Cell Transfusion Use Research Articles

Using Blood Wisely: lessons learnt in establishing a national implementation programme to reduce inappropriate red blood cell transfusion

BackgroundUp to 50% of blood is transfused inappropriately despite best evidence. In 2020, Choosing Wisely Canada launched a major national programme, ‘Using Blood Wisely’, the aim was to engage hospitals...

Red Blood Cell Transfusion Use in Dialysis-Dependent Patients with Anemia of CKD in the United States: A Systematic Literature Review

Red Blood Cell Transfusion Use in Dialysis-Dependent Patients with Anemia of CKD in the United States: A Systematic Literature Review

Evaluation of a closed loop-blood sampling system in intensive care: A pilot randomised controlled trial. The ENCLOSE trial

To test the feasibility of conducting a randomised controlled trial to evaluate the impact of a closed-loop blood sampling system and blood conservation bundle. Single site, parallel group, pilot randomised control trial comparing open system sampling to closed system sampling and conservation bundle aligned with national guidelines. Randomisation sequence was generated by an independent statistician and allocation concealment maintained via sealed opaque envelopes. The study setting was the general intensive care unit of a major metropolitan public hospital in Queensland, Australia. Participants were≥18years who had an arterial catheter inserted in intensive care. Main outcome measures included trial feasibility, blood sample loss, haematocrit (HCT) change, and packed red blood cell transfusion use. Eighty patients were randomised (n=39 open group, n=41 closed group). Characteristics in each group were equal at baseline with overall median age 60years (IQR 48.6-70.4), 58% male, and median APACHE II score 16 (IQR 11-22). The proportion of patients eligible was 29% and missed eligible was 65%. Otherwise, feasibility criteria were met with proportion of eligible patients agreeing to enrolment 99%, 100% of patients receiving allocated treatment; only 1% of data missing. Analysis demonstrated a significant reduction in mean daily blood sample losses (open 32.7 (SD 1.58) mL vs closed 15.5 (SD 5.79) mL, t =-8.454, df=78, p<0.001). A large, multi-site trial is feasible with enhanced eligibility criteria, increased recruitment support. The intervention reduced daily blood sample volumes and transfusion use. Further trials are required to provide both effectiveness and implementation outcomes.

Evaluating variation in perioperative red blood cell transfusion for patients undergoing elective gastrointestinal cancer surgery

BackgroundPatients undergoing gastrointestinal cancer surgery often receive packed red blood cell transfusions. Understanding practice variation is critical to support efforts working toward responsible transfusion use. We measured the extent and importance of variation in perioperative packed red blood cell transfusion use across physicians and hospitals among gastrointestinal cancer surgery patients. MethodsWe identified patients who underwent elective gastrointestinal cancer resection between 2007 and 2019 using linked administrative health data sets in Ontario, Canada. We used funnel plots to describe variation in transfusion use, adjusted for patient case mix. Hierarchical regression models quantified patient-level, between-physician, and between-hospital variation in transfusion use with R2 measures, variance partition coefficients, and median odds ratios. ResultsOf 59,964 included patients (median age 69 years; 43.2% female; 75.8% colorectal resections), 18.0% received perioperative packed red blood cell transfusions. Funnel plots showed variation in transfusion use among physicians and hospitals. Patient characteristics, such as age, comorbidity, and procedure type, combined to explain 12.8% of the variation. After adjusting for case mix, systematic between-physician and between-hospital differences were responsible for 2.8% and 2.1% of the variation, respectively. This translated to an approximately 30% difference in the odds of transfusion for 2 similar patients treated by distinct physicians (median odds ratio: 1.35, 95% confidence interval 1.30–1.40) and hospitals (median odds ratio: 1.30, 95% confidence interval 1.23–1.42). We observed comparable effects across procedure-type subgroups. ConclusionTransfusion provision is highly driven by patient factors. Yet the impact of the treating physician and hospital on variation relative to other factors is important and reflects opportunities to target modifiable processes of care to standardize perioperative packed red blood cell transfusion practice.

Development of a Standardized Transfusion Ratio as a Metric for Evaluating Dialysis Facility Anemia Management Practices

Because transfusion avoidance has been the cornerstone of anemia treatment for patients with kidney disease, direct measurement of red blood cell transfusion use to assess dialysis facility anemia management performance is reasonable. We aimed to explore methods for estimating facility-level standardized transfusion ratios (STfRs) to assess provider anemia treatment practices. Retrospective cohort study. Point prevalent US hemodialysis patients on January 1, 2009, with Medicare as primary payer and dialysis duration of 90 days or longer were included (n = 223,901). All dialysis facilities with eligible patients were included (n = 5,345). Dialysis facility assignment. Receiving a red blood cell transfusion in the inpatient or outpatient setting. We evaluated 3 approaches for estimating STfR: ratio of observed to expected numbers of transfusions (STfR(obs)), a Bayesian approach (STfR(Bayes)), and a modified version of the Bayesian approach (STfR(modBayes)). The overall national transfusion rate in 2009 was 23.2 per 100 patient-years. Our model for predicting the expected number of transfusions performed well. For large facilities, all 3 STfRs worked well. However, for small facilities, while the STfR(modBayes) worked well, STfR(obs) values demonstrated instability and the STfR(Bayes) may produce more bias. Administration of transfusions to dialysis patients reflects medical practice both within and outside the dialysis unit. Some transfusions may be deemed unavoidable and transfusion practices are subject to considerable regional variation. Development of an STfR metric is feasible and reasonable for assessing anemia treatment at dialysis facilities. The STfR(obs) is simple to calculate and works well for larger dialysis facilities. The STfR(modBayes) is more analytically complex, but facilitates comparisons across all dialysis facilities, including small facilities.

Red blood cell transfusion use in patients with chronic kidney disease

There is limited data available on the use of red blood cell (RBC) transfusions in younger chronic kidney disease patients not on dialysis (CKD-ND), for whom the consequences of developing antibodies to foreign antigens (allosensitization) may be particularly relevant. We used the Ingenix medical claims database, comprising data on ∼40 million commercially insured US individuals, to identify annual (2002-08) cohorts of patients 18-64 years of age with newly diagnosed CKD. We followed each cohort for 1 year to estimate RBC transfusion rates and used Cox proportional hazards regression to identify patient characteristics associated with time to first transfusion. We identified 120 790 newly diagnosed CKD patients for the years 2002-08; 54% were 50-64 years of age. Overall, the transfusion rate was 2.64/100 person-years (PYs) (95% CI: 2.52-2.77). Rates were higher among those with diagnosed anemia [9.80/100 PYs (95% CI: 9.31-10.3)] and among those who progressed to end-stage renal disease (ESRD) [28.0/100 PYs (95% CI: 23.7-33.0)]. For those progressing to ESRD, transfusion rates more than doubled between 2002 and 2008. Of the factors evaluated, transfusion history and the presence of heart failure and diabetes were most strongly associated with a receipt of a transfusion. RBC transfusions are relatively common and on the rise among younger CKD-ND patients who are anemic and progress to ESRD. Efforts to decrease the use of transfusions may be important for potential transplant candidates who progress to ESRD.

Abstract 9286: Patterns of Red Blood Cell Transfusion Use in Patients Undergoing Percutaneous Coronary Intervention in Contemporary Clinical Practice

Background Previous studies have shown marked variation in the use of red blood cell transfusion (RBCT) among patients with acute coronary syndromes. Contemporary post-procedure RBCT patterns in patients undergoing PCI are unclear. Methods Using the NCDR Cath-PCI database we evaluated frequency of RBCT in 1323965 patients undergoing PCI at 1282 hospitals between 7/2009-9/2011 excluding those who underwent in-hospital CABG. Site-level variation in RBCT use was examined; differences in patient baseline characteristics and in-hospital outcomes were compared between patients who did and did not receive RBCT. Logistic regression was used to determine the adjusted association between RBCT and in-hospital death, MI, or stroke. Results Of the total sample, 29255(2.2%) patients received RBCT. These patients were older, more often female, and more often had HTN, prior CHF, prior MI, cerebrovascular disease, peripheral arterial disease, diabetes, or be on dialysis. Patients receiving RBCT had lower median pre-procedure Hgb (10.7 g/dl vs 13.7 g/dl, P&lt;0.01) and post-procedure Hgb (8.6 g/dl vs 12.7 g/dl, P&lt;0.01) and more often experienced a post-PCI bleeding event (36% vs 1%, P&lt;0.01). RBCT was more frequent in patients with post-procedure Hgb &lt;10 g/dl, irrespective of PCI indication. With respect to site-level variation, 17% of hospitals gave no RBCT, 76% of hospitals used RBCT in 1-4% of patients, while just 7% of hospitals used RBCT in ≥5% of patients (Figure). After adjustment, the use of RBCT was significantly associated with in-hospital death, MI, or stroke (OR 2.18; 95% CI 2.09-2.26). Similar results were seen after excluding patients who bled. Conclusions In contemporary PCI practice, there is marked site-level variability in the use of RBCT. After adjustment for potential confounders, RBCT is associated with a higher risk for in-hospital adverse events. These data underscore the importance of understanding the appropriate role of RBCT in patients undergoing PCI.

Predictors and patterns of red blood cell transfusion use among newly diagnosed cancer patients with chemotherapy-associated anemia in Western Denmark (1998&amp;ndash;2003)

Objective:Cancer patients receiving chemotherapy are at increased risk of anemia. We conducted a population-based historical cohort study in newly diagnosed cancer patients with chemotherapy-associated anemia in order to characterize red blood cell transfusion (RBCT) use.Design:This study evaluated cancer patients diagnosed between January 1, 1998 and December 31, 2003 using Danish National Patient Registry data. Patients were receiving chemotherapy and had a hemoglobin level ≤10.9 g/dL during the 4 months following cancer diagnosis. We characterized patterns of RBCT use and inpatient and outpatient hospitalization for transfusion. Adjusted Poisson regression models were used to evaluate the likelihood of RBCT, estimated by relative risk (RR), based on demographic and clinical factors.Results:Women constituted 58% of 1782 patients studied; the median age was 58 years. Two-thirds (67%) had solid tumors; 67% had stage III or IV disease at diagnosis. Overall, 713 (40%) patients received an RBCT within 120 days of cancer diagnosis, of which 94% were administered in the inpatient setting; 84% of these patients required subsequent transfusions. The median (Q1, Q3) pretransfusion hemoglobin level was 9.0 (8.4, 9.8) g/dL. Patients aged <20 years were more likely to receive an RBCT than older patients (RR 1.89; 95% confidence interval [CI] 1.44–2.49). Compared with stage IV disease, those with stage II or III disease had a lower likelihood of RBCT (stage II: RR 0.52, 95% CI: 0.37–0.72; stage III: RR 0.68, 95% CI: 0.55–0.83). Patients diagnosed with breast cancer were less likely to receive an RBCT than patients with hematologic cancers (RR 0.34, 95% CI: 0.21–0.55).Conclusion:In this study, 40% of cancer patients with chemotherapy-associated anemia in Western Denmark received an RBCT, usually in the inpatient setting; of these, most required subsequent transfusions. Younger age increased the likelihood of receiving an RBCT, and earlier stage or breast cancer decreased RBCT likelihood.

Temporal Trends in Red Blood Transfusion Among US Dialysis Patients, 1992-2005

Studies addressing patterns and trends in red blood cell transfusion use in US hemodialysis patients surprisingly have received little attention in the last decade. Retrospective cohort study. Point prevalent (as of January 1 of each calendar year 1992 to 2005) dialysis patients with Medicare Part A and Part B as primary insurance (n = 77,347 in 1992, n = 164,933 in 2005). The 6 months preceding January 1 of each year were used to assemble a comorbidity profile based on administrative claims data. Hemoglobin levels, patient characteristics, comorbid conditions. Blood transfusion events obtained from Part A and Part B files using code files for both whole and packed red blood cell transfusions and hemoglobin levels. Comorbid conditions were defined by the presence of 1 or more inpatient/outpatient institutional claims (inpatient hospitalization, skilled nursing facility, or home health agency), 2 or more outpatient or physician/supplier claims, or 1 or more outpatient and 1 or more physician/supplier claims for atherosclerotic heart disease, congestive heart failure, cerebrovascular accidents/transient ischemic attacks, peripheral vascular disease, other cardiovascular diseases, chronic obstructive pulmonary disease, gastrointestinal disorders, liver disease, arrhythmia, and diabetes mellitus. Raw transfusion rates decreased in both outpatient and inpatient settings from 535.33/1,000 patient-years for 1992 prevalent dialysis patients to 263.65/1,000 patient-years in 2005 (P for trend < 0.001, 1992 versus 1999 and 1999 versus 2005). Adjusted rates decreased similarly. This phenomenon could not be explained by changes in case mix. Cause, effect, and confounding cannot be separated in this observational study. The accuracy of blood transfusion billing data is unknown. Temporal trends may be related to factors other than erythropoiesis-stimulating agent use. Transfusion events in hemodialysis patients decreased more than 2-fold from 1992 to 2005; most of the decrease occurred in the first 5 years after erythropoietin was introduced.

The Association Among Blood Transfusions, White Blood Cell Count, and the Frequency of Post–Cardiothoracic Surgery Atrial Fibrillation: A Nested Cohort Study From the Atrial Fibrillation Suppression Trials I, II, and III

To evaluate the impact of postoperative red blood cell transfusions and white blood cell (WBC) counts on post-cardiothoracic surgery atrial fibrillation. A nested cohort study of 550 patients from the Atrial Fibrillation Suppression Trials I, II, and III. A large urban teaching hospital. Patients undergoing cardiothoracic surgery. Endpoints included postoperative atrial fibrillation occurrence and maximum white blood cell counts during the first 5 days postoperatively. Multivariate logistic regression was used to control for potential confounders and calculate adjusted odds ratios (AOR) with 95% confidence intervals (95% CIs). Of the 173 patients (31.5%) who developed postoperative atrial fibrillation, 110 patients (63.5%) received postoperative transfusions and 63 patients (36.5%) did not (crude odds ratio = 1.89; 95% CI, 1.31-2.74; p = 0.001). Postoperative white blood cell counts were significantly greater in patients who developed atrial fibrillation on postoperative days 3 to 5. There were no differences in WBC between patients who did and did not receive transfusions. Upon multivariate logistic regression, the use of postoperative red blood cell transfusions was found to be associated with a 2-fold increase in postoperative atrial fibrillation (AOR 1.95; 95% CI, 1.24-3.06; p = 0.004). Similarly, the maximum white blood cell count also was associated with increased atrial fibrillation odds (AOR 1.09 K/microL; 95% CI, 1.04-1.13; p < 0.001). Postoperative red blood cell transfusion use was found to be a strong independent predictor for the development of postoperative atrial fibrillation, although no direct link between red blood cell transfusion and an increased white blood cell count was seen.