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Blood Transfusion as a Quality Indicator in Cardiac Surgery

Blood Transfusion as a Quality Indicator in Cardiac Surgery In 2007, the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists issued clinical practice guidelines on perioperative blood transfusion and blood conservation in cardiac surgery.1 In a 2009 follow-up survey of clinicians considered the primary target group of these guidelines, more than two-thirds of respondents indicated some degree of familiarity with the guidelines.2 However, reported changes in practice resulting from the guidelines were limited, and about half of the respondents indicated that they did not adhere to the recommended reduced hemoglobin cutoff points as transfusion triggers. Guidelines for blood transfusion have been proposed that attest to the inadequacy of discrete hemoglobin levels as “triggers” for transfusion and acknowledge the necessity of taking other physiologic criteria into account.1,3 It is generally agreed that transfusion is not of benefit when hemoglobin levels are greater than 10 g/dL and possibly of benefit when hemoglobin levels are less than 6 g/dL. Indications for transfusion in patients with hemoglobin levels within these parameters are often tied to other factors such as existing comorbid conditions and perceived risks of discrete organ ischemia. Another common theme in these guidelines is the limited evidence available to support the recommendations, along with frequent calls for research that could lead to further guidance from level 1 evidence. In this issue of JAMA, 2 articles address distinct but related aspects of blood transfusion. Hajjar et al4 report results from a noninferiority randomized controlled trial (RCT) comparing 502 patients undergoing cardiac surgery with cardiopulmonary bypass at a single referral center in São Paulo, Brazil, who were assigned to perioperative red blood cell (RBC) transfusion strategies aimed at maintaining hematocrit at or greater than 30% (hemoglobin approximately 10 g/dL) vs 24% (hemoglobin approximately 8 g/dL). The transfusion strategies resulted in transfusion rates of 78% and 47%, respectively. Patients randomized to either group had comparable mortality and morbidity outcomes. In the other study, Bennett-Guerrero et al5 analyzed data from more than 100 000 patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass in 2008 at 798 centers across the United States and observed substantial variation in rates of RBC (7.8%-92.8%), plasma (0%-97.5%), and platelet (0.4%-90.4%) transfusions (range of rates from 408 larger-volume hospitals provided). The variability in transfusion rates persisted after adjusting for a number of patient- and hospital-related factors. The study by Hajjar et al4 is a notable addition to the existing body of evidence on the narrow benefits of RBC transfusion and its effect on outcomes in patients without hemorrhage. These studies have suggested that reduction or avoidance of transfusion in cardiac patients is associated with improved outcomes.6,7 Given the ethical complexities and methodological challenges, to date no RCT has been conducted comparing a transfused group with a nontransfused group. Transfusion RCTs instead have focused on comparing various transfusion strategies, which may undercut the observed magnitude of differences. Only a minority of patients who are screened and eligible to participate in RCTs agree to do so: 40%, for example, in the TRICC (Transfusion Requirements in Critical Care) study8 and less than 50% in the study by Hajjar et al.4 The subsequent lack of differences in outcomes for these trials may be biased by treating physicians accurately determining, a priori, that their enrolled patients would survive participation in the study. Additionally, cell salvage was not used in the study by Hajjar et al,4 and frequent blood draws performed as part of the study procedures could have contributed to iatrogenic anemia. Moreover, use of relatively fresh, nonleukodepleted blood units in this trial may limit the applicability of the results to other settings. These factors could have contributed to the transfusion rates being relatively high in both study groups. Despite (or because of) these limitations, the trial by Hajjar et al4 showed that patients undergoing cardiac surgery who received fewer RBC transfusions did as well as those transfused more liberally, with no evidence of ischemia or impaired delivery of oxygen to tissues. The study by Bennett-Guerrero et al5 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. Transfusion decisions depend on several factors such as institutional transfusion policies, blood ordering procedures, and availability of blood conservation strategies. Only around 11% of the variation in RBC transfusion rates was explained by hospital characteristics in the study by Bennett-Guerrero et al.5 Additional patient characteristics included several factors known to affect the probability of RBC transfusion and accounted for only 20% of variability in RBC transfusion rates among the hospitals. With the mortality rates unaffected, it is reasonable to assume that most of the blood ordered in hospitals with high transfusion rates was unjustified, consistent with data from other studies2,9,10 Continued inappropriate transfusions among hospitals is a major concern. Transfusions carry risks and are costly, and the supply of blood is limited. Substantial variation in transfusion practices in cardiac surgery was documented in 1991.9 However, despite subsequent publication of transfusion practice guidelines, substantial variability in transfusion practices persisted.10 Now, more than a decade later, the study by Bennett-Guerrero et al5 again documents substantial and unacceptable variation in transfusion practice. Published guidelines have not been effective in reducing this variability in blood transfusion. Institution-level blood management protocols11 are a preferred approach, including demonstration projects supported at the federal or state level to identify and target specific transfusion practices and patient outcomes. Other potential approaches at the institution level include use of computerized practitioner order entry, which can leverage strategies such as requiring information from treating physicians for transfusion indications in blood product order forms; utilization audits; and benchmarking. The measures of quality used by the Society of Thoracic Surgeons in the ratings of cardiac surgery programs do not identify or include RBC transfusions as a quality indicator.12 It may be time for patient blood management to gain status as a performance indicator by accreditation agencies such as the Joint Commission13 or as a quality indicator by professional organizations such as the Society of Thoracic Surgeons as part of transparency and public rankings for consumers. The conservation of blood in cardiac surgery was originally stimulated by concerns that blood product inventory would be inadequate to meet the needs of newly developing open heart surgical programs.14 Subsequently, the recognition of transfusion-related complications, many of which were first described in patients undergoing cardiac surgery, fueled further efforts to limit blood transfusion needs in this setting.15 More recently, accurate accounting of the costs of RBC transfusion has led to the realization that alternatives to allogeneic RBC transfusion (eg, autologous blood salvage and reinfusion) may be increasingly cost-equivalent. Of these 3 motivations for conservative transfusion behavior (blood inventory, blood risks, and blood costs), the primary motivation should be to avoid known (and unknown) risks. The influence of attending surgeons' attitudes has been documented.16 When evaluating a hemoglobin level, treating physicians must resist the temptation to “first do something” and temper this temptation with a philosophy of “first do no harm” to achieve the optimal balance of providing the best risk-benefit and cost-effective outcomes of transfusion therapy for patients. Back to top Article Information Corresponding Author: Lawrence Tim Goodnough, MD, Departments of Pathology and Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Room H-1402, 5626, Stanford, CA 94305-5626 (lgoodnough@stanfordmed.org). Financial Disclosures: None reported. Additional Contributions: We thank Mazyar Javidroozi MD, PhD (Department of Anesthesiology and Critical Care, Englewood Medical Center, Englewood, New Jersey), for his review and input. Dr Javidroozi received no compensation for his contributions. Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association. References 1. Ferraris VA, Ferraris SP, Saha SP, et al; Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg. 2007;83(5):(suppl) S27-S8617462454PubMedGoogle ScholarCrossref 2. Likosky DS, FitzGerald DC, Groom RC, et al. Effect of the perioperative blood transfusion and blood conservation in cardiac surgery clinical practice guidelines of the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists upon clinical practices. Anesth Analg. 2010;111(2):316-32320488928PubMedGoogle ScholarCrossref 3. Consensus conference. Perioperative red blood cell transfusion. JAMA. 1988;260(18):2700-27033054179PubMedGoogle ScholarCrossref 4. Hajjar LA, Vincent J-L, Galas FRBG, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010;304(14):1559-1567Google ScholarCrossref 5. Bennett-Guerrero E, Zhao Y, O’Brien SM, et al. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA. 2010;304(14):1568-1575Google ScholarCrossref 6. Veenith T, Sharples L, Gerrard C, Valchanov K, Vuylsteke A. Survival and length of stay following blood transfusion in octogenarians following cardiac surgery. Anaesthesia. 2010;65(4):331-33620148816PubMedGoogle ScholarCrossref 7. Moskowitz DM, McCullough JN, Shander A, et al. The impact of blood conservation on outcomes in cardiac surgery: is it safe and effective? Ann Thorac Surg. 2010;90(2):451-45820667328PubMedGoogle ScholarCrossref 8. Hébert PC, Wells G, Blajchman MA, et al; Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med. 1999;340(6):409-4179971864PubMedGoogle ScholarCrossref 9. Goodnough LT, Johnston MF, Toy PT.Transfusion Medicine Academic Award Group. The variability of transfusion practice in coronary artery bypass surgery. JAMA. 1991;265(1):86-901984129PubMedGoogle ScholarCrossref 10. Stover EP, Siegel LC, Parks R, et al; Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study. Anesthesiology. 1998;88(2):327-3339477051PubMedGoogle ScholarCrossref 11. Goodnough LT, Shander A. Blood management. Arch Pathol Lab Med. 2007;131(5):695-70117488154PubMedGoogle Scholar 12. Shahian DM, Edwards FH, Ferraris VA, et al; Society of Thoracic Surgeons Quality Measurement Task Force. Quality measurement in adult cardiac surgery, part 1: conceptual framework and measure selection. Ann Thorac Surg. 2007;83(4):(suppl) S3-S1217383407PubMedGoogle ScholarCrossref 13. Blood Management Performance Measures Project. Joint Commission Web site. http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Blood+Management.htm. March 5, 2010. Accessed September 17, 2010 14. Newman MM, Hamstra R, Block M. Use of banked autologous blood in elective surgery. JAMA. 1971;218(6):861-8635170923PubMedGoogle ScholarCrossref 15. Cosgrove DM, Loop FD, Lytle BW, et al. Determinants of blood utilization during myocardial revascularization. Ann Thorac Surg. 1985;40(4):380-3844051620PubMedGoogle ScholarCrossref 16. Salem-Schatz SR, Avorn J, Soumerai SB. Influence of clinical knowledge, organizational context, and practice style on transfusion decision making. Implications for practice change strategies. JAMA. 1990;264(4):476-4832366281PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Blood Transfusion as a Quality Indicator in Cardiac Surgery

JAMA , Volume 304 (14) – Oct 13, 2010

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American Medical Association
Copyright
Copyright © 2010 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2010.1483
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Abstract

In 2007, the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists issued clinical practice guidelines on perioperative blood transfusion and blood conservation in cardiac surgery.1 In a 2009 follow-up survey of clinicians considered the primary target group of these guidelines, more than two-thirds of respondents indicated some degree of familiarity with the guidelines.2 However, reported changes in practice resulting from the guidelines were limited, and about half of the respondents indicated that they did not adhere to the recommended reduced hemoglobin cutoff points as transfusion triggers. Guidelines for blood transfusion have been proposed that attest to the inadequacy of discrete hemoglobin levels as “triggers” for transfusion and acknowledge the necessity of taking other physiologic criteria into account.1,3 It is generally agreed that transfusion is not of benefit when hemoglobin levels are greater than 10 g/dL and possibly of benefit when hemoglobin levels are less than 6 g/dL. Indications for transfusion in patients with hemoglobin levels within these parameters are often tied to other factors such as existing comorbid conditions and perceived risks of discrete organ ischemia. Another common theme in these guidelines is the limited evidence available to support the recommendations, along with frequent calls for research that could lead to further guidance from level 1 evidence. In this issue of JAMA, 2 articles address distinct but related aspects of blood transfusion. Hajjar et al4 report results from a noninferiority randomized controlled trial (RCT) comparing 502 patients undergoing cardiac surgery with cardiopulmonary bypass at a single referral center in São Paulo, Brazil, who were assigned to perioperative red blood cell (RBC) transfusion strategies aimed at maintaining hematocrit at or greater than 30% (hemoglobin approximately 10 g/dL) vs 24% (hemoglobin approximately 8 g/dL). The transfusion strategies resulted in transfusion rates of 78% and 47%, respectively. Patients randomized to either group had comparable mortality and morbidity outcomes. In the other study, Bennett-Guerrero et al5 analyzed data from more than 100 000 patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass in 2008 at 798 centers across the United States and observed substantial variation in rates of RBC (7.8%-92.8%), plasma (0%-97.5%), and platelet (0.4%-90.4%) transfusions (range of rates from 408 larger-volume hospitals provided). The variability in transfusion rates persisted after adjusting for a number of patient- and hospital-related factors. The study by Hajjar et al4 is a notable addition to the existing body of evidence on the narrow benefits of RBC transfusion and its effect on outcomes in patients without hemorrhage. These studies have suggested that reduction or avoidance of transfusion in cardiac patients is associated with improved outcomes.6,7 Given the ethical complexities and methodological challenges, to date no RCT has been conducted comparing a transfused group with a nontransfused group. Transfusion RCTs instead have focused on comparing various transfusion strategies, which may undercut the observed magnitude of differences. Only a minority of patients who are screened and eligible to participate in RCTs agree to do so: 40%, for example, in the TRICC (Transfusion Requirements in Critical Care) study8 and less than 50% in the study by Hajjar et al.4 The subsequent lack of differences in outcomes for these trials may be biased by treating physicians accurately determining, a priori, that their enrolled patients would survive participation in the study. Additionally, cell salvage was not used in the study by Hajjar et al,4 and frequent blood draws performed as part of the study procedures could have contributed to iatrogenic anemia. Moreover, use of relatively fresh, nonleukodepleted blood units in this trial may limit the applicability of the results to other settings. These factors could have contributed to the transfusion rates being relatively high in both study groups. Despite (or because of) these limitations, the trial by Hajjar et al4 showed that patients undergoing cardiac surgery who received fewer RBC transfusions did as well as those transfused more liberally, with no evidence of ischemia or impaired delivery of oxygen to tissues. The study by Bennett-Guerrero et al5 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. Transfusion decisions depend on several factors such as institutional transfusion policies, blood ordering procedures, and availability of blood conservation strategies. Only around 11% of the variation in RBC transfusion rates was explained by hospital characteristics in the study by Bennett-Guerrero et al.5 Additional patient characteristics included several factors known to affect the probability of RBC transfusion and accounted for only 20% of variability in RBC transfusion rates among the hospitals. With the mortality rates unaffected, it is reasonable to assume that most of the blood ordered in hospitals with high transfusion rates was unjustified, consistent with data from other studies2,9,10 Continued inappropriate transfusions among hospitals is a major concern. Transfusions carry risks and are costly, and the supply of blood is limited. Substantial variation in transfusion practices in cardiac surgery was documented in 1991.9 However, despite subsequent publication of transfusion practice guidelines, substantial variability in transfusion practices persisted.10 Now, more than a decade later, the study by Bennett-Guerrero et al5 again documents substantial and unacceptable variation in transfusion practice. Published guidelines have not been effective in reducing this variability in blood transfusion. Institution-level blood management protocols11 are a preferred approach, including demonstration projects supported at the federal or state level to identify and target specific transfusion practices and patient outcomes. Other potential approaches at the institution level include use of computerized practitioner order entry, which can leverage strategies such as requiring information from treating physicians for transfusion indications in blood product order forms; utilization audits; and benchmarking. The measures of quality used by the Society of Thoracic Surgeons in the ratings of cardiac surgery programs do not identify or include RBC transfusions as a quality indicator.12 It may be time for patient blood management to gain status as a performance indicator by accreditation agencies such as the Joint Commission13 or as a quality indicator by professional organizations such as the Society of Thoracic Surgeons as part of transparency and public rankings for consumers. The conservation of blood in cardiac surgery was originally stimulated by concerns that blood product inventory would be inadequate to meet the needs of newly developing open heart surgical programs.14 Subsequently, the recognition of transfusion-related complications, many of which were first described in patients undergoing cardiac surgery, fueled further efforts to limit blood transfusion needs in this setting.15 More recently, accurate accounting of the costs of RBC transfusion has led to the realization that alternatives to allogeneic RBC transfusion (eg, autologous blood salvage and reinfusion) may be increasingly cost-equivalent. Of these 3 motivations for conservative transfusion behavior (blood inventory, blood risks, and blood costs), the primary motivation should be to avoid known (and unknown) risks. The influence of attending surgeons' attitudes has been documented.16 When evaluating a hemoglobin level, treating physicians must resist the temptation to “first do something” and temper this temptation with a philosophy of “first do no harm” to achieve the optimal balance of providing the best risk-benefit and cost-effective outcomes of transfusion therapy for patients. Back to top Article Information Corresponding Author: Lawrence Tim Goodnough, MD, Departments of Pathology and Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Room H-1402, 5626, Stanford, CA 94305-5626 (lgoodnough@stanfordmed.org). Financial Disclosures: None reported. Additional Contributions: We thank Mazyar Javidroozi MD, PhD (Department of Anesthesiology and Critical Care, Englewood Medical Center, Englewood, New Jersey), for his review and input. Dr Javidroozi received no compensation for his contributions. Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association. References 1. Ferraris VA, Ferraris SP, Saha SP, et al; Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg. 2007;83(5):(suppl) S27-S8617462454PubMedGoogle ScholarCrossref 2. Likosky DS, FitzGerald DC, Groom RC, et al. Effect of the perioperative blood transfusion and blood conservation in cardiac surgery clinical practice guidelines of the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists upon clinical practices. Anesth Analg. 2010;111(2):316-32320488928PubMedGoogle ScholarCrossref 3. Consensus conference. Perioperative red blood cell transfusion. JAMA. 1988;260(18):2700-27033054179PubMedGoogle ScholarCrossref 4. Hajjar LA, Vincent J-L, Galas FRBG, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010;304(14):1559-1567Google ScholarCrossref 5. Bennett-Guerrero E, Zhao Y, O’Brien SM, et al. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA. 2010;304(14):1568-1575Google ScholarCrossref 6. Veenith T, Sharples L, Gerrard C, Valchanov K, Vuylsteke A. Survival and length of stay following blood transfusion in octogenarians following cardiac surgery. Anaesthesia. 2010;65(4):331-33620148816PubMedGoogle ScholarCrossref 7. Moskowitz DM, McCullough JN, Shander A, et al. The impact of blood conservation on outcomes in cardiac surgery: is it safe and effective? Ann Thorac Surg. 2010;90(2):451-45820667328PubMedGoogle ScholarCrossref 8. Hébert PC, Wells G, Blajchman MA, et al; Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med. 1999;340(6):409-4179971864PubMedGoogle ScholarCrossref 9. Goodnough LT, Johnston MF, Toy PT.Transfusion Medicine Academic Award Group. The variability of transfusion practice in coronary artery bypass surgery. JAMA. 1991;265(1):86-901984129PubMedGoogle ScholarCrossref 10. Stover EP, Siegel LC, Parks R, et al; Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study. Anesthesiology. 1998;88(2):327-3339477051PubMedGoogle ScholarCrossref 11. Goodnough LT, Shander A. Blood management. Arch Pathol Lab Med. 2007;131(5):695-70117488154PubMedGoogle Scholar 12. Shahian DM, Edwards FH, Ferraris VA, et al; Society of Thoracic Surgeons Quality Measurement Task Force. Quality measurement in adult cardiac surgery, part 1: conceptual framework and measure selection. Ann Thorac Surg. 2007;83(4):(suppl) S3-S1217383407PubMedGoogle ScholarCrossref 13. Blood Management Performance Measures Project. Joint Commission Web site. http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Blood+Management.htm. March 5, 2010. Accessed September 17, 2010 14. Newman MM, Hamstra R, Block M. Use of banked autologous blood in elective surgery. JAMA. 1971;218(6):861-8635170923PubMedGoogle ScholarCrossref 15. Cosgrove DM, Loop FD, Lytle BW, et al. Determinants of blood utilization during myocardial revascularization. Ann Thorac Surg. 1985;40(4):380-3844051620PubMedGoogle ScholarCrossref 16. Salem-Schatz SR, Avorn J, Soumerai SB. Influence of clinical knowledge, organizational context, and practice style on transfusion decision making. Implications for practice change strategies. JAMA. 1990;264(4):476-4832366281PubMedGoogle ScholarCrossref

Journal

JAMAAmerican Medical Association

Published: Oct 13, 2010

Keywords: cardiac surgery procedures,blood transfusion,transfusion

References