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Variation in Red Blood Cell Transfusion Practices During Cardiac Operations Among Centers in Maryland: Results From a
J Trent Magruder1, Elena Blasco-Colmenares2, Todd Crawford1
1Division of Cardiac Surgery, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Insights
Cardiac surgery centers show significant variation in red blood cell (RBC) transfusion practices, even after risk adjustment. This variability persists for both intraoperative and postoperative transfusions across different patient hematocrit levels.
Area of Science:
- Cardiology
- Transfusion Medicine
- Healthcare Quality Improvement
Background:
- Red blood cell (RBC) transfusion practices vary significantly among cardiac surgery centers nationwide.
- A study was conducted to determine if this variation persists within a state quality collaborative after accounting for patient risk factors.
Purpose of the Study:
- To test the hypothesis that significant variation in RBC transfusion practices between centers persists even after risk adjustment.
- To quantify intercenter variability in intraoperative and postoperative RBC transfusions.
Main Methods:
- Utilized a multi-institutional statewide database (Maryland Cardiac Surgery Quality Initiative - MCSQI) including 8,141 patients undergoing coronary artery bypass or aortic valve replacement.
- Employed risk-adjusted multivariable logistic regression to predict intraoperative and postoperative RBC transfusion needs.
- Included anonymized center number as a factor variable to assess intercenter variability.
Main Results:
- Unadjusted intraoperative RBC transfusion rates ranged from 13% to 60%, and postoperative rates from 16% to 41%.
- Significant intercenter variability persisted after risk adjustment, with intraoperative probabilities ranging from 4% to 59% and postoperative from 13% to 39%.
- Variability in intraoperative transfusion was evident across all preoperative hematocrit quartiles, with probabilities ranging widely (e.g., 17%-89% in the lowest quartile).
Conclusions:
- Significant intercenter variation in RBC transfusion practices exists for both intraoperative and postoperative transfusions, even after risk adjustment.
- This variability persists among centers within the state quality collaborative.
- Intraoperative RBC transfusion variability was observed across different levels of preoperative hematocrit.
Background:
Variation in red blood cell (RBC) transfusion practices exists at cardiac surgery centers across the nation. We tested the hypothesis that significant variation in RBC transfusion practices between centers in our state's cardiac surgery quality collaborative remains even after risk adjustment.
Methods:
Using a multiinstitutional statewide database created by the Maryland Cardiac Surgery Quality Initiative (MCSQI), we included patient-level data from 8,141 patients undergoing isolated coronary artery bypass (CAB) or aortic valve replacement at 1 of 10 centers. Risk-adjusted multivariable logistic regression models were constructed to predict the need for any intraoperative RBC transfusion, as well as for any postoperative RBC transfusion, with anonymized center number included as a factor variable.
Results:
Unadjusted intraoperative RBC transfusion probabilities at the 10 centers ranged from 13% to 60%; postoperative RBC transfusion probabilities ranged from 16% to 41%. After risk adjustment with demographic, comorbidity, and operative data, significant intercenter variability was documented (intraoperative probability range, 4% -59%; postoperative probability range, 13%-39%). When stratifying patients by preoperative hematocrit quartiles, significant variability in intraoperative transfusion probability was seen among all quartiles (lowest quartile: mean hematocrit value, 30.5% ± 4.1%, probability range, 17%-89%; highest quartile: mean hematocrit value, 44.8% ± 2.5%; probability range, 1%-35%).
Conclusions:
Significant variation in intercenter RBC transfusion practices exists for both intraoperative and postoperative transfusions, even after risk adjustment, among our state's centers. Variability in intraoperative RBC transfusion persisted across quartiles of preoperative hematocrit values.
