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After cardiac surgery, using a restrictive transfusion threshold – forgoing transfusion until hemoglobin level drops to 7.5 g/dL – does not decrease morbidity or costs of care, compared with using a liberal transfusion threshold of 9 g/dL, according to a report published online March 12 in the New England Journal of Medicine.
Several blood management guidelines and health policy statements recommend the restrictive approach in the hope that it will reduce the increasing demand on blood services and the high costs of storing, handling, and administering red-cell units, and also because transfusions following cardiac surgery have been linked to infection, low cardiac output, acute kidney injury, and increased mortality. Clinicians remain uncertain about a safe threshold for transfusions in this setting, which is evidenced by the striking variation in transfusion rates among cardiac centers in the United States (8%-93%) and the United Kingdom (25%-75%), said Dr. Gavin J. Murphy of the British Heart Foundation and department of cardiovascular sciences, University of Leicester (England), and his associates.
They performed the Transfusion Indication Threshold Reduction (TITRe2) study to test the hypothesis that the restrictive approach is superior to the liberal approach regarding both postoperative morbidity and health care costs. Adults undergoing nonemergency cardiac surgery at 17 specialty centers in the United Kingdom were randomly assigned to a restricted (1,000 patients) or a liberal (1,003 patients) transfusion threshold. The median patient age was 70 years, and 68% were men. Most of the procedures were CABG or valve surgeries.
Contrary to expectations, the primary outcome – a composite of serious infection or an ischemic event such as stroke, MI, gut infarction, or acute kidney injury within 3 months – occurred in 35.1% of patients in the restrictive-threshold group and 33.0% in the liberal-threshold group. Secondary outcomes, including length of ICU stay and rates of clinically significant pulmonary complications, also were similar between the two study groups. Rates of other serious postoperative complications were similar, at 35.7% and 34.2%, as was general health status as assessed via the EuroQol Group 5-Dimension Self-Report Questionnaire, further contradicting the study hypothesis.
Mean health care costs were similar between the two study groups: the equivalent of $17,762 U.S. dollars with restrictive-threshhold transfusions and $18,059 with liberal-threshold transfusions, Dr. Murphy and his associates noted (N. Engl. J. Med. 2015 March 12 [doi:10.1056/NEJMoa1403612]).
Unexpectedly, 3-month mortality was significantly higher with restrictive- than with liberal-threshold transfusions (4.2% vs 2.6%). This association persisted in sensitivity analyses and “is a cause for concern,” but it may be due to chance alone, the investigators added.
Findings like those of Murphy et al. provide a great opportunity for discussion and debate, which could lead to development of a consensus on the best postoperative care for these patients. Cardiac surgery departments should review the TITRe2 trial results and decide which threshold they deem to be the most appropriate for transfusion.
The extreme range in hospitals’ rates of transfusion in cardiac surgery – from less than 5% to more than 90% – is extraordinary. Having clinicians actively debate the evidence presented in TITRe2, create transparent interpretations, develop protocols, and hold themselves accountable for following those protocols would represent important steps for improving patient care.
John Spertus, M.D., is at the University of Missouri-Kansas City and Saint Luke’s Mid America Heart Institute, Kansas City. He reported receiving grant support from Lilly, Gilead, Amorcyte, Genentech, and Abbott Vascular; receiving personal fees from United Healthcare, Novartis, and Amgen; having an equity interest in Health Outcomes Sciences; and owning copyrights to the Seattle Angina Questionnaire, the Kansas City Cardiomyopathy Questionnaire, and the Peripheral Artery Questionnaire. Dr. Spertus made these remarks in an editorial accompanying Dr. Murphy’s report (N. Engl. J. Med. 2015 March 12 [doi:10.1056/NEJMe1415394]).
Findings like those of Murphy et al. provide a great opportunity for discussion and debate, which could lead to development of a consensus on the best postoperative care for these patients. Cardiac surgery departments should review the TITRe2 trial results and decide which threshold they deem to be the most appropriate for transfusion.
The extreme range in hospitals’ rates of transfusion in cardiac surgery – from less than 5% to more than 90% – is extraordinary. Having clinicians actively debate the evidence presented in TITRe2, create transparent interpretations, develop protocols, and hold themselves accountable for following those protocols would represent important steps for improving patient care.
John Spertus, M.D., is at the University of Missouri-Kansas City and Saint Luke’s Mid America Heart Institute, Kansas City. He reported receiving grant support from Lilly, Gilead, Amorcyte, Genentech, and Abbott Vascular; receiving personal fees from United Healthcare, Novartis, and Amgen; having an equity interest in Health Outcomes Sciences; and owning copyrights to the Seattle Angina Questionnaire, the Kansas City Cardiomyopathy Questionnaire, and the Peripheral Artery Questionnaire. Dr. Spertus made these remarks in an editorial accompanying Dr. Murphy’s report (N. Engl. J. Med. 2015 March 12 [doi:10.1056/NEJMe1415394]).
Findings like those of Murphy et al. provide a great opportunity for discussion and debate, which could lead to development of a consensus on the best postoperative care for these patients. Cardiac surgery departments should review the TITRe2 trial results and decide which threshold they deem to be the most appropriate for transfusion.
The extreme range in hospitals’ rates of transfusion in cardiac surgery – from less than 5% to more than 90% – is extraordinary. Having clinicians actively debate the evidence presented in TITRe2, create transparent interpretations, develop protocols, and hold themselves accountable for following those protocols would represent important steps for improving patient care.
John Spertus, M.D., is at the University of Missouri-Kansas City and Saint Luke’s Mid America Heart Institute, Kansas City. He reported receiving grant support from Lilly, Gilead, Amorcyte, Genentech, and Abbott Vascular; receiving personal fees from United Healthcare, Novartis, and Amgen; having an equity interest in Health Outcomes Sciences; and owning copyrights to the Seattle Angina Questionnaire, the Kansas City Cardiomyopathy Questionnaire, and the Peripheral Artery Questionnaire. Dr. Spertus made these remarks in an editorial accompanying Dr. Murphy’s report (N. Engl. J. Med. 2015 March 12 [doi:10.1056/NEJMe1415394]).
After cardiac surgery, using a restrictive transfusion threshold – forgoing transfusion until hemoglobin level drops to 7.5 g/dL – does not decrease morbidity or costs of care, compared with using a liberal transfusion threshold of 9 g/dL, according to a report published online March 12 in the New England Journal of Medicine.
Several blood management guidelines and health policy statements recommend the restrictive approach in the hope that it will reduce the increasing demand on blood services and the high costs of storing, handling, and administering red-cell units, and also because transfusions following cardiac surgery have been linked to infection, low cardiac output, acute kidney injury, and increased mortality. Clinicians remain uncertain about a safe threshold for transfusions in this setting, which is evidenced by the striking variation in transfusion rates among cardiac centers in the United States (8%-93%) and the United Kingdom (25%-75%), said Dr. Gavin J. Murphy of the British Heart Foundation and department of cardiovascular sciences, University of Leicester (England), and his associates.
They performed the Transfusion Indication Threshold Reduction (TITRe2) study to test the hypothesis that the restrictive approach is superior to the liberal approach regarding both postoperative morbidity and health care costs. Adults undergoing nonemergency cardiac surgery at 17 specialty centers in the United Kingdom were randomly assigned to a restricted (1,000 patients) or a liberal (1,003 patients) transfusion threshold. The median patient age was 70 years, and 68% were men. Most of the procedures were CABG or valve surgeries.
Contrary to expectations, the primary outcome – a composite of serious infection or an ischemic event such as stroke, MI, gut infarction, or acute kidney injury within 3 months – occurred in 35.1% of patients in the restrictive-threshold group and 33.0% in the liberal-threshold group. Secondary outcomes, including length of ICU stay and rates of clinically significant pulmonary complications, also were similar between the two study groups. Rates of other serious postoperative complications were similar, at 35.7% and 34.2%, as was general health status as assessed via the EuroQol Group 5-Dimension Self-Report Questionnaire, further contradicting the study hypothesis.
Mean health care costs were similar between the two study groups: the equivalent of $17,762 U.S. dollars with restrictive-threshhold transfusions and $18,059 with liberal-threshold transfusions, Dr. Murphy and his associates noted (N. Engl. J. Med. 2015 March 12 [doi:10.1056/NEJMoa1403612]).
Unexpectedly, 3-month mortality was significantly higher with restrictive- than with liberal-threshold transfusions (4.2% vs 2.6%). This association persisted in sensitivity analyses and “is a cause for concern,” but it may be due to chance alone, the investigators added.
After cardiac surgery, using a restrictive transfusion threshold – forgoing transfusion until hemoglobin level drops to 7.5 g/dL – does not decrease morbidity or costs of care, compared with using a liberal transfusion threshold of 9 g/dL, according to a report published online March 12 in the New England Journal of Medicine.
Several blood management guidelines and health policy statements recommend the restrictive approach in the hope that it will reduce the increasing demand on blood services and the high costs of storing, handling, and administering red-cell units, and also because transfusions following cardiac surgery have been linked to infection, low cardiac output, acute kidney injury, and increased mortality. Clinicians remain uncertain about a safe threshold for transfusions in this setting, which is evidenced by the striking variation in transfusion rates among cardiac centers in the United States (8%-93%) and the United Kingdom (25%-75%), said Dr. Gavin J. Murphy of the British Heart Foundation and department of cardiovascular sciences, University of Leicester (England), and his associates.
They performed the Transfusion Indication Threshold Reduction (TITRe2) study to test the hypothesis that the restrictive approach is superior to the liberal approach regarding both postoperative morbidity and health care costs. Adults undergoing nonemergency cardiac surgery at 17 specialty centers in the United Kingdom were randomly assigned to a restricted (1,000 patients) or a liberal (1,003 patients) transfusion threshold. The median patient age was 70 years, and 68% were men. Most of the procedures were CABG or valve surgeries.
Contrary to expectations, the primary outcome – a composite of serious infection or an ischemic event such as stroke, MI, gut infarction, or acute kidney injury within 3 months – occurred in 35.1% of patients in the restrictive-threshold group and 33.0% in the liberal-threshold group. Secondary outcomes, including length of ICU stay and rates of clinically significant pulmonary complications, also were similar between the two study groups. Rates of other serious postoperative complications were similar, at 35.7% and 34.2%, as was general health status as assessed via the EuroQol Group 5-Dimension Self-Report Questionnaire, further contradicting the study hypothesis.
Mean health care costs were similar between the two study groups: the equivalent of $17,762 U.S. dollars with restrictive-threshhold transfusions and $18,059 with liberal-threshold transfusions, Dr. Murphy and his associates noted (N. Engl. J. Med. 2015 March 12 [doi:10.1056/NEJMoa1403612]).
Unexpectedly, 3-month mortality was significantly higher with restrictive- than with liberal-threshold transfusions (4.2% vs 2.6%). This association persisted in sensitivity analyses and “is a cause for concern,” but it may be due to chance alone, the investigators added.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point: After cardiac surgery, using a restrictive transfusion threshold – forgoing transfusion unless hemoglobin level drops to 7.5 g/dL – doesn’t decrease morbidity or costs, compared with using a liberal transfusion threshold (9 g/dL).
Major finding: Contrary to expectations, the primary outcome, a composite of serious infection or an ischemic event such as stroke, MI, gut infarction, or acute kidney injury within 3 months, occurred in 35% of patients in the restrictive-threshold group and 33% in the liberal-threshold group.
Data source: A multicenter randomized controlled trial comparing restrictive and liberal transfusion thresholds in 2,003 cardiac surgery patients in the United Kingdom who were followed for 3 months for the development of serious complications.
Disclosures: The National Institute for Health Research’s Health Technology Assessment Program, the NIHR Bristol Biomedical Research Unit in Cardiovascular Disease, and the British Heart Foundation supported the study. Dr. Murphy and his associates reported having no financial disclosures.