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Thorac Cardiovasc Surg 2021; 69(07): 621-629
DOI: 10.1055/s-0039-1697600
Original Cardiovascular

Cost Analysis of Transfusion Therapy in Coronary Artery Surgery

Mirna Petricevic‡   *
1   University of Split School of Medicine, Split, Croatia
,
Mate Petricevic   *
2   Department of Cardiac Surgery, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
,
Marijan Pasalic
3   Department for Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
,
Branka Golubic Cepulic
4   Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia
,
Mirela Raos
4   Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia
,
Dora Dujmic
5   Dora Dujmic, Lawrence University, Appleton, Wisconsin, United States
,
Viktor Kalamar
2   Department of Cardiac Surgery, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
,
Vice Mestrovic
6   Andrija Stampar Teaching Institute of Public Health, Leadership and Management of Health Services, Zagreb, Croatia
,
Hrvoje Gasparovic
2   Department of Cardiac Surgery, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
,
Vesna Vasicek
7   Accounting Department, Faculty of Economics and Business, University of Zagreb, Zagreb, Croatia
,
Klaus Goerlinger
8   Klinik fur Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, and TEM International GmbH, Munich, Germany
,
Bojan Biocina
2   Department of Cardiac Surgery, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
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Abstract

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.

Keywords

coronary artery bypass grafting - surgery - complications - health economics - cost analysis - blood transfusion

Authors' Contribution

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.




Publication History

Received: 27 May 2019

Accepted: 05 August 2019

Article published online:
11 October 2019

© 2019. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 7 Varney SJ, Guest JF. The annual cost of blood transfusions in the UK. Transfus Med 2003; 13 (04) 205-218
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 15 Görlinger K, Dirkmann D, Hanke AA. Potential value of transfusion protocols in cardiac surgery. Curr Opin Anaesthesiol 2013; 26 (02) 230-243
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 18 Zbrozek A, Magee G. Cost of bleeding in trauma and complex cardiac Surgery. Clin Ther 2015; 37 (09) 1966-1974
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 25 Vasicek V, Dragija M, Michele B. et al. Procesni pristup obračunu troškova u sustavu zdravstva. tim4pin.doo, 2016
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 30 Grimm AM, Flaharty KK, Hopkins LE, Mauskopf J, Besarab A, Vlasses PH. Economics of epoetin therapy. Clin Pharm 1989; 8 (11) 807-810
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 32 Mohandas K, Aledort L. Transfusion requirements, risks, and costs for patients with malignancy. Transfusion 1995; 35 (05) 427-430
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar