Odds Of Transfusion Research Articles

Assessment of routine pre-operative group and save testing in patients undergoing cholecystectomy: a retrospective cohort study.

Routine group and save (G&S) testing is frequently performed prior to cholecystectomy, despite growing evidence that a targeted approach is safe and avoids unnecessary investigations. This retrospective cohort study explored frequency of testing in our unit, rates of peri-operative blood transfusion and pre-operative risk factors for requiring transfusion. Health records of 453 consecutive adults who underwent cholecystectomy in a UK NHS trust were reviewed for blood transfusion up to 30 days post-operatively. We compared the need for transfusion against patient demographics, indication and urgency of surgery, and the number of prior emergency hospital attendances with gallstone complications. Logistic regression determined whether prior attendances with complications of gallstones independently predicted the need for transfusion. Peri-operative blood transfusions within 30 days of operation occurred in 1.1% of cases, with no requirement for uncrossmatched blood. Patients who received a blood transfusion tended to have higher American Society of Anesthesiologists (ASA) grades ( p = 0.017), were more likely to have an underlying primary haematological malignancy (20.0% vs. 0.2%; p = 0.022) and prior emergency hospital attendances with gallstone complications (median 4 vs. 1; p < 0.001). Logistic regression showed each prior emergency attendance was associated with 4.6-fold odds of transfusion ( p = 0.019). Receiver operating characteristic curve analysis showed an area under the curve of 0.92. Three or more attendances predicted need for transfusion with 60.0% sensitivity and 98.0% specificity. 74% of patients had at least one G&S sample taken pre-operatively, costing the trust approximately £3,800 per year in materials. The findings of this study suggest that pre-operative G&S testing prior to cholecystectomy is not routinely required. Increased frequency of prior emergency hospital attendances with gallstone complications and co-morbidities associated with coagulopathies were pre-operative risk factors for post-operative blood transfusion. More selective testing could provide large financial savings for health institutions without compromising patient safety.

Assessment of routine pre-operative group and save testing in patients undergoing cholecystectomy: a retrospective cohort study

Background Routine group and save (G&amp;S) testing is frequently performed prior to cholecystectomy, despite growing evidence that a targeted approach is safe and avoids unnecessary investigations. This retrospective cohort study explored frequency of testing in our unit, and rates of and independent pre-operative risk factors for peri-operative blood transfusion. Methods Health records of 453 consecutive adults who underwent cholecystectomy in a UK NHS trust were reviewed for blood transfusion up to 30 days post-operatively. We compared the need for transfusion against patient demographics, indication and urgency of surgery, and the number of prior emergency hospital attendances with gallstone complications. Logistic regression determined whether prior attendances with complications of gallstones independently predicted the need for transfusion. Results Peri-operative blood transfusions within 30 days of operation occurred in 1.1% of cases, with no requirement for uncrossmatched blood. Patients who received a blood transfusion tended to have higher American Society of Anesthesiologists (ASA) grades (p&lt;0.001), were more likely to have an underlying primary haematological malignancy (20.0% vs. 0.2%; p&lt;0.001) and prior emergency hospital attendances with gallstone complications (median 4 vs. 1; p&lt;0.001). Logistic regression showed each prior emergency attendance was associated with 4.6-fold odds of transfusion (p=0.019). Receiver operating characteristic curve analysis showed an area under the curve of 0.92. Three or more attendances predicted need for transfusion with 60.0% sensitivity and 98.0% specificity. Seventy-four percent had at least one G&amp;S sample taken pre-operatively, costing the trust approximately £3,800 per year in materials. Conclusions Pre-operative G&amp;S testing prior to cholecystectomy may not be routinely required. Increased frequency of prior emergency hospital attendances with gallstone complications and co-morbidities associated with coagulopathies were pre-operative risk factors for post-operative blood transfusion. More selective testing could provide large financial savings for health institutions without compromising patient safety.

MP51-06 SAFETY AND EFFICACY OF GREENLIGHT PVP IN OCTOGENARIANS: EVALUATION OF THE GLOBAL GREENLIGHT GROUP DATABASE

MP51-06 SAFETY AND EFFICACY OF GREENLIGHT PVP IN OCTOGENARIANS: EVALUATION OF THE GLOBAL GREENLIGHT GROUP DATABASE

Safety and efficacy of GreenLight PVP in octogenarians: evaluation of the Global GreenLight Group database.

The present study analyzes the largest international GreenLight database, the Global GreenLight Group (GGG), to evaluate the functional and safety profile of GreenLight photoselective vaporization of the prostate (PVP) in octogenarians. The GGG is a database comprised of patients that underwent GreenLight PVP from 2011 to 2019 performed by 8 experienced urologists at 7 international hospitals. Patients 80years or older at the time of surgery were categorized as octogenarians. They were compared to a similar group of PVP patients below the age of 80. Among 3,648 patients, 586 men were above the age of 80. Compared to patients under the age of 80, octogenarians had larger prostates (76.0 vs 71.9ml, p = 0.02) and a lower BMI (25.6 vs 26.7, p = 0.045). Operative time was not significantly longer in octogenarians. The improvement in functional outcomes between 80-year-old patients and control patients was not significantly different at one-year follow-up, with the exception of maximum urinary flow (Qmax) that favoured younger patients (10.3 vs 12.6ml/s, p = 0.02). The odds of transfusion were greater for older patients [OR 8.2 (95% CI 3.6-18.9, p < 0.01)], but they were not at increased risk of hematuria. Octogenarians had higher readmission rates (23.0 vs 11.9%, p < 0.01). GreenLight PVP is a safe option in well-selected octogenarians in a cohort of patients treated by surgeons experienced with the technology. The odds of transfusion were higher in patients over 80, but the absolute risk remains low. The 30-day hospital readmission rate was higher in octogenarians.

Optimal predelivery hemoglobin to reduce transfusion and adverse perinatal outcomes

Maternal anemia has been associated with poor obstetrical outcomes; however, the optimal hemoglobin level for reducing blood transfusion at delivery has not been well-defined. This study aimed to measure the association of maternal anemia immediately before delivery with peripartum transfusion and other adverse perinatal outcomes. We also sought to identify the optimal hemoglobin level for predicting transfusion. This was a retrospective cohort study of patients who had hemoglobin or hematocrit collected before delivery of live, nonanomalous neonates at ≥23 weeks' gestation at a single center (2013-2018). Patients were excluded if they had sickle cell disease or were receiving anticoagulation. Patients were categorized as having anemia or no anemia on the basis of predelivery hemoglobin or hematocrit levels using criteria set by the American College of Obstetricians and Gynecologists. The primary outcome was transfusion of ≥1 unit of packed red blood cells during the delivery admission. Secondary outcomes included select adverse perinatal outcomes. Bivariable analyses compared baseline characteristics and outcomes between the anemia and no-anemia groups. Multivariable logistic regression estimated the association between anemia and outcomes. The hemoglobin cutoff optimizing sensitivity and specificity for transfusion was identified by the Liu method. Of the 18,357 patients included in the analysis, 5444 (30%) had predelivery anemia (mean hemoglobin, 10.0±0.8 g/dL) vs 12,913 (70%) who did not (mean hemoglobin, 12.3±1.1 g/dL). Patients with anemia were more likely to be non-Hispanic Black and publicly insured and less likely to be nulliparous. Anemia was associated with 5-fold higher odds of packed red blood cell transfusion (6.0% vs 1.3%; adjusted odds ratio, 5.23 [95% confidence interval, 4.09-6.69]) compared with no anemia. For each 1 g/dL increase in predelivery hemoglobin, the odds of transfusion were 56% lower (adjusted odds ratio, 0.44 [confidence interval, 0.40-0.48]). The optimal hemoglobin for prediction of transfusion was 10.6 g/dL (sensitivity: 80%, specificity: 86%). There was no association between anemia and composite maternal or neonatal morbidity after adjustment for covariates, but anemia was associated with higher odds of postpartum readmission (adjusted odds ratio, 1.35 [1.11-1.64]). Maternal anemia before delivery was associated with 5-fold higher odds of packed red blood cell transfusion and postpartum readmission, but not other perinatal morbidity. Optimizing predelivery hemoglobin, particularly ≥10.6 g/dL, may reduce peripartum transfusion.

Abstract A11: The international prognostic score and HIV status predict red cell concentrate transfusion need in Hodgkin Lymphoma

Abstract Background There is a significant burden of anaemia in advanced Hodgkin Lymphoma (HL) in an HIV burdened setting, however there is a paucity of data evaluating red cell concentrate (RCC) transfusion in newly diagnosed HL receiving treatment. We performed a retrospective study to determine predictors of transfusion. Methods Patients 13 years and older consecutively diagnosed with and treated for HL from 2010 to 2019 in Groote Schuur Hospital, University of Cape Town, were retrospectively studied. Patients were staged according to the Lugano classification, with clinical staging according to the National Cancer Comprehensive Network and categorized with both the HL International Prognostic Score (IPS)-7 and the HL IPS-3. Results Two hundred and eighty-five patients received first-line treatment for HL from 2010 to 2019. Patients had a median age of 34.5 years and were predominantly male (62.9%). The HIV prevalence was 39.5% and majority of patients (74.2%) had advanced disease. Bone marrow involvement was confirmed in 41% of cases by trephine examination or PET-imaging; the majority (35%) of these cases the bone marrow appeared to be the primary site with no lymphadenopathy peripherally or on imaging. Primary bone marrow HL was strongly associated with HIV infection. RCC transfusion was observed in 24.6% patients, with significantly more HIV-positive patients (40.4%) transfused than HIV-negative patients (14.1%) (P&amp;lt;0.001). The median number of transfusions for the total cohort was 2 (IQR 1-5). HIV-positive patients received significantly more RCC units (median 3, IQR 2-5) than HIV-negative patients (median 2, IQR 1-3); P=0.035. In univariable logistic regression, each one-point increase in HL IPS-7 was associated with a two-fold increase in the odds of transfusion, while each one-point increase in HL IPS-3 was associated with a two-and-a-half-fold increase in the odds of transfusion. In multivariable analyses, HL IPS-7 and HIV positivity were significantly associated with transfusion after adjusting for B symptoms and ECOG. Similar results were observed after replacing the HL IPS-7 with HL IPS-3. Conclusion The HL IPS-7 as well as HIV status proved to be strong predictors of RCC transfusion need in a newly diagnosed HL cohort in the developing world. The HL IPS-3 consisting of only age, haemoglobin and Lugano stage IV, is equally predictive of transfusion need and simple in use. Lugano stage IV was a surrogate marker for the high (41%) HL bone marrow involvement. Citation Format: Estelle R Verburgh, Kudakwashe Simba, Zainab Mohamed, Jessica J Opie, Karryn Brown, Jenna Oosthuizen, Katherine R Antel, Lillian Andera, Cecile du Toit, Vernon J Louw. The international prognostic score and HIV status predict red cell concentrate transfusion need in Hodgkin Lymphoma [abstract]. In: Proceedings of the Third AACR International Meeting: Advances in Malignant Lymphoma: Maximizing the Basic-Translational Interface for Clinical Application; 2022 Jun 23-26; Boston, MA. Philadelphia (PA): AACR; Blood Cancer Discov 2022;3(5_Suppl):Abstract nr A11.

Effect of an Elevated Preoperative International Normalized Ratio on Transfusion and Complications in Primary Total Hip Arthroplasty with the Enhanced Recovery after Surgery Protocol

ObjectiveTo verify whether an elevated preoperative international normalized ratio (INR) increases transfusion and complications independently in primary total hip arthroplasty (THA) with the management of an enhanced recovery after surgery (EARS) protocol.MethodsWe retrospectively reviewed the database of adults who underwent primary THA between 2014 and 2018 by the same surgeon. A total of 552 patients were assigned into three groups by preoperative INR class: INR ≤ 0.9, 0.9 < INR < 1.0, and INR ≥ 1.0. We regarded transfusion within 90 days during the same hospitalization as the primary outcome. We also included perioperative blood loss, maximum Hb drop, postoperative anaemia requiring medicine, and length of hospital stay (LOS) during the same hospitalization in the study. Complications and reoperation at 90 days and mortality at 90 days and 12 months were also included in the study. Univariable analyses were utilized to compare baselines and outcomes among the three groups. Multivariate logistic regressions were used to adjust for differences at baseline among the groups.ResultsAll patients had an INR < 1.5 preoperatively and were managed with the ERAS protocol. Among them, 93 (16.8%) patients had INR ≤ 0.9, 268 (48.6%) patients had 0.9 < INR < 1.0, and 191 (34.6%) patients had INR ≥ 1.0. In the univariable analyses, as the INR increased, the transfusion rates increased from 1.08% for INR ≤ 0.9, to 1.12% for 0.9 < INR < 1.0 and to 5.76% for INR ≥ 1.0 (P < 0.05). The overall complication rate increased from 10.8% for INR ≤ 0.9, to 16.4% for 0.9 < INR < 1.0, and to 22.5% for INR ≥ 1.0 (P < 0.05). The length of stay (LOS) in the INR ≥ 1.0 group was 5.7 ± 2.2 days, which was significantly longer than that in the INR ≤ 0.9 group (4.7 ± 1.6 days, P = 0.000) and 0.9 < INR < 1.0 group (5.1 ± 2.0 days, P = 0.007). No statistical significance was detected among the groups regarding blood loss, maximum Hb drop, or the incidence of postoperative anaemia that required medicine. There was no significant difference in reoperation or mortality among the groups. When controlling for demographic and comorbidity characteristics, there was no statistically significant difference in the odds of transfusion during the same hospitalization or overall complications at 90 days among the groups (P > 0.05).ConclusionsElevated preoperative INR cannot increase transfusion or complication rates independently in primary THA with the management of the ERAS protocol. With the improvement in the ERAS protocol and the use of tranexamic acid (TXA), an INR < 1.5 is still a conventional safe threshold for THA surgery.

Determining Optimal Treatment to Correct Preoperative Anemia and Reduce Perioperative Allogeneic Blood Transfusions in Cardiac Surgery: A Retrospective Cohort Study

Preoperative anemia management reduces red blood cell (RBC) transfusion and adverse outcomes, but how best to optimize the patient's hemoglobin (Hgb) before cardiac surgery remains unclear. The authors sought to determine the optimal treatment of anemia using iron and epoetin alfa before cardiac surgery. Retrospective cohort study. Sunnybrook Health Sciences Centre, University of Toronto. The study comprised 532 consecutive patients referred to the outpatient Blood Conservation Clinic and who underwent cardiac surgery between 2008 and 2018. Of the 532 patients, 207 received oral iron, 84 received intravenous (IV) iron, 71 received epoetin alfa, 92 received combination therapy, and 78 received no treatment. Multivariate linear, logistic, and Poisson regressions modelled preoperative Hgb, the change from referral to preoperative Hgb (∆Hgb), the odds of transfusion, and the number of RBC units transfused, while accounting for baseline covariates. Higher ∆Hgb was associated with IV iron >600 mg (9.80 g/L [6.17-13.42]), epoetin alfa >80,000 U (5.80 g/L [2.20-9.40]), and higher referral Hgb (1.91 g/L [1.09-2.74] per 10 g/L). Higher preoperative Hgb (odds ratio 0.76 [0.64-0.90]; count ratio 0.84 [0.77-0.93] per 10 g/L) corresponded to a lower likelihood of being transfused and transfusion of fewer RBC units. Preoperative IV iron >600 mg and epoetin alfa >80,000 U each was associated with significant increases in Hgb. Higher preoperative Hgb was associated with a lower likelihood of transfusion and transfusion of fewer RBC units. The authors recommend that cumulative preoperative doses of IV iron >600 mg and epoetin alfa >80,000 U be used for treatment of anemia before cardiac surgery.

Pre-hospital hypothermia is associated with transfusion risk after traumatic injury.

In traumatically injured patients, excessive blood loss necessitating the transfusion of red blood cell (RBC) units is common. Indicators of early RBC transfusion in the pre-hospital setting are needed. This study aims to evaluate the association between hypothermia (<36°C) and transfusion risk within the first 24 hours after arrival to hospital for a traumatic injury. We completed an audit of all traumatically injured patients who had emergent surgery at a single tertiary care center between 2010 and 2014. Using multivariable logistic regression analysis, we evaluated the association between pre-hospital hypothermia and transfusion of ≥1 unit of RBC within 24 hours of arrival to the trauma bay. Of the 703 patients included to evaluate the association between hypothermia and RBC transfusion, 203 patients (29%) required a transfusion within 24 hours. After controlling for important confounding variables, including age, sex, coagulopathy (platelets and INR), hemoglobin, and vital signs (blood pressure and heart rate), hypothermia was associated with a 68% increased odds of transfusion in multivariable analysis (OR: 1.68; 95% CI: 1.11-2.56). Hypothermia is strongly associated with RBC transfusion in a cohort of trauma patients requiring emergent surgery. This finding highlights the importance of early measures of temperature after traumatic injury and the need for intervention trials to determine if strategies to mitigate the risk of hypothermia will decrease the risk of transfusion and other morbidities.

Isolated femoral shaft fractures in children rarely require a blood transfusion

BackgroundNo recent study has examined how a trend toward surgical fixation for pediatric femoral shaft fractures has impacted blood loss and transfusion requirements. The purpose of this study was to determine the factors influencing transfusions in the treatment of pediatric femoral shaft fractures. MethodsA retrospective review of patients with femoral shaft fractures treated surgically from 2004 – 2017 at a tertiary pediatric hospital was conducted. Electronic medical records were reviewed for fixation method, additional injuries, blood loss (estimated blood loss (EBL), hemoglobin, hematocrit) and transfusion. The relationship between fixation method with blood loss and transfusion was examined. Two groups were compared, those with and without additional injuries. Additional injuries were defined as additional fractures and/or abdominal, chest, or head injuries. Results172 patients met inclusion criteria. There were 129 patients with isolated femoral shaft fractures and 43 patients with femoral shaft fractures and concomitant additional injuries. The transfusion rate in patients with isolated femoral shaft fractures was 0.8% (1/129) which was significantly lower than in patients with additional injuries; 39.5% (17/43) (p < 0.05). In patients with additional injuries, there was a significant relationship between number of additional surgeries and odds of transfusion (OR=2.1, CI: 1.2–3.6, p < 0.05). In patients with isolated femoral shaft fractures, EBL was higher in patients treated with rigid intramedullary nails (148.5 ± 119.0 mL) than flexible intramedullary nails (34.1 ± 56.3 mL) (p < 0.05). However, there was no significant difference in transfusion or changes in hemoglobin/hematocrit between fixation methods in patients with isolated femoral shaft fractures. ConclusionPediatric patients with surgically treated isolated femoral shaft fractures rarely require transfusion (<1%), while patients with femoral shaft fractures and additional injuries had a high transfusion rate (39.5%). Surgical fixation method had a significant impact on EBL, with rigid intramedullary nail fixation having a significantly higher EBL than flexible intramedullary nails, however it did not lead to higher rates of transfusions. Blood transfusions are rarely needed in isolated femoral shaft fractures, despite the trend towards increase in surgical fixation and newer fixation techniques.

Effects of changes in adult erythropoietin dosing guidelines on erythropoietin dosing practices, anemia, and blood transfusion in children on hemodialysis: findings from North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS).

While adult hemodialysis (HD) patients have increased morbidity with higher target hemoglobin levels, similar findings have not been demonstrated in pediatric patients. We evaluated changes in transfusions, anemia frequency, and erythropoietin (epo) dosing among pediatric HD patients before, during, and after implementation of federal dialysis payment policies regarding epo dosing for adult HD patients. This is a retrospective cohort study of pediatric HD patients enrolled in NAPRTCS. We evaluated need for transfusion, anemia, median hemoglobin, and median epo dose 6 months after starting HD in 3 eras: baseline (2003-2007), implementation (2008-2011), and post implementation (2012-2016). We used multivariate logistic regression models to evaluate potential differences in transfusion across the eras. Six months after dialysis initiation, 12.6% of patients required transfusion pre-implementation, 17.9% during implementation, and 15.5% post implementation. Anemia occurred in 17.4% of patients pre, 23.5% during, and 23.8% post implementation, with median hemoglobin levels of 11.9 g/dL pre, 11 g/dL during, and 11 g/dL post implementation. Epo use was high across all 3 eras, but epo dosing decreased during and post implementation, despite more anemia during these periods. Odds of transfusion in implementation era compared with pre-implementation was 1.75 (95% CI 1.11-2.77) and odds of transfusion in post implementation era compared with pre was 1.19 (95% CI 0.71-1.98), controlling for age, race, gender, and prior transplant status. During and following implementation of adult epo dosing guidelines, transfusion and anemia frequency increased in pediatric HD patients. Ideal target hemoglobin levels for pediatric dialysis patients warrant further study.

Intraoperative cell salvage use reduces the rate of perioperative allogenic blood transfusion in patients undergoing periacetabular osteotomy.

Blood loss during periacetabular osteotomy (PAO) is variable, with losses ranging from 100 to 3900 ml in published series. Perioperative allogenic blood transfusion is frequently utilized although is associated with significant risk of morbidity. Cell salvage (CS) is a common blood conservation tool; however, evidence supporting its use with PAO is lacking. Our aim was to assess whether CS affects perioperative allogenic blood transfusion rate in patients undergoing PAO. The clinical records of 58 consecutive PAOs in 54 patients (median age 24.7 years, interquartile range 17.8–29.4 years) performed by a single surgeon between 1 January 2016 and 30 April 2018 were reviewed. Autologous blood pre-donation and surgical drains were not used. Due to variable technician availability, CS was intermittently used during the study period. PAOs were allocated into a CS group or no cell salvage group (NCS group), according to whether an intraoperative CS system was used. There was no significant difference in patient age, gender, body mass index, dysplasia severity, regional anesthetic technique, tranexamic acid administration, surgical duration or estimated blood loss (all P > 0.05) between the two groups. The CS group had a lower preoperative hemoglobin compared to the NCS group (median, 13.4 g/dl versus 14.4 g/dl, P = 0.006). The incidence of allogenic blood transfusion was significantly lower in the CS group compared to the NCS group (2.5% versus 33.3% patients transfused, P = 0.003). Multivariate modeling showed CS use to be protective against allogenic blood transfusion (P = 0.003), with an associated 80-fold reduction in the odds of transfusion (odds ratio, 0.01; 95th% CI, 0–0.57). To our knowledge, this is the first study to assess the effect of CS use on allogenic transfusion rate in patients undergoing PAO. Our results demonstrate CS to be a mandatory component of blood conservation for all patients undergoing PAO.

The incidence and importance of anaemia in patients undergoing cardiac surgery in the UK - the first Association of Cardiothoracic Anaesthetists national audit.

The importance and variability of pre-operative anaemia in cardiac surgical patients across the UK is not known, and there is debate about its association with patient outcomes. The Association of Cardiothoracic Anaesthetists carried out its first national audit on anaemia and transfusion, and analysed data from 19,033 patients operated on in 12 cardiac surgical centres between 2010 and 2012; 5895 (31%) had pre-operative anaemia. Centre-specific prevalence of anaemia varied from 23% to 45%; anaemia was associated with older patients, diabetes and surgical risk (EuroSCORE). Nevertheless, controlling for these factors, regional variation remained an independent effect (p < 0.001). Multivariable analysis demonstrated an independent association of anaemia with transfusion (odds ratio (95% confidence interval) 2.75 (2.55-2.95), p < 0.001), mortality (1.42 (1.18-1.71), p < 0.001) and hospital stay (geometric mean ratio (95% confidence interval) 1.15 (1.13-1.17), p < 0.001). Haemoglobin concentration per se was also independently associated with worse outcomes; a 10 g.l(-1) decrease in haemoglobin was associated with a 43% increase (95% confidence interval 40-46%) in the odds of transfusion and a 16% increase (95% confidence interval 10-22%) in the odds of mortality (both p < 0.001). This large UK-wide audit has demonstrated marked regional variation in both anaemia and transfusion, with a consistently high incidence of both. The independent association between pre-operative anaemia and worse outcomes in UK practice has also been confirmed, and robust prospective study of anaemia treatment before cardiac surgery is required; these data will assist in designing such trials.

Odds of Transfusion for Older Adults Compared With Younger Adults Undergoing Surgery

Odds of Transfusion for Older Adults Compared With Younger Adults Undergoing Surgery

Maternal Risk Factors for Peripartum Transfusion

Postpartum hemorrhage remains one of the most significant maternal complications of childbirth in the United States, with peripartum transfusion the most commonly identified morbidity. We completed a retrospective cohort study of women delivering at 20+ weeks at a large regional obstetric hospital between 2000 and 2008. Data were extracted from the institutional data warehouse; women with a potential coagulopathy were excluded. The association of maternal and obstetric factors with odds of transfusion was explored using univariate and multivariable logistic regression. We identified 59,282 deliveries and 614 cases of transfusion, an incidence rate of 10.4/1,000 deliveries. Rates were highest for black (14.1/1,000 deliveries) and lowest for white (8.4/1,000 deliveries) women. Increased odds of perinatal transfusion were seen for women with anemia at entry to labor and delivery (odds ratio [OR] 3.03, 95% confidence interval [CI] 2.43-3.79 for hemoglobin (Hgb) 9.5-10.5 g/dL; OR 12.65, 95% CI 10.35-15.46 for Hgb<9.5 g/dL) and those undergoing a cesarean delivery (OR 4.28, 95% CI 3.62-5.05). The excess risk associated with black race was eliminated after adjusting for anemia and other covariates. A synergistic effect of anemia with delivery method was observed. Anemia was estimated to account for 31.7% of transfusions. Potentially modifiable factors most strongly associated with risk for transfusion were antenatal anemia and cesarean delivery, and their co-occurrence was synergistic. Anemia is an easily identified and treatable risk factor and warrants focus as part of preconception and interconception care in childbearing women.

Hematologic outcomes and blood utilization in cancer patients with chemotherapy-induced anemia (CIA) pre- and post-national coverage determination (NCD): results from a multicenter chart review

In July 2007, the Centers for Medicare and Medicaid Services (CMS) limited coverage of erythropoiesis-stimulating agents (ESAs) in cancer patients with chemotherapy-induced anemia (CIA) through a National Coverage Determination (NCD). The primary objective of this study was to compare transfusion rates in patients with CIA with lung, breast, or colorectal cancer before and after the NCD. Adult Medicare patients with CIA treated at 49 community oncology clinics were selected from two time periods based on clinics' NCD implementation date. Chart data were abstracted for 12 weeks post-CIA episode start, defined as hemoglobin (Hb) level <11 g/dL while receiving chemotherapy or within 60 days of the last chemotherapy dose. Multivariate analyses were used to calculate the odds of transfusion and to assess the units of blood transfused, controlling for differences in demographics, clinical history, and chemotherapy. Eight hundred pre-NCD and 994 post-NCD patients from 49 sites were selected. Of the patients, 56% used ESAs post-NCD vs. 88% pre-NCD (p < 0.0001). The duration of ESA use decreased in the post-NCD (32.1 days) vs. pre-NCD (48.4 days, p < 0.0001) group. The post-NCD group reported significantly lower Hb levels, higher odds of receiving a transfusion (odds ratio: 1.41, 95% CI 1.05-1.89, p = 0.0238) and increased blood utilization of 53% (units transfused: OR 1.53, 95% CI 1.15-2.04, p = 0.0034). Decreased frequency and duration of ESA administration were reported in the post-NCD vs. pre-NCD period. Findings were accompanied by a modest but statistically significant increase in transfusions and a decrease in Hb values.