Do Institution-Level Blood Utilization and Blood Management Initiatives Meaningfully Impact Transfusion Practices in Cardiac Surgery?

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In the current issue of Anesthesia & Analgesia, Camaj et al1 present findings from a study examining “organizational contributors” to center-level variation in low volume (1–2 units) intraoperative red blood cell (RBC) transfusion rates in the setting of isolated, nonemergent coronary artery bypass grafting (CABG) procedures. Cardiac surgery programs participating in the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative were surveyed regarding organizational blood management practices at their respective institutions. For the purpose of the study, programs were stratified into 2 groups (ie, low versus high transfusion rate centers) based on each center’s 1 to 2 units intraoperative RBC transfusion rate. Survey results did not identify any meaningful differences in organizational blood management practices between low- and high-rate intraoperative transfusion centers, leading the authors to suggest that other determinants, including organizational culture and/or provider-level transfusion practices, may help to explain the variation in transfusion rates.
The transfusion of even 1 unit of RBCs is a costly procedure associated with an increased risk of postoperative morbidity and mortality in the setting of cardiac surgery.2,3 Additionally, transfusions are associated with a host of well-documented infectious and noninfectious risks, including potentially fatal transfusion reactions, transfusion-related acute lung injury, transfusion-associated circulatory overload, and alloimmunization.4 Recognizing these risks, as well as the critical importance of a responsible approach to patient blood management (PBM) for improving patient outcomes, the Society for the Advancement of Blood Management was founded in 2001. According to the Society for the Advancement of Blood Management, the average cost of transfusing just 1 unit of RBCs is $1200, while up to 50% of transfusions are prescribed for no justifiable reason, at a societal cost of $8.4 billion (excluding costs of complications).5 Accordingly, without interventions, such as center-level PBM programs, it is likely that demand for blood products will outstrip supply with a continually growing and aging patient population. It is also worth noting that cardiac surgery is among the largest consumers of blood products in medicine, accounting for up to 25% of all RBC transfusions in the United States.6,7
In light of their study results, Camaj et al1 acknowledge that there is significant support in the literature for the use and value of PBM programs.8 In particular, the authors highlight our experience at the University of Alabama at Birmingham (UAB) Hospital reported by Oliver et al.9 Recognizing a steady increase in RBC demand, exceeding desired targets (best practice benchmarks) provided by a blood management consultant, which coincided with severe RBC shortages, a multidisciplinary effort was started at UAB in 2007 to close the gap between blood collections and RBC utilization.10 Of note, 6 of the top 15 Medical Severity-Diagnostic Related Groups for RBC use involved cardiac surgery. Following institution of a restrictive RBC transfusion approach, a 43% reduction in RBC units transfused per patient discharged was observed from 2007 to 2011. Pre-PBM, 19,888 RBC units were transfused (0.96 units per patient discharged), compared with 14,472 post-PBM (0.55 units per discharge). Of further interest was the observation that the largest absolute decrease in RBC transfusion occurred in cardiovascular surgery, with a decrease of 1.5 units per patient (average of 3.3 vs 1.8 units per patient, respectively; P < .0001). This trend has continued at UAB beyond the 2011 data evaluated in the study by Oliver et al,9 both across the institution and, specifically, within cardiovascular surgery (DS Deas, MD, unpublished data, 2017). Of particular relevance to this discussion, is a significant decrease in the number of patients receiving RBC transfusions (and number of units per transfused patient) during hospitalizations for CABG procedures (Figure).

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