1
|
Power SJ, Stewart KE, Tanaka KA, Butt AL. Comment on "Impact of Red Blood Cell Transfusion on In-hospital Mortality of Isolated Coronary Artery Bypass Graft Surgery". ANNALS OF SURGERY OPEN 2023; 4:e330. [PMID: 37746618 PMCID: PMC10513141 DOI: 10.1097/as9.0000000000000330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/22/2023] [Indexed: 09/26/2023] Open
Affiliation(s)
- Sarah J. Power
- From the Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK
| | - Kenneth E. Stewart
- Department of Surgery and Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Kenichi A. Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Amir L. Butt
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| |
Collapse
|
2
|
Tang AY, Zhou M, Maillis AN, Lai KW, Lane PA, Snyder AB. Trends in blood transfusion, hydroxyurea use, and iron overload among children with sickle cell disease enrolled in Medicaid, 2004-2019. Pediatr Blood Cancer 2023; 70:e30152. [PMID: 36579749 DOI: 10.1002/pbc.30152] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND There have been significant changes in clinical guidelines for sickle cell disease (SCD) over the past two decades, including updated indications for hydroxyurea, transfusions, and iron overload management. In practice however, there are few studies that examine SCD care utilization over time. METHODS We conducted a serial cross-sectional cohort study of pediatric SCD patients from 2004 to 2019 using Georgia Medicaid claims data. For each year, we reported receipt of any transfusion, chronic transfusion, or three or more filled hydroxyurea prescriptions. For children receiving chronic transfusion (six or more annual transfusions), we evaluated iron overload diagnosis, monitoring, and chelation use. Among children with sickle cell anemia (SCA), we examined rates of transfusions and hydroxyurea use. The Cochran-Armitage test was used to assess trend. RESULTS There were 5316 unique children 2-18 years old with SCD enrolled in Georgia Medicaid from 2004 to 2019. Children receiving any transfusion increased from 2004 to 2010, then stabilized. In SCA patients, chronic transfusions initially increased from 2004 to 2010, then stabilized from 2010 to 2019. For chronically transfused children, monitoring of iron burden and filled chelator prescriptions both increased significantly. Hydroxyurea use in SCA patients increased from 12% to 37%, with increases noted within each age group, most notably from 21% to 60% in the 13-18-year-old cohort. CONCLUSION We demonstrated changes in SCD care utilization over time, including increased hydroxyurea use, changes in transfusion rates, and increased attention to iron overload management. While trends in clinical management do follow updates in treatment guidelines, there is still delayed and suboptimal uptake of guideline recommendations in pediatric SCD patients.
Collapse
Affiliation(s)
- Amy Y Tang
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Division of Hematology/Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mei Zhou
- Georgia Health Policy Center, Andrew Young School of Policy Studies, Georgia State University, Atlanta, Georgia, USA
| | - Alexander N Maillis
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kristina W Lai
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Peter A Lane
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Division of Hematology/Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Angela B Snyder
- Georgia Health Policy Center, Andrew Young School of Policy Studies, Georgia State University, Atlanta, Georgia, USA
| |
Collapse
|
3
|
Roh DJ, Carvalho Poyraz F, Magid-Bernstein J, Elkind MSV, Agarwal S, Park S, Claassen J, Connolly ES, Hod E, Murthy SB. Red Blood Cell Transfusions and Outcomes After Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:105317. [PMID: 32992186 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105317] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Low red blood cell (RBC) levels are associated with worse intracerebral hemorrhage (ICH) outcomes. However, relationships of RBC transfusions on ICH outcomes are unclear given the overlap of RBC transfusion, comorbidities, and disease severity. We investigated RBC transfusion relationships on ICH outcomes while accounting for comorbidities and disease severity. METHODS ICH hospitalizations between 2002 and 2011 and RBC transfusion exposure were identified from the Nationwide Inpatient Sample using ICD-9-CM codes. Logistic regression was used to study the relationship between RBC transfusion on outcomes after adjusting for demographics, baseline comorbidities, and markers of disease severity. Additional sensitivity analyses stratified by comorbidity burden and disease severity were performed. RESULTS Of 597,046 ICH hospitalizations, RBC transfusions were administered in 22,904 (4%). RBC transfusion was associated with higher odds of in-hospital mortality (adjusted OR: 1.22 [95%CI: 1.10-1.35]). In sensitivity analyses, RBC transfusions resulted in poor outcomes regardless of the comorbidity burden, but attenuation in this relationship was notable with lower comorbidities (adjusted OR 1.43 [95%CI: 1.34-1.51] vs 1.18 [95%CI: 1.10-1.29]). There were no associations of RBC transfusions with poor outcomes in hospitalizations without mechanical ventilation (adjusted OR 0.88 [95%CI: 0.83-1.13]) and in cases requiring ventriculostomy drains (adjusted OR 1.05 [95%CI: 0.97-1.10]). CONCLUSIONS In a large, nationally representative sample, RBC transfusion was associated with poor ICH outcomes. However, there were variations in this relationship based on comorbidities and disease severity. Additional prospective studies are required to assess direct risks and benefits from RBC transfusions in ICH.
Collapse
Affiliation(s)
- David J Roh
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Fernanda Carvalho Poyraz
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Jessica Magid-Bernstein
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Mitchell S V Elkind
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States; Mailman School of Public Health, Columbia University, New York, NY, United States.
| | - Sachin Agarwal
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Soojin Park
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Jan Claassen
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - E Sander Connolly
- Vagelos College of Physicians and Surgeons, Department of Neurosurgery, Columbia University, New York, NY, United States.
| | - Eldad Hod
- Vagelos College of Physicians and Surgeons, Department of Pathology and Cell Biology, Columbia University, New York, NY, United States.
| | - Santosh B Murthy
- Clinical and Translational Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, NY, United States.
| |
Collapse
|
4
|
A Restrictive Hemoglobin Transfusion Threshold of Less Than 7 g/dL Decreases Blood Utilization Without Compromising Outcomes in Patients With Hip Fractures. J Am Acad Orthop Surg 2019; 27:887-894. [PMID: 30829898 DOI: 10.5435/jaaos-d-18-00374] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION In patients with hip fracture, a transfusion threshold of hemoglobin (Hb) <8 g/dL is associated with similar or better outcomes than more liberal thresholds. Whether a more restrictive threshold of <7 g/dL Hb produces equivalent outcomes in such patients is unknown. The aim of the study was to examine whether a restrictive threshold of <7 g/dL Hb is safe in this population. METHODS In January 2015, a blood management program was implemented that uses a restrictive transfusion threshold of <7 g/dL Hb in hemodynamically stable patients and <8 g/dL in patients with symptomatic anemia or a history of coronary artery disease. We identified 498 patients treated for hip fractures from January 2013 through May 2017. We compared perioperative outcomes of 207 patients treated before with those of 291 patients treated after restrictive threshold implementation. RESULTS After restrictive threshold implementation, the proportion of patients receiving packed red blood cell (PRBC) transfusions decreased from 51% to 33% (P < 0.001); the mean number of PRBC units transfused per patient decreased by 40% (from 1.1 to 0.7; P < 0.001); inpatient cardiac morbidity decreased from 22.2% to 12.4% (P = 0.004); 30-day readmissions decreased from 14% to 8.6% (P = 0.04); and length of stay was unchanged (P = 0.06). Compared with the prerestrictive threshold cohort, the postrestrictive threshold group had lower odds of transfusion (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.29 to 0.62); transfusion of >1 unit of PRBCs (OR = 0.34; 95% CI, 0.22 to 0.52); and inpatient cardiac morbidity (OR = 0.45; 95% CI, 0.27 to 0.75). No significant differences were observed in inpatient morbidity, mortality, 30-day readmission, or 90-day survival. DISCUSSION A restrictive threshold of <7 g/dL Hb in hemodynamically stable patients with hip fractures is associated with noninferior perioperative outcomes and less blood utilization compared with a threshold of <8 g/dL. LEVEL OF EVIDENCE Level III, retrospective cohort study.
Collapse
|
5
|
Mullan CW, Pichert MD, Geirsson A. Effects of blood transfusions on transcatheter aortic valve replacement outcomes. J Thorac Cardiovasc Surg 2019; 158:e181. [PMID: 31324423 DOI: 10.1016/j.jtcvs.2019.05.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 05/06/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Clancy W Mullan
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Matthew D Pichert
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| |
Collapse
|
6
|
Pacini D, Murana G. Reply: "Sensitivity" and "specificity" reduction of blood transfusion after transcatheter aortic valve replacement: Is that all that matters? J Thorac Cardiovasc Surg 2019; 158:e182-e183. [PMID: 31279517 DOI: 10.1016/j.jtcvs.2019.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giacomo Murana
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| |
Collapse
|
7
|
Kolte D, Aronow HD, Kennedy KF, Ehsan A. Reply: Analysis of administrative claims data provides valid and meaningful conclusions despite its imperfections. J Thorac Cardiovasc Surg 2019; 158:e181-e182. [PMID: 31235354 DOI: 10.1016/j.jtcvs.2019.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 05/22/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Dhaval Kolte
- The Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| | - Herbert D Aronow
- The Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| | | | - Afshin Ehsan
- The Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| |
Collapse
|
8
|
Howard DH, Roback JD, Murphy DJ. Trends in transfusion rates after the FOCUS trial. J Comp Eff Res 2018; 7:113-120. [PMID: 29464966 DOI: 10.2217/cer-2017-0038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AIM We estimate the impact of the FOCUS trial, which concluded that hip surgery patients with hemoglobin values above 8 g/dl do not benefit from routine transfusions, on transfusion rates. METHODS We evaluated trends in transfusion rates using inpatient discharge data from four states. RESULTS The transfusion rate was 5.2 percentage points lower in the fourth quarter of 2013 than it would have been had pre-FOCUS trends continued. Transfusion rates declined more in hospitals with a low end-of-life treatment intensity index, a general measure of treatment intensity. CONCLUSION The FOCUS trial affected practice, but there are additional opportunities to reduce the use of transfusions.
Collapse
Affiliation(s)
- David H Howard
- Department of Health Policy & Management, Emory University, Atlanta, GA 303222, USA
| | - John D Roback
- Department of Pathology & Laboratory Medicine, Center for Transfusion & Cellular Therapies, Emory University, Atlanta, GA 303223, USA
| | - David J Murphy
- Division of Pulmonary, Allergy, Sleep & Critical Care Medicine, Emory University, Atlanta, GA 30308, USA
| |
Collapse
|
9
|
Roberts DJ. Expanding access to Transfusion Medicine and improving practice: guidelines, patient blood management, protocols and products. Transfus Med 2017; 27 Suppl 5:315-317. [PMID: 29076249 DOI: 10.1111/tme.12484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- D J Roberts
- National Health Service Blood and Transplant, University of Oxford, John Radcliffe Hospital, Oxford, UK
| |
Collapse
|