Red blood cell, plasma transfusions decline nationwide

Ruchika Goel

Use of red blood cell and plasma transfusions declined across the United States from 2011 through 2014, according to study results.

Ruchika Goel, MD, MPH — assistant professor of pathology and laboratory medicine, assistant professor of pediatrics in the division of pediatric hematology/oncology, and assistant medical director of transfusion medicine and cellular therapy at NewYork-Presbyterian Hospital and Weill Cornell Medicine — and colleagues analyzed data from the National Inpatient Sample from 1993 to 2014.

Investigators used weighted estimates of more than 30 million discharges each year from 1,100 hospitals in 47 states across the country.

The proportion of patients who underwent red blood cell transfusions during hospitalization increased steadily from 1993 to 2011, when it peaked at 6.8%. The rate declined to 5.7% in 2014 (adjusted risk ratio = 0.83; 95% CI, 0.78-0.88).

The decrease in red blood cell transfusions over time appeared larger among elective admissions than nonelective admissions (P for interaction < .001).

Researchers reported statistically significant reductions in red blood cell transfusions regardless of patient sex, race/ethnicity, risk severity and payer type. However, results showed no significant reduction in red blood cell transfusions among children.

The percentage of patients who underwent plasma transfusions during hospitalization also declined from 1% in 2011 to 0.87% in 2014 (adjusted risk ratio = 0.87; 95% CI, 0.8-0.95).

Results showed no decrease in platelet transfusions nationwide.

HemOnc Today spoke with Goel about these findings, as well as their potential implications on clinical outcomes and resource utilization.

Question: To what do you attribute the reductions in transfusions?

Answer: We attribute these reductions in transfusions to the successful implementation of restrictive red blood cell transfusion thresholds; blood conservation initiatives, such as use of cell salvage; improved surgical techniques and use of pharmacotherapy; advocacy from various medical organizations; and increased adherence to transfusion practice guidelines.

Q : How can a reduction in transfusions improve patient outcomes?

A: There is high-quality evidence from multiple randomized controlled trials showing that lower hemoglobin transfusion thresholds are safe and well tolerated and, in fact, may lead to improved patient outcomes. Thus, there has been an advent toward restrictive transfusion practices.

Q: How can a reduction in transfusions save resources ?

A: The average purchase cost of a unit of blood is $200 to $300 in the United States. The cost of transfusion, however, is much greater than the cost of the blood. It can range from more than $500 to more than $1,100 per unit when accounting for storage, labor and wastage. The decrease in unnecessary blood transfusions reduces hospital costs and conserves clinical resources. Thus, with fewer transfusions, we are improving patient care while also lowering cost for health care. It truly is a win-win situation.

Q: Can you quantify the role of blood management programs ?

A: The reduction in transfusions largely reflects the collective success of various patient blood management initiatives across the nation. Patient blood management has truly been a revolution in the world of transfusion medicine. It is a patient-centered approach and aims to optimize hemostasis, minimize blood loss and correct preoperative anemia and, thus, eliminate unnecessary blood transfusions. Together, these efforts align to improve patient outcomes.

Q: You acknowledged a couple limitations to the study. Can you elaborate?

A: The National Inpatient Sample is the largest all-payer inpatient database in the United States. It used ICD-9 and, most recently, ICD-10 coding to identify diagnoses and procedures. The coding is carried out primarily for billing purposes, and it is not possible to verify its accuracy. Reassuringly, prior medical record audit studies have specifically shown National Inpatient Sample coding to have both adequate sensitivity and specificity. In addition, we are only reporting on changes in transfusions for hospitalized patients, not outpatients.

Q: What do these findings mean for clinical practice?

A: Traditionally, there has been a liberal approach to blood transfusions in transfusing red blood cells when hemoglobin levels are less than 10 g/dL. Although clinical decisions need to be individualized, there is high-quality evidence from a multitude of randomized controlled trials that most people can tolerate a lower hemoglobin level — around 7 g/dL to 8 g/dL. Clinicians should try to be restrictive in their transfusion practices whenever it is possible and well tolerated. Also, it is important for clinicians to remember the patient blood management slogan — “Why give two when one will do?” — and transfuse one unit at a time. This alone cuts down transfusions significantly. – by Rob Volansky

Reference:

Goel R, et al. JAMA. 2018;doi:10.1001/jama.2017.20121.

For more information:

Ruchika Goel, MD, MPH, can be reached at 525 E. 68th St., M-024, Transfusion Medicine and Cellular Therapy Suite, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY 10065; email: ruchikagoel1@gmail.com.

Disclosure: Goel reports no relevant financial disclosures.