Lives, money saved by protocol-guided transfusion use at cardiac surgery

Statewide implementation of a protocol for managing the intraoperative and postoperative use of blood products with cardiac surgery not only cut down on transfusion-related clinical risks, as would have been expected, it saved money.

As a decision to use transfusions represents a trade-off between immediate benefit and certain inherent risks, the blood-product management plan put together by the Virginia Cardiac Surgery Quality Initiative (VCSQI) helped optimize the process and lowered the overall use of transfusions, cutting related mortality by half and saving about $50 million statewide over two years, reported Dr Damien J LaPar (University of Virginia, Charlottesville) here at the American Association of Thoracic Surgery 2012 Annual Meeting.

As the assigned discussant following LaPar's presentation, Dr Edward D Verrier (University of Washington, Seattle) noted that the clinical gains from protocol management of such blood-product use are not new observations; a similar protocol effort at his institution having found about the same thing over the past 20 years. "And we strictly follow that transfusion protocol today." But documentation of cost savings with such a wide-scale protocol implementation represents "a significant contribution."

The researchers in Virginia compared blood-product use and 30-day outcomes associated with isolated, nonemergency CABG surgeries from 2006 to 2008, before use of the protocol, and from 2008 to 2010 following protocol implementation. The 17 participating centers accounted for 99% of cardiac surgeries in the state during those periods.

Intraoperative transfusions were used in 24% of the 7059 cardiac surgeries in the preguidelines period and only 17.7% of the 7200 surgeries after the guidelines were in place. The use of postoperative transfusions fell from 39.1% to 32.8%. Decreased use of packed red blood cells accounted for most of both differences, which were significant (p<0.001).

Adjusted odds ratios (OR) for major complications (including pneumonia, prolonged ventilation, renal failure, and hemodialysis) and mortality went up significantly with intraoperative and postoperative transfusions whether used before or after protocol implementation. But the postimplementation era itself was a determinant of reduced mortality.

Odds ratio (OR, 95% CI) for effect of transfusion type and guidelines era (pre- vs postimplementation) on risk-adjusted outcomes

Endpoint	Guidelines era	Intraoperative transfusion	Postoperative transfusion
Major complications	0.97 (0.88-1.08)*	1.25 (1.12-1.41)	4.50 (4.03-5.03)
30-d mortality	0.53 (0.37-0.74)	1.86 (1.35-2.55)	4.61 (3.19-6.68)

*p=0.64; all other ORs p<0.001

At the patient level, the mortality-adjusted overall cost of an intraoperative transfusion rose by $4408 from before to after guidelines implementation; the increase in cost reached $10 479 for a postoperative transfusion. Total and average hospital costs went down significantly.

Costs associated with cardiac surgeries in Virginia before (2006-2008) and after (2008-2010) guidelines implementation

Parameter	2006-2008 ($)	2008-2010 ($)
Statewide total hospital costs	261 million	212 million
Median total hospital costs	30 487	26 197
Median ICU/CCU costs	6355	5710

p<0.001 for all differences by guidelines era

ICU=intensive care unit; CCU=coronary care unit

Verrier pointed out that parts of the observed clinical and financial gains could have derived from other improvements in the later period compared with the earlier one. "I suspect the modest improvements in outcomes noted by the authors might also have been seen over that time frame" on a national basis; cost savings, as well.

LaPar acknowledged that CABG outcomes tended to improve nationally; other limitations of the analysis, he said, included being retrospective and lacking long-term follow-up.

Verrier said, "I hope that [the analysis] is now extended, based on this experience at the state level, to the national level, because the implications at the national level both on the cost analysis and the outcomes would be significant."