Geographic variability in potentially discretionary red blood cell transfusions after coronary artery bypass graft surgery

Abstract

We assessed regional differences in potentially discretionary [<3 units of red blood cell (RBC)] transfusions across 56 medical centers and 11,200 patients undergoing isolated non-emergent coronary artery bypass (CABG) surgery. Regional variation in overall RBC rates remained after risk adjustment, perhaps due to differences in regional practice environments. Objective A number of established regional quality improvement collaboratives have partnered to assess and improve care across their regions under the umbrella of the “Cardiac Surgery Quality IMPROVEment (IMPROVE) Network”. The first effort of the IMPROVE Network has been to assess regional differences in potentially discretionary [<3 units of red blood cell (RBC)] transfusions. Methods We examined 11,200 patients undergoing isolated non-emergent coronary artery bypass (CABG) surgery across 56 medical centers in four IMPROVE Network regions between January 2008 and June 2012. Each center submitted the most recent 200 patients who received 0, 1, or 2 units of RBC transfusion during the index admission. Patient and disease characteristics, intra-operative practices, and percentage of cases receiving RBC transfusions were collected. Region-specific transfusion rates were calculated, after adjusting for pre- and intra-operative factors among region-specific centers. Results There were small, but significant, differences in patient case mix across regions. RBC transfusions of 1 or 2 units occurred among 25.2% (2,826/11,200) of CABG procedures. Significant variation in use and number of RBCs existed across regions [None: 74.8% (min:max 70.0%, 84.1%), 1 unit: 9.7% (5.1%, 11.8%), 2 units: 15.5% (9.1%, 18.2%)], p<0.001. Variation in overall transfusion rates remained after adjustment (9.1% – 31.7%, p<0.001). Conclusions Delivery of small volumes of RBC transfusions was common, yet varied across geographic regions. These data suggest that differences in regional practice environments, including transfusion triggers and anemia management, may contribute to variability in RBC transfusion rates.

Continued decline in blood collection and transfusion in the United States–2015

“…The shift toward transfusion of fewer blood products nationally, in part, can be attributed to a growing evidence base that supports the judicious use of blood and blood products. For example, inconsistent use of blood products during various surgical procedures, including coronary artery bypass grafting, has heightened scrutiny over the appropriateness of transfusion across medical and surgical procedures . Recent studies also have described an association between liberal transfusion policies and increased incidence of health care‐associated infections, including surgical site infections and sepsis .…”

“…For example, inconsistent use of blood products during various surgical procedures, including coronary artery bypass grafting, has heightened scrutiny over the appropriateness of transfusion across medical and surgical procedures. [25][26][27][28] Recent studies also have described an association between liberal transfusion policies and increased incidence of health care-associated infections, 29 including surgical site infections and sepsis. 30,31 Other studies have implicated high PLT dosing as a risk factor for transfusion-associated adverse events, 32,33 and transfusions in patients with certain gastrointestinal and other metastatic diseases may be associated with reduced chances of remission and survival.…”

Declining blood collection and utilization in the United States

“…Declining blood utilization in the United States more likely represents the impact of PBM initiatives and other improvements in clinical practices, such as decrease in myeloablative transplantation, increase in minimally invasive surgery, success with cytokine‐based therapies, and immunosuppression for aplastic anemia . Previous studies have described wide variations in transfusion practice with a substantial proportion of transfusions identified as inappropriate . Additionally, risks related to transfusions, including adverse transfusion‐related reactions, associations with healthcare‐associated infections, increased cancer recurrence, and poorer surgical outcomes have been described .…”

“…[28][29][30][31] Previous studies have described wide variations in transfusion practice with a substantial proportion of transfusions identified as inappropriate. [32][33][34] Additionally, risks related to transfusions, including adverse transfusion-related reactions, associations with healthcare-associated infections, increased cancer recurrence, and poorer surgical outcomes have been described. 2,13,[35][36][37] Therefore, PBM interventions have focused on the reduction of the need for transfusion and thereby improve patient outcomes.…”

Patient blood management

“…The decision to transfuse also includes the individual patient characteristics and symptoms [9,[17][18][19]. Therefore, it is not surprising that a huge variability in the administration of blood and blood products exist between countries, centers, and physicians worldwide [20]. Nevertheless, this might explain but does not legitimate RBC transfusion variability for example from 1.5 to 77.8% for total hip replacement [21], 2-48% for primary colectomy, 22-66% for coronary artery bypass surgery [22,23], and 3-79% for primary pancreaticoduodenectomy [21], respectively.…”