implementation of single pillar programs, however, might be compromised if surgery is scheduled short term or if hospitals do not have the necessary resources.

No significant association between number of implemented measures and outcome was detected probably due to heterogeneity and different impact on clinical outcomes. It is noteworthy to mention that simple addition of 2 different combinations does not double any effect size. We therefore propose that clinicians and policy makers should concentrate their efforts on the initial adoption of the 3-pillar framework, to promote a step-by-step implementation of further PBM measures that fit best to the individual conditions. Furthermore, our data indicate that PBM implementation is feasible and successful in different types of hospitals and different types of surgical disciplines.

Critical evaluation of the appropriateness and assessment of cost- effectiveness are crucial to support further dissemination and implementation of PBM. However, comparison between studies that provided cost analysis data is challenging because cost effectiveness of PBM is determined in different ways. Future studies should not only focus on blood acquisition costs but also consider cost- effectiveness for anemia management, use of cell salvage, complication rate , duration of hospital stay, adverse events to transfusion, reduced workload in hospital blood transfusion laboratories, and reduced material and general personal costs, for example.

Nevertheless, we would like to point out that the primary objective of this meta-analysis was the impact of PBM on clinical outcomes. Only a few regulatory authorities support the implementation of PBM worldwide. For example, the European Commission previously released an EU PBM implementation and dissemination guide 53,54 ; however, PBM measures are not an obligatory part of clinical routine yet.

The National Blood Authority supported the first worldwide implementation of PBM in Western Australia in 13 and the National Institute for Health and Care Excellence guidelines in the UK postulate treatment with iron in iron-deficiency anemic patients 2 weeks before surgery.

Although this meta-analysis provides important and novel data, there are a few limitations. Due to the current body of evidence, we provide specified results for orthopedic, cardiac, vascular, and general surgery. The extent to which our conclusions can be generalized or applied to other surgical or medical fields demands further investigations. We cannot exclude that additional references might have been missed by our systematic search of databases, particularly during the years before the term PBM was introduced in Furthermore, differences in clinical implementation, treatment duration, study designs, and characteristics of included studies may have contributed to heterogeneity.

Differences in perioperative care apart from PBM interventions may have contributed to positive clinical outcomes. Two studies indicated additional physiotherapeutic treatments enhanced recovery program, 28 more aggressive mobilization 29 and were consequently judged as high risk for confounding variables. Loftus et al stated that the participation rate was similar between the pre-PBM and the PBM group, and Ma et al argued that the improved mobilization rate was the result of fewer symptoms of anemia.

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A meta-analysis of large prospective randomized controlled trials would be preferred to relate changes in outcome parameters resulting from blood conservation and management. In view of the current literature that supports the beneficial effects of individual PBM measures and published guidelines, 53,54,57 some national authorities may decline any approval of a prospective and randomized comparison between multimodal PBM interventions versus a control treatment without attention to prevent anemia, to minimize blood loss, and to respect physiological transfusion thresholds.

In conclusion, our study has several implications for clinical practice.

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In addition, the successful implementation of PBM was associated with a significant reduction in complication rate and mortality. In this manner, results of this first meta-analysis investigating a multimodal approach should enable all executives and health care providers to support and strengthen further activities in the field of PBM.

The authors would like to thank the following authors of included studies for providing clarification of data or additional information: J. The cooperative collaboration was essential to include all available data in our meta-analysis. You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page. Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent.

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Availability, safety and quality of blood products. Accessed October 27, Cited Here Transfusion medicine: looking to the future.

References currently unavailable

Lancet ; — PubMed CrossRef. Patient blood management : the global view. Transfusion ; 56 suppl 1 :S94—S Goodnough LT, Shander A. Patient blood management. Anesthesiology ; — Patient blood management bundles to facilitate implementation. Transfus Med Rev ; — Implementation of a blood management program at a tertiary care hospital: effect on transfusion practices and clinical outcomes among patients undergoing surgery. Ann Surg ; Nov 2 [Epub ahead of print]. Association between preoperative anaemia with length of hospital stay among patients undergoing primary total knee arthroplasty in Singapore: a single-centre retrospective study.

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BMJ Open ; 7:e The efficacy of an intraoperative cell saver during cardiac surgery: a meta-analysis of randomized trials. Anesth Analg ; — Harms associated with single unit perioperative transfusion: retrospective population based analysis. BMJ ; h Butcher A, Richards T. Cornerstones of patient blood management in surgery. Transfus Med ; — Implementation of a patient blood management monitoring and feedback program significantly reduces transfusions and costs. Transfusion ; — A model-based cost- effectiveness analysis of patient blood management. Blood Transfusion ; — Best Pract Res Clin Anaesthesiol ; — Isbister JP.

The three-pillar matrix of patient blood management. Ann Intern Med ; — Meta-analysis of observational studies in epidemiology: a proposal for reporting. JAMA ; — Testing a tool for assessing the risk of bias for nonrandomized studies showed moderate reliability and promising validity. J Clin Epidemiol ; — Higgins J, Green S.

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Accessed September. Assessment of the introduction of a blood management program in orthopaedic surgery. Rev Esp Anestesiol Reanim ; — Blood transfusion reduction in cardiac surgery: multidisciplinary approach at a community hospital. Ann Thorac Surg ; — View Full Text PubMed. Impact of a blood management protocol on transfusion rates and outcomes following total hip and knee arthroplasty. Ann R Coll Surg Engl ; —