Aslam Ejaz1, Steven M Frank2, Gaya Spolverato3, Yuhree Kim3, Timothy M Pawlik3. 1. Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago. 2. Department of Anesthesiology and Critical Care Medicine, Interdisciplinary Blood Management Program, The Johns Hopkins University School of Medicine, Baltimore, Maryland. 3. Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Abstract
IMPORTANCE: Transfusion practice among surgeons varies despite several evidence-based recommendations supporting the restrictive use of blood products. OBJECTIVE: To define the economic impact of liberal blood transfusions as assessed through an analysis of hemoglobin (Hb) triggers. DESIGN, SETTING, AND PARTICIPANTS: Using a prospective database, data on Hb levels that triggered a transfusion and overall blood product use were obtained for patients undergoing pancreas, liver, or colorectal surgery between January 1, 2010, and August 31, 2013, at Johns Hopkins Hospital. An economic analysis was performed using a range of costs for a single unit of packed red blood cells (PRBCs) based on actual institutional acquisition costs ($220/unit) and an estimated activity-based cost ($760/unit). Guidelines define a liberal Hb trigger as transfusion of PRBCs for an intraoperative Hb level of 10 g/dL or greater or a postoperative Hb level of 8 g/dL or greater (to convert to grams per liter, multiply by 10.0). MAIN OUTCOMES AND MEASURES: Numbers of surgical patients who received PRBC transfusion, estimated cost per transfusion, and estimated cost of excessive blood transfusions. RESULTS: Among 3027 patients, 942 (31.1%) received at least 1 PRBC transfusion, intraoperatively in 264 patients (8.7%), postoperatively in 429 (14.2%), or both in 249 (8.2%). A total of 4000 units of PRBCs (range, 0-167 units/patient) were transfused in the intraoperative (1581 units [39.5%]) and postoperative (2419 units [60.5%]) periods. Estimated total costs of PRBC transfusion ranged from $880,000 to $3,040,000, with marked variation in costs per patient across procedure type and surgeon. Among the 942 patients who received a transfusion, 456 units (11.4%) were transfused using a liberal trigger (intraoperative, 122 patients [13.0%]; postoperative, 79 patients [8.4%]). By adopting a restrictive trigger, total overall PRBC transfusion costs may have been reduced by $100,320 to $346,560 during the 44-month study period or $27,360 to $94,516 per year for patients undergoing a pancreas, liver, or colorectal resection. CONCLUSIONS AND RELEVANCE: More than 1 in 10 units of PRBCs were transfused using a liberal Hb trigger. Patient blood management programs should aim to identify and reduce liberal transfusion practice in the surgical patient.
IMPORTANCE: Transfusion practice among surgeons varies despite several evidence-based recommendations supporting the restrictive use of blood products. OBJECTIVE: To define the economic impact of liberal blood transfusions as assessed through an analysis of hemoglobin (Hb) triggers. DESIGN, SETTING, AND PARTICIPANTS: Using a prospective database, data on Hb levels that triggered a transfusion and overall blood product use were obtained for patients undergoing pancreas, liver, or colorectal surgery between January 1, 2010, and August 31, 2013, at Johns Hopkins Hospital. An economic analysis was performed using a range of costs for a single unit of packed red blood cells (PRBCs) based on actual institutional acquisition costs ($220/unit) and an estimated activity-based cost ($760/unit). Guidelines define a liberal Hb trigger as transfusion of PRBCs for an intraoperative Hb level of 10 g/dL or greater or a postoperative Hb level of 8 g/dL or greater (to convert to grams per liter, multiply by 10.0). MAIN OUTCOMES AND MEASURES: Numbers of surgical patients who received PRBC transfusion, estimated cost per transfusion, and estimated cost of excessive blood transfusions. RESULTS: Among 3027 patients, 942 (31.1%) received at least 1 PRBC transfusion, intraoperatively in 264 patients (8.7%), postoperatively in 429 (14.2%), or both in 249 (8.2%). A total of 4000 units of PRBCs (range, 0-167 units/patient) were transfused in the intraoperative (1581 units [39.5%]) and postoperative (2419 units [60.5%]) periods. Estimated total costs of PRBC transfusion ranged from $880,000 to $3,040,000, with marked variation in costs per patient across procedure type and surgeon. Among the 942 patients who received a transfusion, 456 units (11.4%) were transfused using a liberal trigger (intraoperative, 122 patients [13.0%]; postoperative, 79 patients [8.4%]). By adopting a restrictive trigger, total overall PRBC transfusion costs may have been reduced by $100,320 to $346,560 during the 44-month study period or $27,360 to $94,516 per year for patients undergoing a pancreas, liver, or colorectal resection. CONCLUSIONS AND RELEVANCE: More than 1 in 10 units of PRBCs were transfused using a liberal Hb trigger. Patient blood management programs should aim to identify and reduce liberal transfusion practice in the surgical patient.
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