Risk‐adjusted clinical outcomes in patients enrolled in a bloodless program

Abstract

BACKGROUND Although clinical outcomes have been reported for patients who do not accept allogeneic blood transfusion (ABT), many previous studies lack a control group, fail to use risk adjustment, and focus exclusively on cardiac surgery. STUDY DESIGN AND METHODS We report a risk-adjusted, propensity score–matched, retrospective case-control study of clinical outcomes for inpatients who did not accept ABT (bloodless, n = 294) and those who did accept ABT (control, n = 1157). Multidisciplinary specialized care was rendered to the bloodless patients to conserve blood and optimize clinical outcomes. Differences in hemoglobin (Hb), mortality, five morbid outcomes, and hospital charges and costs were compared. Subgroups of medical and surgical patients were analyzed, and independent predictors of outcome were determined by multivariate analysis. RESULTS Overall, mortality was lower in the bloodless group (0.7%) than in the control group (2.7%; p = 0.046), primarily attributed to the surgical subgroup. After risk adjustment, bloodless care was not an independent predictor of the composite adverse outcome (death or any morbid event; p = 0.91; odds ratio, 1.02; 95% confidence interval, 0.68–1.53). Discharge Hb concentrations were similar in the bloodless (10.8 ± 2.7 g/dL) and control (10.9 ± 2.3 g/dL) groups (p = 0.42). Total and direct hospital costs were 12% (p = 0.02) and 18% (p = 0.02) less, respectively, in the bloodless patients, a difference attributed to the surgical subgroup. CONCLUSIONS Using appropriate blood conservation measures for patients who do not accept ABT results in similar or better outcomes and is associated with equivalent or lower costs. This specialized care may be beneficial even for those patients who accept ABT.

Bloodless medicine: what to do when you can't transfuse

“…[1][2][3] In fact, several academic health centers are establishing "Bloodless Medicine & Surgery Programs" that specialize in treating patients who do not accept allogeneic blood transfusions (ABTs). [4][5][6][7][8][9][10][11][12][13][14][15][16] A multidisciplinary approach is frequently required to optimize clinical outcomes for these patients, particularly in the setting of multiple comorbidities or high-risk surgical procedures.…”

“…[4][5][6][7][8][9][10][11][12][13][14][15][16] Based on religious beliefs, these individuals do not accept blood products considered to be "primary components," which includes RBCs, WBCs, platelets, or plasma. 4 In addition, JW patients do not typically accept autologous blood donated preoperatively, although most will accept autologous blood that is considered to be physically contiguous with one's body. 4 For example, surgical practices such as blood salvage and intraoperative autologous hemodilution can be used.…”

“…4 In addition, JW patients do not typically accept autologous blood donated preoperatively, although most will accept autologous blood that is considered to be physically contiguous with one's body. 4 For example, surgical practices such as blood salvage and intraoperative autologous hemodilution can be used. 4 Fractions of blood products, such as cryoprecipitate, albumin, clotting factors, or hemostatic agents (thrombin), can also be used in some cases because the decision to accept these products is left to the discretion of each individual.…”

“…4 For example, surgical practices such as blood salvage and intraoperative autologous hemodilution can be used. 4 Fractions of blood products, such as cryoprecipitate, albumin, clotting factors, or hemostatic agents (thrombin), can also be used in some cases because the decision to accept these products is left to the discretion of each individual. The majority of JW patients will agree to accept these products because they are considered to be "minor blood fractions" according to their religious doctrine.…”

“…Importantly, the JW faith currently includes Ͼ8 million people worldwide, with 1.2 million in the United States alone, and the number is increasing. 4 Therefore, there is a growing population of patients who require bloodless medicine. As discussed here, these patients provide a unique challenge to health care providers, particularly when presenting for surgeries or invasive procedures that can be associated with significant blood loss or for complex medical illnesses.…”