Rates of blood transfusions for CABG surgery varies widely among US hospitals

October 12, 2010

A study that includes data on more than 100,000 patients who underwent coronary artery bypass graft surgery finds that there is wide variability among hospitals in the U.S. on the use of blood transfusions, without a large difference in the rate of death, suggesting that many transfusions may be unnecessary, according to a study in the October 13 issue of JAMA. Another study in this issue of JAMA examines the effect of a restrictive transfusion strategy on outcomes after cardiac surgery.

"Patients who undergo cardiac surgery receive a significant proportion of the 14 million units of allogeneic [taken from a different individual] red blood cells (RBCs) transfused annually in the United States," the authors write. "Perioperative [around the time of surgery] blood transfusions are costly and have safety concerns. As a result, there have been multiple initiatives to reduce transfusion use. However, the degree to which perioperative transfusion rates vary among hospitals is unknown."

Elliott Bennett-Guerrero, M.D., of Duke University Medical Center, Durham, N.C., and colleagues conducted a study to assess the use of RBC, fresh-frozen plasma, and platelet transfusions in coronary artery bypass graft (CABG) surgery in current practice, and to determine the degree to which transfusion practices vary among U.S. hospitals. The study included 102,470 patients undergoing CABG surgery during 2008 at 798 sites in the United States.

The researchers found significant variability in the observed hospital-specific transfusion rates for all 3 blood products among the patients and hospitals included in the study. To ensure that between-center differences would not be dominated by random statistical variation, the researchers also analyzed the subset of hospitals performing at least 100 eligible on-pump CABG operations during the year. At these 408 sites (n = 82,446 cases), the frequency of blood transfusion rates ranged from 7.8 percent to 92.8 percent for RBCs, 0 percent to 97.5 percent for fresh-frozen plasma, and 0.4 percent to 90.4 percent for platelets.

"Multivariate analysis including data from all 798 sites (102,470 cases) revealed that after adjustment for patient-level risk factors, hospital transfusion rates varied by geographic location, academic status, and hospital volume. However, these 3 hospital characteristics combined only explained 11.1 percent of the variation in hospital risk-adjusted RBC usage," the authors write.

There was no significant association between hospital-specific RBC transfusion rates and all-cause mortality.

"As is the case in other areas of medicine, the degree of variability in clinical practice we observed represents a potential quality improvement opportunity. This is particularly complex in relation to transfusion practice in CABG surgery. The decision to transfuse has multiple triggers, resulting from a wide array of clinical scenarios and the consequent inability to apply standardized algorithms. The multiplicity of health care practitioners in CABG surgery care generates differences of opinion about safety and efficacy. Transfusion thresholds will change during the course of care; the threshold for a rapidly bleeding patient is different than for a stable patient postoperatively. Improvement in quality related to transfusion practice in CABG surgery is a multifactorial, complex but critically important, challenge," the researchers write.

(JAMA. 2010;304[14]:1568-1575. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Blood Transfusion as a Quality Indicator in Cardiac Surgery

In an accompanying editorial, Aryeh S. Shander, M.D., of Englewood Hospital and Medical Center, Englewood, N.J., and Lawrence T. Goodnough, M.D., of the Stanford University School of Medicine, Stanford, Calif., write that this study provides a snapshot of transfusion practices in a subset of patients undergoing cardiac surgery across the United States.

"The data showing highly variable transfusion rates are disconcerting. Yet despite magnitudes of differences between hospitals in terms of RBC transfusion rates, there were no significant differences in mortality rates between the hospitals. The absence of differences in mortality among centers with varying transfusion rates strongly suggests inappropriate transfusions."

(JAMA. 2010;304[14]:1610-16111. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

The JAMA Network Journals

Related Cardiac Surgery Articles from Brightsurf:

New surgical tools with smart sensors can advance cardiac surgery and therapy
Researchers developed a new class of medical instruments equipped with an advanced soft electronics system that could dramatically improve the diagnoses and treatments of a number of cardiac diseases and conditions.

How commonly do patients develop persistent opioid use after cardiac surgery?
A large, national database was used to determine how common it was for patients who hadn't used opioids before undergoing a coronary artery bypass grafting or heart valve procedure to subsequently develop persistent opioid use after surgery.

Preoperative levels of heart proteins may help predict death or cardiac complications in patients undergoing noncardiac surgery
Assessing preoperative levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), a biomarker of heart stress and structural changes, may improve risk prediction beyond the clinical risk score in patients having noncardiac surgery.

Study finds connection between cardiac blood test before surgery and adverse outcomes
The VISION study looked at whether levels of a cardiac blood test, NT-proBNP, measured before surgery can predict cardiac and vascular complications.

Mayo Clinic study: 20% of patients are prescribed opioids after cardiac device implantation surgery
One in five patients is prescribed opioids after having a pacemaker or similar device implanted, according to a large US study conducted at Mayo Clinic published in HeartRhythm.

Careful monitoring of children following cardiac surgery may improve long-term outcomes
In a medical records study covering thousands of children, a US-Canadian team led by researchers at Johns Hopkins Medicine concludes that while surgery to correct congenital heart disease (CHD) within 10 years after birth may restore young hearts to healthy function.

Chest cavity fire during emergency cardiac surgery
At this year's Euroanaesthesia Congress (the annual meeting of the European Society of Anaesthesiology) in Vienna, Austria (1-3 June), doctors present the unique case of a man who suffered a flash fire in his chest cavity during emergency heart surgery caused by supplemental oxygen leaking from a ruptured lung.

Steroid use during cardiac bypass surgery did not reduce risk of severe kidney injury
Using steroids during cardiopulmonary bypass surgery did not reduce the risk of acute kidney injury in people at increased risk of death, according to a study conducted in 18 countries published in CMAJ (Canadian Medical Association Journal).

Cardiac surgery for patients with persistent opioid use associated with higher rate of complications, increased costs
Persistent use of opioids by patients is a public health concern in the United States but not much is known about the effect of that use on patients undergoing cardiac surgery.

Blood thinner significantly reduces the risk of death after non-cardiac surgery
The study enrolled 1,754 patients in 19 countries, 51 percent of whom were male, with an average age of 70 years.

Read More: Cardiac Surgery News and Cardiac Surgery Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.