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Determinants of hospital variability in perioperative red blood cell transfusions during coronary artery bypass graft
David C Fitzgerald1, Annie N Simpson1, Robert A Baker2
1College of Health Professions, Medical University of South Carolina, Charleston, SC.
Insights
Patient and procedural factors alone do not explain variations in red blood cell transfusions during coronary artery bypass grafting surgery. Further investigation into organizational culture and infrastructure is needed to understand these transfusion practice differences.
Area of Science:
- Cardiovascular Surgery
- Transfusion Medicine
- Health Services Research
Background:
- Significant variation exists in allogeneic red blood cell transfusion rates among centers performing coronary artery bypass grafting (CABG).
- Understanding the drivers of this variation is crucial for optimizing transfusion strategies and patient outcomes.
Purpose of the Study:
- To determine the extent to which patient and procedural characteristics explain center-level transfusion variation in CABG surgery.
- To identify factors contributing to disparities in transfusion practices across different cardiac surgical programs.
Main Methods:
- An observational cohort study was conducted using data from 43 adult cardiac surgical programs (July 2011-July 2017).
- Iterative multilevel logistic regression models incorporated patient demographics, preoperative risk factors, and intraoperative strategies to analyze transfusion variability.
- A total of 22,272 patients undergoing isolated CABG with cardiopulmonary bypass were included.
Main Results:
- 32.5% of patients received at least one unit of red blood cells, with center-level rates ranging from 10.9% to 59.9%.
- Transfused patients were older, more likely to be women, and had a lower body surface area.
- Models including patient and intraoperative factors explained only a modest portion of the center-level transfusion variation (intraclass correlation coefficients ranging from 0.12 to 0.14).
Conclusions:
- Patient and procedural factors alone are insufficient to explain the observed center-level variation in red blood cell transfusions during CABG.
- Further research into organizational culture and programmatic infrastructure is warranted to fully understand and address transfusion practice variability.
Objective:
To identify to what extent distinguishing patient and procedural characteristics can explain center-level transfusion variation during coronary artery bypass grafting surgery.
Methods:
Observational cohort study using the Perfusion Measures and Outcomes Registry from 43 adult cardiac surgical programs from July 1, 2011, to July 1, 2017. Iterative multilevel logistic regression models were constructed using patient demographic characteristics, preoperative risk factors, and intraoperative conservation strategies to progressively explain center-level transfusion variation.
Results:
Of the 22,272 adult patients undergoing isolated coronary artery bypass surgery using cardiopulmonary bypass, 7241 (32.5%) received at least 1 U allogeneic red blood cells (range, 10.9%-59.9%). When compared with patients who were not transfused, patients who received at least 1 U red blood cells were older (68 vs 64 years; P < .001), were women (41.5% vs 15.9%; P < .001), and had a lower body surface area (1.93 m2 vs 2.07 m2; P < .001), respectively. Among the models explaining center-level transfusion variability, the intraclass correlation coefficients were 0.07 for model 1 (random intercepts), 0.12 for model 2 (patient factors), 0.14 for model 3 (intraoperative factors), and 0.11 for model 4 (combined). The coefficient of variation for center-level transfusion rates were 0.31, 0.29, 0.40, and 0.30 for models 1 through 4, respectively. The majority of center-level variation could not be explained through models containing both patient and intraoperative factors.
Conclusions:
The results suggest that variation in center-level red blood cells transfusion cannot be explained by patient and procedural factors alone. Investigating organizational culture and programmatic infrastructure may be necessary to better understand variation in transfusion practices.
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