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Cost Analysis of Transfusion Therapy in Coronary Artery Surgery
Background In patients undergoing coronary artery bypass grafting (CABG), wide variability in transfusion rate (7.8% to 92.8%) raises the question of the amount of unnecessary transfusions. The aim of the study was (1) to identify CABG patients at low risk of bleeding to whom transfusion treatment should be avoided and (2) to calculate the amount of possible cost savings that would be achieved by avoiding transfusion in low bleeding risk patients.
Methods This retrospective observational study enrolled patients undergoing isolated elective CABG from January 2010 to January 2018. Patients were divided with respect to the presence of excessive bleeding and transfusion costs were compared between the two groups. Predictors for postoperative excessive bleeding were defined and multivariable logistic regression analysis and risk modeling were performed. The use of a model to predict patients at low risk of bleeding allowed for the estimation of transfusion cost savings assuming the patients who were found to be at low risk of bleeding should not be transfused.
Results A total of 1,426 patients were enrolled in the analysis. Of those, 28.3% had excessive postoperative bleeding. The multivariate logistic regression analysis model was developed to identify/predict patients without excessive bleeding (receiver operating characteristic curve analysis, area under the curve 72.3%, p < 0.001). When applied to the existing database, the use of the developed model identifying patients at low risk of bleeding may result in a 39.1% reduction of transfusions. Specifically, cost savings would be 48.2% for packed red blood cells, 38.9% for fresh frozen plasma, 10.9% for platelets concentrate, and 17.9% for fibrinogen concentrate.
Conclusion The clinical and economic burdens associated with unnecessary transfusions are significant. Avoiding transfusion in CABG patients found to be at low risk of bleeding may result in significant reduction of transfusion rate and transfusion-associated costs.
Keywordscoronary artery bypass grafting - surgery - complications - health economics - cost analysis - blood transfusion
M.P., M.P., M.P., V.K., V.V., K.G., and B.B.: Contributed most to the work, including drafting the article and revising it critically for important intellectual content.
M.P., M.P., M.P., B.G.C., V.M., V.V., K.G., and B.B.: Substantial contributions to the conception or design of the work.
M.P., M.P., M.P., B.G.C., V.M., H.G., V.V., K.G., and B.B.: Literature overview, data acquisition, analysis, and interpretation of data.
M.P., M.P., M.P., B.G.C., M.R., D.D., V.K., V.M., H.G., V.V., K.G., and B.B.: Final approval of the version.
M.P., M.P., M.P., B.G.C., M.R., D.D., V.K., V.M., H.G., V.V., K.G., and B.B.: Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
M.P., M.P., V.K., V.M., V.V., K.G., and B.B.: Figures.
M.P., M.P., M.P., B.G.C., M.R., D.D., V.K., V.M., H.G., V.V., K.G., and B.B.: Drafting the work for important intellectual content.
* Petricevic Mirna and Petricevic Mate are co-first authors.
Received: 27 May 2019
Accepted: 05 August 2019
Article published online:
11 October 2019
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- 1 Ferraris VA, Brown JR, Despotis GJ. et al; Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion; International Consortium for Evidence Based Perfusion. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91 (03) 944-982
- 2 Bennett-Guerrero E, Zhao Y, O'Brien SM. et al. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA 2010; 304 (14) 1568-1575
- 3 Goodnough LT, Soegiarso RW, Birkmeyer JD, Welch HG. Economic impact of inappropriate blood transfusions in coronary artery bypass graft surgery. Am J Med 1993; 94 (05) 509-514
- 4 McQuilten ZK, Andrianopoulos N, Wood EM. et al. Transfusion practice varies widely in cardiac surgery: results from a national registry. J Thorac Cardiovasc Surg 2014; 147 (05) 1684-1690.e1
- 5 Snyder-Ramos SA, Möhnle P, Weng YS. et al; Investigators of the Multicenter Study of Perioperative Ischemia; MCSPI Research Group. The ongoing variability in blood transfusion practices in cardiac surgery. Transfusion 2008; 48 (07) 1284-1299
- 6 Goodnough LT, Johnston MF, Toy PT. ; Transfusion Medicine Academic Award Group. The variability of transfusion practice in coronary artery bypass surgery. JAMA 1991; 265 (01) 86-90
- 7 Varney SJ, Guest JF. The annual cost of blood transfusions in the UK. Transfus Med 2003; 13 (04) 205-218
- 8 Crémieux PY, Barrett B, Anderson K, Slavin MB. Cost of outpatient blood transfusion in cancer patients. J Clin Oncol 2000; 18 (14) 2755-2761
- 9 Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini GD. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007; 116 (22) 2544-2552
- 10 Rao SV, Kaul PR, Liao L. et al. Association between bleeding, blood transfusion, and costs among patients with non-ST-segment elevation acute coronary syndromes. Am Heart J 2008; 155 (02) 369-374
- 11 Ganz ML, Wu N, Rawn J, Pashos CL, Strandberg-Larsen M. Clinical and economic outcomes associated with blood transfusions among elderly Americans following coronary artery bypass graft surgery requiring cardiopulmonary bypass. Blood Transfus 2014; 12 (Suppl. 01) s90-s99
- 12 Boer C, Meesters MI, Milojevic M. et al; Task Force on Patient Blood Management for Adult Cardiac Surgery of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Cardiothoracic Anaesthesiology (EACTA). 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32 (01) 88-120
- 13 Görlinger K, Shore-Lesserson L, Dirkmann D, Hanke AA, Rahe-Meyer N, Tanaka KA. Management of hemorrhage in cardiothoracic surgery. J Cardiothorac Vasc Anesth 2013; 27 (4, Suppl): S20-S34
- 14 Weber CF, Görlinger K, Meininger D. et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 2012; 117 (03) 531-547
- 15 Görlinger K, Dirkmann D, Hanke AA. Potential value of transfusion protocols in cardiac surgery. Curr Opin Anaesthesiol 2013; 26 (02) 230-243
- 16 Husereau D, Drummond M, Petrou S. et al; CHEERS Task Force. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. BMC Med 2013; 11: 80
- 17 Petricevic M, Biocina B, Milicic D. et al. Bleeding risk assessment using multiple electrode aggregometry in patients following coronary artery bypass surgery. J Thromb Thrombolysis 2013; 35 (01) 31-40
- 18 Zbrozek A, Magee G. Cost of bleeding in trauma and complex cardiac Surgery. Clin Ther 2015; 37 (09) 1966-1974
- 19 Toner RW, Pizzi L, Leas B, Ballas SK, Quigley A, Goldfarb NI. Costs to hospitals of acquiring and processing blood in the US: a survey of hospital-based blood banks and transfusion services. Appl Health Econ Health Policy 2011; 9 (01) 29-37
- 20 Hrvatskoj U. doza koncentrata eritrocita 28, a u Irskopj 240 eura. Accessed date is: April 20, 2019. Available at: http://www.poslovni.hr
- 21 Shaw RE, Johnson CK, Ferrari G. et al. Balancing the benefits and risks of blood transfusions in patients undergoing cardiac surgery: a propensity-matched analysis. Interact Cardiovasc Thorac Surg 2013; 17 (01) 96-102
- 22 Whitson BA, Huddleston SJ, Savik K, Shumway SJ. Bloodless cardiac surgery is associated with decreased morbidity and mortality. J Card Surg 2007; 22 (05) 373-378
- 23 Möhnle P, Snyder-Ramos SA, Miao Y. et al; Multicenter Study of Perioperative Ischemia (McSPI) Research Group. Postoperative red blood cell transfusion and morbid outcome in uncomplicated cardiac surgery patients. Intensive Care Med 2011; 37 (01) 97-109 . doi: 10.1007/s00134-010-2017-z
- 24 Cantor SB, Hudson Jr DV, Lichtiger B, Rubenstein EB. Costs of blood transfusion: a process-flow analysis. J Clin Oncol 1998; 16 (07) 2364-2370
et al. Procesni pristup obračunu troškova u sustavu zdravstva. tim4pin.doo,
- 26 Asadi MJ, Baltz WA. Activity-based costing for clinical paths. An example to improve clinical cost & efficiency. J Soc Health Syst 1996; 5 (02) 1-7
- 27 Etchason J, Petz L, Keeler E. et al. The cost effectiveness of preoperative autologous blood donations. N Engl J Med 1995; 332 (11) 719-724
- 28 Fergusson D, Hébert PC, Barrington KJ, Shapiro SH. Effectiveness of WBC reduction in neonates: what is the evidence of benefit?. Transfusion 2002; 42 (02) 159-165
- 29 Forbes JM, Anderson MD, Anderson GF, Bleecker GC, Rossi EC, Moss GS. Blood transfusion costs: a multicenter study. Transfusion 1991; 31 (04) 318-323
- 30 Grimm AM, Flaharty KK, Hopkins LE, Mauskopf J, Besarab A, Vlasses PH. Economics of epoetin therapy. Clin Pharm 1989; 8 (11) 807-810
- 31 Jackson BR, Umlas J, AuBuchon JP. The cost-effectiveness of postoperative recovery of RBCs in preventing transfusion-associated virus transmission after joint arthroplasty. Transfusion 2000; 40 (09) 1063-1066
- 32 Mohandas K, Aledort L. Transfusion requirements, risks, and costs for patients with malignancy. Transfusion 1995; 35 (05) 427-430
- 33 Sheingold SH, Churchill DN, Muirhead N, Laupacis A. Recombinant human erythropoietin: factors to consider in cost-benefit analysis. Am J Kidney Dis 1991; 17 (01) 86-92
- 34 Wayne AS, Schoenike SE, Pegelow CH. Financial analysis of chronic transfusion for stroke prevention in sickle cell disease. Blood 2000; 96 (07) 2369-2372