Original Research

Analysis of Predictors and Outcomes of Allogeneic Blood Transfusion After Shoulder Arthroplasty

Am J Orthop. 2015 December;44(12):E486-E492

In shoulder arthroplasty, patients often receive postoperative blood transfusions. Studies of predictors of allogeneic blood transfusion (ABT) in these patients have been limited by sample size.

We conducted a study to identify predictors of ABT in patients undergoing shoulder arthroplasty and to evaluate the effect of ABT on postoperative outcomes, including inpatient mortality, adverse events, prolonged hospital stay, and nonroutine discharge. Using the Nationwide Inpatient Sample, we stratified an estimated 422,371 patients who presented for shoulder arthroplasty between January 1, 2002, and December 31, 2011, into total shoulder arthroplasty (59.3%) and hemiarthroplasty (40.7%) cohorts, and then subdivided these cohorts into patients who received blood transfusions and those who did not.

Patients who received ABTs were older, female, and nonwhite and had Medicare or Medicaid insurance. Many had a primary diagnosis of proximal humerus fracture. Those who received ABT were more likely to experience adverse events or a prolonged hospital stay and were more often discharged to a nursing home or an extended-care facility. The 5 most significant predictors of ABT in a population of 422,371 patients who underwent shoulder arthroplasty were fracture, fracture nonunion, deficiency anemia, coagulopathy, and avascular necrosis.

Given these findings, it is important to identify at-risk patients before surgery in order to provide education and minimize risk.

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References

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In shoulder arthroplasty, it is not uncommon for patients to receive postoperative blood transfusions; rates range from 7% to 43%.^1-6 Allogeneic blood transfusions (ABTs) are costly and not entirely free of risks.⁷ The risk for infection has decreased because of improved screening and risk reduction strategies, but there are still significant risks associated with ABTs, such as clerical errors, acute and delayed hemolytic reactions, graft-versus-host reactions, transfusion-related acute lung injury, and anaphylaxis.^8-10 As use of shoulder arthroplasty continues to increase, the importance of minimizing unnecessary transfusions is growing as well.⁷

Predictive factors for ABT have been explored in other orthopedic settings, yet little has been done in shoulder arthroplasty.^1-6,11-15 Previous shoulder arthroplasty studies have shown that low preoperative hemoglobin (Hb) levels are independent risk factors for postoperative blood transfusion. However, there is debate over the significance of other variables, such as procedure type, age, sex, and medical comorbidities. Further, prior studies were limited by relatively small samples from single institutions; the largest series included fewer than 600 patients.^1-6

We conducted a study to determine predictors of ABT in a large cohort of patients admitted to US hospitals for shoulder arthroplasty. We also wanted to evaluate the effect of ABT on postoperative outcomes, including inpatient mortality, adverse events, prolonged hospital stay, and nonroutine discharge. According to the null hypothesis, in shoulder arthroplasty there will be no difference in risk factors between patients who require ABT and those who did not, after accounting for confounding variables.

Materials and Methods

This study was exempt from institutional review board approval, as all data were appropriately deidentified before use in this project. We used the Nationwide Inpatient Sample (NIS) to retrospectively study the period 2002–2011, from which all demographic, clinical, and resource use data were derived.¹⁶ NIS, an annual survey conducted by the Agency for Healthcare Research and Quality (AHRQ) since 1988, has generated a huge amount of data, forming the largest all-payer inpatient care database in the United States. Yearly samples contain discharge data from about 8 million hospital stays at more than 1000 hospitals across 46 states, approximating a 20% random sample of all hospital discharges at participating institutions.¹⁷ These data are then weighted to generate statistically valid national estimates.

The NIS database uses International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes to identify 15 medical diagnoses up to the year 2008 and a maximum of 25 medical diagnoses and 15 procedures thereafter. In addition, the database includes information on patient and hospital characteristics as well as inpatient outcomes such as length of stay, total hospitalization charges, and discharge disposition.^18,19Given its large sample size and data volume, NIS is a powerful tool in the analysis of data associated with a multitude of medical diagnoses and procedures.²⁰

We used the NIS database to study a population of 422,371 patients (age, >18 years) who underwent total shoulder arthroplasty (TSA) or hemiarthroplasty (HSA) between 2002 and 2011. ICD-9-CM procedure codes for TSA (81.80, 81.88) and HSA (81.81) were used to identify this population. We also analyzed data for reverse TSA for the year 2011. Then we divided our target population into 2 different cohorts: patients who did not receive any blood transfusion products and patients who received a transfusion of allogeneic packed cells (ICD-9-CM code 99.04 was used to identify the latter cohort).

In this study, normal distribution of the dataset was assumed, given the large sample size. The 2 cohorts were evaluated through bivariate analysis using the Pearson χ² test for categorical data and the independent-samples t test for continuous data. The extent to which diagnosis, age, race, sex, and medical comorbidities were predictive of blood transfusion after TSA or HSA was evaluated through multivariate binary logistic regression analysis. Statistical significance was set at P < .05. All statistical analyses and data modeling were performed with SPSS Version 22.0.

Results

Using the NIS database, we stratified an estimated 422,371 patients who presented for shoulder arthroplasty between January 1, 2002, and December 31, 2011, into a TSA cohort (59.3%) and an HSA cohort (40.7%). Eight percent (33,889) of all patients received an ABT; the proportion of patients who received ABT was higher (P < .001) for the HSA cohort (55.6%) than the TSA cohort (39.4%). Further, the rate of ABT after shoulder arthroplasty showed an upward inclination (Figure).

Demographically, patients who received ABT tended (P < .001) to be older (74±11 years vs 68±11 years) and of a minority race (black or Hispanic) and to fall in either the lowest range of median household income (21.5% vs 20.7%; ≤$38,999) or the highest (27.3% vs 25.4%; ≥$63,000). Shoulder arthroplasty with ABT occurred more often (P < .001) at hospitals that were urban (13.3% vs 11.3%), medium in size (27.3% vs 23.4%), and nonteaching (56.2% vs 54.3%). In addition, ABT was used more often (P < .001) in patients with a primary diagnosis of fracture (43.1% vs 14.3%) or fracture nonunion (4.4% vs 2.1%). These groups also had a longer (P < .001) hospital stay (5.0±4.3 days vs 2.5±2.2 days). Table 1 summarizes these findings.