Effect of liberal blood transfusion on clinical outcomes and cost in spine surgery patients.
BACKGROUND CONTEXT
Blood transfusions in spine surgery are shown to be associated with increased patient morbidity. The association between transfusion performed using a liberal hemoglobin (Hb) trigger-defined as an intraoperative Hb level of ≥10 g/dL, a postoperative level of ≥8 g/dL, or a whole hospital nadir between 8 and 10 g/dL-and perioperative morbidity and cost in spine surgery patients is unknown and thus was investigated in this study.


PURPOSE
This study aimed to describe the perioperative outcomes and economic cost associated with liberal Hb trigger transfusion among spine surgery patients.


STUDY DESIGN/SETTING
This is a retrospective study.


PATIENT SAMPLE
The surgical billing database at our institution was queried for inpatients discharged between 2008 and 2015 after the following procedures: atlantoaxial fusion, anterior cervical fusion, posterior cervical fusion, anterior lumbar fusion, posterior lumbar fusion, lateral lumbar fusion, other procedures, and tumor-related surgeries. In total, 6,931 patients were included for analysis.


OUTCOME MEASURES
The primary outcome was composite morbidity, which was composed of (1) infection (sepsis, surgical-site infection, Clostridium difficile infection, or drug-resistant infection); (2) thrombotic event (pulmonary embolus, deep venous thrombosis, or disseminated intravascular coagulation); (3) kidney injury; (4) respiratory event; and (5) ischemic event (transient ischemic attack, myocardial infarction, or cerebrovascular accident).


MATERIALS AND METHODS
Data on intraoperative transfusion were obtained from an automated, prospectively collected anesthesia data management system. Data on postoperative hospital transfusion were obtained through a Web-based intelligence portal. Based on previous research, we analyzed the data using three definitions of a liberal transfusion trigger in patients who underwent red blood cell transfusion: a liberal intraoperative Hb trigger as a nadir Hb level of 10 g/dL or greater, a liberal postoperative Hb trigger as a nadir Hb level of 8 g/dL or greater, or a whole hospital nadir Hb level of 8-10 g/dL. Variables analyzed included in-hospital morbidity, mortality, length of stay, and total costs associated with a liberal transfusion strategy.


RESULTS
Among patients with a whole hospital stay nadir Hb between 8 and 10 g/dL, transfused patients demonstrated a longer in-hospital stay (median [interquartile range], 6 [5-9] vs. 4 [3-6] days; p<.0001) and a higher perioperative morbidity (n=145 [11.5%] vs. n=74 [6.1%], p<.0001) than those not transfused. Even after adjusting for age, gender, race, American Society of Anesthesiologists class, Charlson Comorbidity Index score, estimated blood loss, baseline Hb value, and surgery type, logistic regression analysis revealed that patients with a nadir Hb of 8-10 g/dL who were transfused had an independently higher risk of perioperative morbidity (odds ratio=2.11, 95% confidence interval, 1.44-3.09; p<.0001). Estimated additional costs associated with liberal trigger use, defined as a transfusion occurring in patients with a whole hospital stay nadir Hb of 8-10 g/dL, ranged from $202,675 to $700,151 annually.


CONCLUSIONS
Transfusion using a liberal trigger is associated with increased morbidity, even after controlling for possible confounders. Our results suggest that modification of transfusion practice may be a potential area for improving patient outcomes and reducing costs.
['Purvis|Taylor E|TE|', 'Goodwin|C Rory|CR|', 'De la Garza-Ramos|Rafael|R|', 'Ahmed|A Karim|AK|', 'Lafage|Virginie|V|', 'Neuman|Brian J|BJ|', 'Passias|Peter G|PG|', 'Kebaish|Khaled M|KM|', 'Frank|Steven M|SM|', 'Sciubba|Daniel M|DM|']
D000328:Adult D000368:Aged D003365:Costs and Cost Analysis D017707:Erythrocyte Transfusion D005260:Female D006454:Hemoglobins D006801:Humans D007902:Length of Stay D008297:Male D008875:Middle Aged D010351:Patient Discharge D012189:Retrospective Studies D013530:Surgical Wound Infection
Transfusion Outcomes Surgery Economic Red blood cells Cost saving