How you look determines what you find: severity of illness and variation in blood transfusion for hip fracture

Risk of perioperative blood transfusions and postoperative complications associated with serotonergic antidepressants in older adults undergoing hip fracture surgery

Serotonergic antidepressants (SAds) are associated with bleeding-related adverse events. An increased risk of bleeding with SAds may have important implications in surgical settings. Our study evaluates the risk of red blood cell (RBC) transfusions and postoperative complications associated with SAds among older adults undergoing hip fracture surgery. We conducted a retrospective cohort study of individuals 66 years or older who underwent hip fracture surgery in Ontario, Canada. The risk of RBC transfusion among current users of SAds and nonserotonergic antidepressants (NSAds) was compared with recent former SAd users. Secondary outcomes included measures of postoperative morbidity and mortality. Subgroup analyses were undertaken in groups who were coprescribed other medications known to effect bleeding. Multivariable logistic regression was utilized to determine the odds ratios (ORs) for antidepressants and postoperative outcomes. A total 11,384 individuals were included in the study sample. Current SAd users had an increased risk of RBC transfusion compared with recent former users of SAds (OR, 1.28; 95% confidence interval, 1.14-1.43) as did current NSAd users (OR, 1.17; 95% confidence interval, 1.03-1.33). The risk of RBC transfusion with SAds or NSAds was further increased among individuals receiving antiplatelet agents. However, postoperative morbidity and mortality were not increased among either group of antidepressant users. In conclusion, SAds are associated with an increased risk of RBC transfusions, although this does not appear to result in major postoperative complications. Clinicians should be aware of this increased risk, although routine discontinuation of antidepressants before surgery is likely unwarranted in most cases.

Association between hospital intraoperative blood transfusion practices for surgical blood loss and hospital surgical mortality rates

OBJECTIVE

Blood loss during surgery is an important operative complication in patients undergoing major noncardiac surgery and may increase postoperative morbidity and mortality. Variations in the delivery of operative blood transfusions to treat blood loss depend not only on the patient and surgery characteristics but also on the hospital transfusion practices, and may explain differences in the hospitals' postoperative outcomes. We determine the relationship between hospital-level rates of intraoperative blood transfusion and 30-day mortality among older patients with significant intraoperative blood loss.

METHODS

Among 46,608 operative patients aged 65 years or older whose estimated blood loss was 500 mL or greater in 122 Veterans Affairs (VA) hospitals during years 1997 to 2004, we examined the relationship between hospital-level transfusion rates and adjusted 30-day postoperative mortality rates using linear regression modeling.

RESULTS

Hospital-level rates of intraoperative blood transfusion for older surgical patients with significant blood loss varied from 10% to 92%. Hospitals in the highest tertile for the rate of intraoperative transfusion had the highest number of patients with 500 mL or more surgical blood loss and lowest risk-adjusted 30-day surgical mortality. For every 10% increase in the rate of intraoperative blood transfusion, there was a 0.7% (95% CI: 0.3%-1.1%) decrease in the hospital's adjusted 30-day postoperative mortality for these high-risk patients.

CONCLUSIONS

Large variation exists in hospitals' intraoperative blood transfusion practices for older patients with significant surgical blood loss. Hospitals with higher transfusion rates for patients with significant surgical blood loss have lower adjusted 30-day mortality for these patients. Hospital intraoperative blood transfusion practices may be a promising surgical quality indicator.

Is anemia at admission related to short-term outcomes of elderly hip fracture patients?

Hip fracture in elderly people is associated with high morbidity and mortality. Therefore, it is important to identify risk factors that potentially influence outcomes after hip surgery. The main purpose of this study was to evaluate the relationship of anemia at admission and short-term outcomes after hip fracture. We studied 343 community-dwelling patients who underwent surgery for hip fracture from March 2009 to March 2010. Functional mobility at discharge, postoperative complications, hospital length of stay and in-hospital mortality were analyzed in respect to presence and severity of anemia at admission. Anemia (defined as hemoglobin levels < 13.0 g/dl for men and < 12.0g/dl for women) was present in 185 (53.9%) patients, of whom 54 (29.2%) were severely anemic (defined as hemoglobin level 10.0g/dl or below). In multivariate analysis anemia was associated with age, gender (female), type of fracture (intertrochanteric) and American Society of Anesthesiologists (ASA) classification (3 or 4), while severity of anemia was associated with recovery of ambulatory ability at discharge. There was no difference in the incidence of postoperative complication, in-hospital mortality and length of hospital stay between the groups at discharge. Overall anemia at admission is an indicator of poor general health status. Ambulatory recovery in hip fracture patients is independently related to severity of anemia at admission.

Drivers of transfusion decision making and quality of the evidence in orthopedic surgery: a systematic review of the literature

Reasons for variation in transfusion practice in orthopedic surgery are not well understood. This systematic review identified and appraised the quality of the literature in this area to assess the impact of factors associated with the use of allogeneic red blood cell (RBC) transfusion in orthopedic procedures. MEDLINE and EMBASE databases were searched for relevant English language publications. Articles containing a range of MeSH and text terms regarding "blood transfusion," "predictors," and "multiple logistic regression" were retrieved. Articles that focused on patients undergoing orthopedic procedures and that met prespecified inclusion criteria were appraised in terms of potential bias and the appropriateness of statistical approach. A total of 3641 citations were retrieved, and 29 met the inclusion criteria for the review. Articles reported on a range of orthopedic procedures including total hip arthroplasty; total knee arthroplasty, total shoulder arthroplasty, and spinal surgery. Most studies were conducted in the United States (n = 12) or Canada (n = 5). Study quality was moderate; 50% or more of the quality criteria were assessed in 15 articles. Particular areas of concern were the lack of prospective studies, lack of clarity in defining the time interval between risk factor assessment and transfusion outcome, and lack of model validation. A narrative synthesis found that 2 factors consistently influenced the use of RBC transfusion-decreased hemoglobin (n = 25) and increased patient age (n = 18). Increased surgical complexity (n = 12), low body weight (n = 9), presence of additional comorbidities (n = 9), and female sex (n = 7) were also important factors. The general quality of the studies in the field is weak. However, low hemoglobin and increasing age were consistently identified as independent risk factors for RBC transfusion in orthopedic practice. Additional or alternative analytical approaches are required to obtain a more comprehensive, holistic understanding of the decision to transfuse RBCs to patients undergoing orthopedic surgery.

Development of an index to characterize the "invasiveness" of spine surgery: validation by comparison to blood loss and operative time

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To create and validate an index describing the extent of spine surgical intervention to allow fair comparisons of complication rates among patients treated by different surgeons, devices, or hospitals.

SUMMARY OF BACKGROUND DATA

Safety comparisons in spine surgery are limited by lack of methods that adjust for important variations in the surgical "case-mix." Among other factors, the magnitude of an operation is likely to have a substantial influence on the likelihood of complications.

METHODS

We created a spine surgery invasiveness index defined as the sum, across all vertebral levels, of 6 possible interventions on each operated vertebra: anterior decompression, anterior fusion, anterior instrumentation, posterior decompression, posterior fusion, and posterior instrumentation. We assessed the validity of this index by examining its association with blood loss and surgery duration in 1723 spine surgeries, adjusting for important factors including age, gender, body mass index, diagnosis, neurologic deficit, revision surgery, and vertebral level of surgery.

RESULTS

Blood loss increased by 11.5% and surgery duration increased by 12.8 minutes for each unit increase in the invasiveness index. The invasiveness index explained 44% of the variation in blood loss and 52% of the variation in surgery duration. For specific surgical components, blood loss increased by 9.4% and surgery duration by 11.4 minutes for each vertebral level of anterior decompression, 19.4% and 33.8 minutes for each segment of anterior instrumentation, 12.9% and 22.7 minutes for each level of posterior decompression, and 25.1% and 18.8 minutes for each segment of posterior instrumentation.

CONCLUSION

An "invasiveness" index based on the number of vertebrae decompressed, fused, or instrumented showed the expected associations with both blood loss and surgery duration. This quantitative description of surgery invasiveness may be useful to adjust for surgical variations when making safety comparisons in spine surgery.

[Acute orthogeriatric care (II). Clinical aspects]

The present article reviews the clinical principles of acute orthogeriatric care. The application of geriatric medicine to patients with hip fracture is explained. The principal stages of geriatric intervention in this process are mentioned, as are the interventions to be carried out by the geriatric team. Subsequently, we discuss the management of several frequent problems in these patients, such as high surgical risk, pain management, anaemia, delirium, malnutrition, and discharge planning. Lastly, the characteristics of several kinds of patients with special characteristics are mentioned, such as those diagnosed with dementia, nursing home residents or the oldest-old. Areas of improvement in the acute phase are also reviewed, such as mortality reduction, functional outcome improvement and the need for more efficient resource use in patients in the acute phase of hip fracture.

Blood management: a primer for clinicians

Blood transfusions are common in the hospital setting. Despite the large commitment of resources to the delivery of blood components, many clinicians have only a vague understanding of the complexities associated with blood management and transfusion therapy. The purpose of this primer is to broaden the awareness of health care practitioners in terms of the risks versus benefits of blood transfusions, their economics, and alternative treatments. By developing and implementing comprehensive blood management programs, hospitals can promote safe and clinically effective blood utilization practices. The cornerstones of blood management programs are the implementation of evidence-based transfusion guidelines to reduce variability in transfusion practice, and the employment of multidisciplinary teams to study, implement, and monitor local blood management strategies. Pharmacists can play a key role in blood management programs by providing technical expertise as well as oversight and monitoring of pharmaceutical agents used to reduce the need for allogeneic blood.

Erythropoietic therapy: Cost efficiency and reimbursement

PURPOSE

The practice of blood conservation is aimed at improving patient outcomes by avoiding allogeneic transfusions via a coordinated multidisciplinary, multipronged approach. The numerous blood conservation techniques and transfusion alternatives now available are described.

SUMMARY

Ongoing concerns exist regarding the availability of the nation's and the world's blood supply. In addition, the number of measures required to ensure blood safety has led to increases in the price of blood and blood products over the past 10-15 years. Moreover, blood transfusion carries inherent risks even under the most favorable circumstances. Investigations have established that injudicious transfusion is associated with development of ventilator-associated pneumonia, nosocomial infection, and organ dysfunction. Because most single blood-conservation techniques reduce blood usage by a mere 1-2 units, a series of integrated conservation approaches are required. These include preoperative autologous donation, use of erythropoietic agents, blood conservation techniques such as acute normovolemic hemodilution, individualized assessment of anemia tolerance, implementation of conservative transfusion thresholds, meticulous surgical techniques, and judicious use of phlebotomy and pharmacologic agents for limiting blood loss. Erythropoietic agents such as epoetin alfa have been used successfully to increase hemoglobin and decrease transfusion requirements, and are appropriate when used in advance of elective surgical procedures. Acquisition costs of erythropoietic stimulating agents versus costs of blood justify economic evaluation by hospitals to make the most cost-effective choice under current economic constraints.

CONCLUSION

Initiating a blood management program requires planning and support from those who are concerned about blood usage reduction and outcomes improvement. Launching a vigorous and ongoing educational program to raise awareness about the risks and hazards associated with blood transfusion is an important step in helping to reshape the medical staffs' attitudes about transfusion and the most cost-effective way to achieve clinical goals.

Preoperative characteristics identify patients with hip fractures at risk of transfusion

Routine cross-matching places substantial demands on limited blood resources. The primary objective of this study was to identify patients with hip fractures at risk of transfusion, which may allow implementation of a more selective cross-matching policy. We also sought to determine the hemoglobin level that triggered a transfusion, the rate of urgent (intraoperative) transfusions, and these patients' characteristics. We reviewed 124 consecutive patients admitted with hip fractures. Patients' clinical and radiologic details, transfusion rates, timing of transfusion, and preoperative and postoperative hemoglobin were reviewed. Older age, low admission hemoglobin, and peritrochanteric fractures were identified as risk factors for transfusion. Eighty-six percent of patients who received transfusions had two or more risk factors, compared with 48% of the total population. The mean hemoglobin that triggered a transfusion was 7.8 g/dL. Although 30% (37/124) of patients received transfusions, only 5% (six of 124) received transfusions intraoperatively, and the majority of these patients (five of six) had at least two risk factors of transfusion. Routine cross-matching for patients with hip fractures requiring surgery can safely be converted to cross-matching on demand in all but high-risk patients. Restrictive cross-matching policies would improve costs in healthcare delivery and prevent unnecessary use of blood resources.

Perioperative stimulation of erythropoiesis with intravenous iron and erythropoietin reduces transfusion requirements in patients with hip fracture. A prospective observational study

BACKGROUND AND OBJECTIVES

Patients undergoing surgery for hip fracture (HF) often receive perioperative allogeneic blood transfusions (ABT) to avoid anaemia. However, concerns about the adverse effects of ABT have prompted the review of transfusion practice and the search for a safer treatment of perioperative anaemia.

MATERIALS AND METHODS

We prospectively investigated the effect of a blood-saving protocol of perioperative iron sucrose (3 x 200 mg/48 h, intravenously) plus erythropoietin (1 x 40,000 IU, subcutaneously) if admission haemoglobin level < 130 g/l, on transfusion requirements and postoperative morbid-mortality in patients with HF (group 2; n= 83). A parallel series of 41 HF patients admitted to another surgical unit within the same hospital served as the control group (group 1). Perioperative blood samples were taken for haematimetric, iron metabolism and inflammatory parameter determination.

RESULTS

This blood-saving protocol reduced the number of transfused patients (P < 0.001), the number of transfused units (P < 0.0001), increased the reticulocyte count and improved iron metabolism. In addition, the blood-saving protocol also reduced the rate of postoperative infections (P = 0.016), but not the 30-day mortality rate or the mean length of hospital stay.

CONCLUSIONS

The blood-saving protocol implemented seems to reduce ABT requirements in patients with HF, and is associated with a lower postoperative morbidity. The possible mechanisms involved in these effects are discussed.

Facteurs de qualité de la prise en charge des sujets âgés opérés d’une fracture de l’extrémité supérieure du fémur

Hip fractures are one of the leading causes for admission of elderly subjects to healthcare facilities. Because of population aging, the incidence of hip fractures has increased considerably over the last years and will continue to increase in industrialized countries. Hip fracture in an elderly subject may be life threatening and has a significant functional and social impact not only because of the fracture itself, but also because of the risk of complications related to the patient's health status and the long hospital stay. The purpose of this work was to identify in the published literature professional practices, excepting the surgical procedure, associated with better early and long-term outcome in elderly patients with hip fracture. Questions raised concerning the patient's hospital stay include factors related to the preoperative phase (time to surgery, usefulness of traction), the operation itself (antibiotic prophylaxis, anesthesia technique), and the postoperative phase (prevention of venous thrombosis, malnutrition, episodes of confusion, duration of indwelling bladder catheter, correction of anemia, geriatric care during the stay in the orthopedic ward, early and intense rehabilitation, prevention of recurrence). Among these factors, several appear to be associated with better outcome, including long-term outcome--surgery as early as possible in light of the patient's general status, antibiotic prophylaxis in accordance with standard recommendations (SFAR), prevention of venous thrombosis with low-molecular-weight heparin initiated at admission and associated with elastic contention. Oral nutritional support is probably beneficial and should be proposed for all patients. Particular attention must be given to prevention of confusion in order to reduce the rate of institutionalization. The rythm of rehabilitation exercises should be at least five sessions per week. Finally, there are several methods, which are effective in preventing recurrence, taking into account osteoporosis, risk of falls. Preventive measures should be instituted for all patients undergoing surgery for hip fracture.

Patients with pertrochanteric hip fracture may benefit from preoperative intravenous iron therapy: a pilot study

BACKGROUND

Patients undergoing pertrochanteric hip fracture (PHF) repair surgery often receive perioperative allogeneic blood transfusions (ABTs) to avoid the deleterious effects of anemia. Nevertheless, concerns about adverse effects of ABTs have prompted the review of transfusion practice and the search for a safer treatment of perioperative anemia.

MATERIAL AND METHODS

The effect of preoperative 200 to 300 mg of intravenous (IV; Group 2; n = 55) iron sucrose administration on transfusion requirements and postoperative morbidity-mortality in patients with PHF has been prospectively investigated. A previous series of 102 PHF patients served as the control group (Group 1). All patients were older than 65 years and were operated on at the third day after admission to the hospital, by the same medical team and with the same implant.

RESULTS

Iron sucrose was well tolerated and reduced the transfusion rate in patients with admission hemoglobin levels of greater than 120 g per L (p < 0.05) who also received fewer units of red blood cells (p < 0.05). In addition, iron sucrose reduced postoperative infection rate (p < 0.05), but not 30-day mortality rate or mean length of hospital stay.

CONCLUSION

The administration of IV iron sucrose seems to reduce ABT requirements in patients with PHF and is associated to lower postoperative morbidity. The possible mechanisms involved in these effects are discussed.

Seguridad y eficacia del hierro intravenoso en la anemia aguda por fractura trocantérea de cadera en el anciano

BACKGROUND AND OBJECTIVE

An important percentage of patients with hip fracture need allogeneic transfusion to resolve their perioperative anemia. Our goal was to determine the safety profile and usefulness of parenteral iron in order to avoid allogeneic transfusions in trochanteric hip fracture (THF).

PATIENTS AND METHOD

A pseudo-experimental study was performed comparing a historic THF group (n = 104) with another group (n = 23) treated with parenteral iron (Venofer) (doses of 100 mg). Patients who had primary blood diseases or were receiving anticoagulation therapy were excluded. Age, gender, elapsed time, type of THF (international AO classification), surgical procedure, transfusion procedure and quantity, hemoglobin and hematocrit at days 0 and +2 (if a surgical procedure was not performed) and postoperatively were examined. We also analyzed the morbidity (post-surgical infection) and hospital stay and mortality rate at the first month.

RESULTS

We have not observed any adverse reactions upon iron administration. The iron group was transfused less times (39.1% vs. 56.7%) and had lower morbidity (infection) (20.3% vs. 35.4%) (p = 0.04), lower mortality (13% vs. 16.3%), less blood consumption (0.87 vs. 1.31 units) and less stay (13.7 vs. 14.3 days).

CONCLUSIONS

Parenteral administration of iron could be a safe and effective way to avoid or reduce allogeneic blood transfusions in THF patients. The reduction in the transfusional rate in the iron treated group is also accompanied by a reduction in the morbidity, infection rate, mortality rate and hospital stay.

Effects of blood transfusion on clinical and functional outcomes in patients with hip fracture

BACKGROUND

Anemia and transfusion are common among elderly patients requiring surgery. The effects of transfusion on morbidity and mortality are controversial. The influence of transfusion on risk-adjusted mortality, readmissions, and functional mobility was examined.

STUDY DESIGN AND METHODS

A consecutive cohort of 551 patients undergoing surgery for hip fracture at four hospitals was prospectively studied. Outcomes were death, readmission, and functional independence measure-locomotion scores within 60 days of discharge. The trigger Hb level was defined as the lowest value before the first postoperative transfusion. Multivariate analyses adjusted for a validated, hip-fracture-specific risk model and predictors of transfusion.

RESULTS

Overall, 54.4 percent of patients received transfusions after surgery. Seventy-two percent of patients with a lowest postoperative Hb level of less than 10.0 g per dL received transfusions compared to 19.6 percent of those whose lowest measurement was at least 10.0 g per dL (p < 0.0001). In the 60 days after discharge, 3.8 percent of patients died and 16.9 percent were readmitted. Transfusion was associated with lower risk-adjusted odds of readmission (OR, 0.54; 95% CI, 0.30-0.97), but it did not influence mortality or mobility functioning. In subgroups analyses, the benefit of transfusion on readmission rates appeared to be concentrated among patients with a trigger Hb level of less than 10.0 g per dL. For patients with a trigger Hb level of at least 10.0 g per dL, transfusion did not affect risk-adjusted rates of death or readmission, but was associated with better risk-adjusted functional mobility scores (p < 0.01).

CONCLUSIONS

Postoperative transfusion reduced the risk of readmission but did not decrease mortality or improve mobility. Randomized controlled trials of different transfusion strategies will be needed to clarify the true benefits and risks of transfusion in surgical patients.

Review of the clinical practice literature on patient characteristics associated with perioperative allogeneic red blood cell transfusion

There is evidence to suggest that there exists considerable variation in red blood cell (RBC) transfusion practices, especially in the surgical specialties. This is in large part related to difficulties in defining specific transfusion threshold criteria, given that there is no minimum acceptable hemoglobin threshold concentration and there is variability in assigning importance to patient factors. The purpose of this study is to identify patient-related factors that might be associated with the need for allogeneic RBC transfusion in surgical patients. We systematically identified, selected, and reviewed all observational or interventional studies describing patient-specific or related variables associated with the need for allogeneic RBC transfusion in the surgical patient population. We also evaluated the methodological characteristics of the individual studies. Sixty-two studies met our inclusion criteria and were analyzed for this review. Most of these studies were conducted in patients undergoing cardiac surgery (n = 30) and orthopedic surgery (n = 16). Decreased preoperative red cell reserve was most frequently associated with RBC transfusions, being identified as a significant variable in 46 studies. The other factors commonly associated with transfusion were advancing age (n = 28), female gender (n = 21), and small body size (n = 14). Only 2 studies attempted to prospectively validate a predictive model for RBC transfusion based on the variables identified. This systematic review shows that preoperative anemia, advancing age, female gender, and small body size are often associated with perioperative allogeneic RBC transfusion. However, the retrospective nature of most of the studies and the small sample sizes make it difficult to formulate a clinically useful prediction rules regarding allogeneic RBC transfusion. Ongoing research in designing large prospective cohort studies evaluating transfusion patterns are needed to further elucidate how patient characteristics impact the transfusion threshold.

[Predictive factors for transfusion requirements in patients over 65 years old with subcapital hip fracture]

BACKGROUND AND OBJECTIVE

Our goal was to know the patient's clinical and hematologic characteristics that could influence the use of blood in subcapital hip fracture (SCHF).

PATIENTS AND METHOD

A prospective study of all patients affected by SCHF having surgery during 1998. Patients younger than 65 years, with primary blood diseases or under anticoagulation therapy were excluded. Age, gender, elapsed time, type of SCHF (international AO classification), surgical procedure (nail vs. hip arthroplasty), transfusional procedure and total used; hemoglobin (Hb) and hematocrit (Hct) levels at days 0 and + 2 (if surgical procedure was not performed) and after surgery were studied. Also we analyzed different hematimetric parameters: VCM, HCM, and RDW, transfusional act and blood consume. Statistical univariant analysis included T-Student test for numeric variables and Pearson X2 test for string variables. Statistical significance differences were considered when p < 0.05. A multivariate stepwise logistic regression model was carried out.

RESULTS

75 patients with SCHF were studied: 18 B1, 8 B2 and 49 B3 according to AO classification. Male/female: 12/63; age 81(SD: 8) years (range 65-99). At the admission day, the Hb level was 128 (SD: 23) g/L; Hct 0.39 L/L (SD: 0.06) (range 13-52), HCM 30.3 pg, VCM 91.4 fL and RDW 14.3%. The elapsed time was 5 (SD: 2.8) days. 22 patients (29.3%) had anemia on admission. Surgery consisted of: nails in 23 (31%) and hip arthroplasty in 52 (69%) patients. At day + 2 (n: 36) Hb was 119 g/L (SD: 12) and Hct 0.36 L/L (SD: 0.04). 34 (45%) patients were not transfused. On the statitiscal univariant study, Hb and Hct levels at admission and after surgery, RDW (anisocytosis), type of fracture and the surgical act were all associated with a transfusional procedure. In the transfused patients the Hb level (119.9 g/L) was lower than in non-transfused ones (138 g/L) (p < 0.01). 71% hip arthroplasty patients were transfused vs 17% nail patients (p < 0.01). On the logistic regression only the preoperative Hb level (p < 0.01) was identified as an independent predictor of transfusion.

CONCLUSIONS

These results invite us to improve the hematological parameters in this elderly population and to promote earlier and less aggressive surgical procedures (nails) and to promote the use of alternatives methods to reduce the use of allogenic blood.

The relationship between admission hemoglobin level and outcome after hip fracture

OBJECTIVE

To determine the effect of admission hemoglobin level on patient outcome after hip fracture.

STUDY DESIGN

Prospective, consecutive.

PATIENTS

From July 1991 to June 1997, 395 community-dwelling patients sixty-five years of age or older who had sustained an operatively treated femoral neck or intertrochanteric fracture were prospectively followed up.

MAIN OUTCOME MEASUREMENTS

Postoperative complications, in-hospital mortality rate, hospital length of stay, hospital discharge status, place of residence at one year, and mortality and recovery of ambulatory ability and activities of daily living status at three, six, and twelve months.

RESULTS

Women with admission hemoglobin levels below 12.0 grams per deciliter and men with admission hemoglobin levels below 13.0 grams per deciliter were classified as anemic. One hundred eighty patients (45.6 percent) were considered anemic on admission. Patients who were anemic were more likely to have an American Society of Anesthesiologists rating of III or IV and have sustained an intertrochanteric fracture. Hospital length of stay and mortality rate at six and twelve months were significantly higher for patients who were anemic on admission. There were no differences in the incidence of postoperative complications, hospital discharge status, place of residence at one year, in-hospital mortality rate, and three-month mortality rate between patients who were and were not anemic on admission. In addition, there were no differences in the recovery of ambulatory ability and of basic and instrumental activities of daily living status at three, six, and twelve months between the two patient groups.

CONCLUSIONS

Patients at risk for poor outcomes after hip fracture can be identified by assessing hemoglobin levels at hospital admission.

Autologous blood transfusion in the United States: clinical and nonclinical determinants of use

BACKGROUND

Preoperative donation of blood lowers the risk of allogeneic RBC transfusion. The use of autologous blood is not well quantified. This study aimed at identifying the frequency and determinants of use of autologous transfusion in the United States.

STUDY DESIGN AND METHODS

This national cross-sectional study, using the Nationwide Inpatient Sample, included all patients admitted to 900 hospitals in 19 states in 1996. Logistic regression with weighting yielded nationally representative results for the independent effects of clinical and nonclinical patient characteristics on autologous blood use.

RESULTS

Autologous transfusion was used in 19 of 1000 hospitalizations. The procedures using autologous blood most frequently were knee arthroplasty, hip replacement, prostatectomy, spinal fusion, and hysterectomy. Blacks and Hispanics were less likely to receive autologous transfusion than were whites (OR, 0. 64; 95% CI, 0.45-0.83); patients with Medicaid were less likely than the privately insured to receive autologous transfusions (OR, 0.29; 95% CI, 0.20-0.43), with racial differences greatest among the privately insured. Women received autologous blood for cardiovascular surgeries much less often than men (OR, 0.32; 95% CI, 0.20-0.49).

CONCLUSION

Ethnic minorities, women, and patients with Medicaid appear to receive fewer autologous blood transfusions than the rest of the population. Although this could reflect either better or worse quality of care, nonclinical determinants of transfusion practice warrant attention and further investigation.

The impact of statistical adjustment on economic profiles of interventional cardiologists

OBJECTIVES

The objective of this study was to identify preprocedure patient factors associated with percutaneous intervention costs and to examine the impact of these patient factors on economic profiles of interventional cardiologists.

BACKGROUND

There is increasing demand for information about comparative resource use patterns of interventional cardiologists. Economic provider profiles, however, often fail to account for patient characteristics.

METHODS

Data were obtained from Duke Medical Center cost and clinical information systems for 1,949 procedures performed by 13 providers between July 1, 1997, and December 31, 1998. Patient factors that influenced cost were identified using multiple regression analysis. After assessing interprovider variation in unadjusted cost, mixed linear models were used to examine how much cost variability was associated with the provider when patient characteristics were taken into account.

RESULTS

Total hospital costs averaged $15,643 (median, $13,809), $6,515 of which represented catheterization laboratory costs. Disease severity, acuity, comorbid illness and lesion type influenced total costs (R(2) = 38%), whereas catheterization costs were affected by lesion type and acuity (R(2) = 32%). Patient characteristics varied significantly among providers. Unadjusted total costs were weakly associated with provider, and this association disappeared after accounting for patient factors. The provider influence on catheterization costs persisted after adjusting for patient characteristics. Furthermore, the pattern of variation changed: the adjusted analysis identified three new outliers, and two providers lost their outlier status. Only one provider was consistently identified as an outlier in the unadjusted and adjusted analyses.

CONCLUSIONS

Economic profiles of interventional cardiologists may be misleading if they do not adequately adjust for patient characteristics before procedure.