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Trends in blood utilization in United States cardiac surgical patients
Michael P Robich1, Colleen G Koch2, Douglas R Johnston1
1Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Insights
Blood product use in cardiac surgery increased significantly after 2007 guidelines. Patient and hospital factors influenced transfusion rates, but overall utilization rose despite recommendations.
Area of Science:
- Cardiovascular Surgery
- Transfusion Medicine
- Health Services Research
Background:
- The Society of Thoracic Surgeons published blood conservation guidelines in 2007.
- The impact of these guidelines on transfusion rates and influencing factors remains unclear.
Purpose of the Study:
- To evaluate the effect of 2007 blood conservation guidelines on transfusion rates in cardiac surgery.
- To identify patient- and hospital-level factors associated with blood product usage.
Main Methods:
- Analysis of 4,465,016 cardiac surgery patients from the Nationwide Inpatient Sample (1999-2010).
- Comparison of transfusion rates before (n=3,202,404) and after (n=1,262,612) guideline publication.
- Hierarchical linear modeling to account for patient and hospital clustering.
Main Results:
- Overall blood product transfusion rates increased from 13% in 1999 to 34% in 2010.
- Aortic aneurysm repair (54%), valvular operations (36%), and combined operations (40%) showed high transfusion rates in 2010.
- Anemia, coagulopathy, diabetes, renal failure, and liver disease were significant risk factors for transfusion. Higher-volume hospitals used fewer products.
Conclusions:
- Blood product utilization in cardiac surgery has increased post-2007 guidelines, irrespective of patient and hospital factors.
- Further strategies are needed to effectively reduce blood product usage in cardiac surgery.
- Cell salvage use remained low (<5%) throughout the study period.
Background:
We sought to determine whether publication of blood conservation guidelines by the Society of Thoracic Surgeons in 2007 influenced transfusion rates and to understand how patient- and hospital-level factors influenced blood product usage.
Study Design And Methods:
We identified 4,465,016 patients in the Nationwide Inpatient Sample database who underwent cardiac operations between 1999 and 2010 (3,202,404 before the guidelines and 1,262,612 after). Hierarchical linear modeling was used to account for hospital- and patient-level clustering.
Results:
Transfusion rates of blood products increased from 13% in 1999 to a peak of 34% in 2010. Use of all blood components increased over the study period. Aortic aneurysm repair had the highest transfusion rate with 54% of patients receiving products in 2010. In coronary artery bypass grafting, the number of patients receiving blood products increased from 12% in 1999 to 32% in 2010. Patients undergoing valvular operations had a transfusion rate of 15% in 1999, increasing to 36% in 2010. Patients undergoing combined operations had an increase from 13% to 40% over 11 years. Risk factors for transfusion were anemia (odds ratio [OR], 2.05; 95% confidence interval [CI], 2.01-2.09), coagulopathy (OR, 1.54; 95% CI, 1.51-1.57), diabetes (OR, 1.32; 95% CI, 1.28-1.36), renal failure (OR, 1.29; 95% CI, 1.26-1.32), and liver disease (OR, 1.23; 95% CI, 1.16-1.31). Compared to the Northeast, the risk for transfusion was significantly lower in the Midwest; higher-volume hospitals used fewer blood products than lower-volume centers. Cell salvage usage remained below 5% across all years.
Conclusion:
Independent of patient- and hospital-level factors, blood product utilization continues to increase for all cardiac operations despite publication of blood conservation guidelines in 2007.
