Transfusion Rates Vary Widely at Academic Hospitals

Wide variations in perioperative blood transfusion rates among patients undergoing major noncardiac procedures across U.S. hospitals highlight the need to further investigate evidence-based "transfusion triggers" in this population of surgical patients, according to a study published ahead of print in Annals of Surgery.

"In light of the increased risk of mortality and major complications associated with blood transfusion, the extensive variability in hospital transfusion practice in noncardiac surgery may represent an important opportunity to improve surgical outcomes," wrote Feng Qian, Ph.D., of the University of Rochester (N.Y.), and associates.

The researchers used the University HealthSystem Consortium hospital database to compare transfusion rates of allogeneic red blood cells, fresh frozen plasma, and platelets in patients undergoing elective primary total hip replacement (54,405 patients), colectomy (21,334), or pancreaticoduodenectomy (7,929) at 77 hospitals between June 2006 and September 2010. Most of the hospitals were teaching hospitals with at least 500 beds.

Transfusion rates varied widely before and after adjustment for comorbidities and other patient risk factors. Patients who were treated in hospitals with high rates of transfusions were about twice as likely to receive a blood transfusion as were patients at hospitals with average transfusion rates (Ann. Surg. 2012 July 13[doi:10.1097/SLA.0b013e31825ffc37]).

In hospitals where the transfusion rate for one procedure was high, transfusion rates also tended to be high for the other two procedures. There was some evidence indicating that a higher volume of surgical cases was associated with lower transfusion rates.

After adjusting for patient risk factors, the authors determined that transfusion rates for the different blood components among those undergoing a total hip replacement ranged from 1.3% to almost 75% (red blood cells), from 0.1% to 7.7% (fresh frozen plasma), and from 0.1% to 2% (platelets). Among colectomy patients, transfusion rates ranged from 1.9% to 47.8% (RBCs), from 1.4% to 17.7% (fresh frozen plasma), and from 1.3% to 6.2% (platelets). Among those undergoing a pancreaticoduodenectomy, the rates ranged from 3% to 78.6% (RBCs), from 1% to 47% (fresh frozen plasma), and from 1.4% to 12.6% (platelets).

The variability, the authors said, "reflects, in part, the complexity of the medical decision-making process underlying transfusion therapy." Because the data included patients from 90% of academic medical centers in the United States, the results provide "a broad and contemporary picture of transfusion practices in academic surgical centers" and "reflect transfusion practices that are being taught to the next generation of academic and private-practice clinicians during residency training," they noted.

To the best of their knowledge, the authors said, there are no large randomized studies that have compared liberal and restrictive transfusion strategies in noncardiac surgery patients, and they believe that such trials are "urgently needed to better define evidence-based transfusion triggers for patients undergoing noncardiac surgery."

The study was supported by a grant from the Agency for Healthcare and Quality Research and funding from the department of anesthesiology at the University of Rochester. No disclosures were reported by the authors.