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January 2, 1991, Vol 265, No. 1 >
ARTICLE | January 2, 1991

The Variability of Transfusion Practice in Coronary Artery Bypass Surgery FREE

Lawrence T. Goodnough, MD; Marilyn F. M. Johnston, MD, PhD; Pearl T. C. Y. Toy, MD
[+] Author Affiliations

This is a collaborative study among 18 recipients of Transfusion Medicine Academic Awards from the National Heart, Lung, and Blood Institute, National Institutes of Health.

Reprint requests to Department of Medicine, Case Western Reserve University, University Hospitals of Cleveland, 2074 Abington Rd, Cleveland, OH 44106 (Dr Goodnough).


JAMA. 1991;265(1):86-90. doi:10.1001/jama.1991.03460010086037
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References

We audited 540 patients undergoing elective first-time coronary artery bypass grafts at 18 institutions. The purposes of the study were to describe the variability in transfusions among institutions and to determine factors that may account for variability. Mean homologous red blood cell use per patient was 2.9(±0.1) U (institutional range, 0.4 to 6.3 U). One hundred seventy-seven patients (32%) received plasma (institutional range, 0% to 97%), and 119 (22%) received platelets (institutional range, 0% to 80%). After controlling for patient and surgical practice variables, transfusion practice factors still accounted for variation in red blood cell transfusions. Variation in patients receiving plasma and platelet transfusions among institutions was determined in part by prophylactic transfusions. We conclude that blood component usage for coronary artery bypass grafts differs widely among institutions. The variability in use of these components is accounted for in part by unnecessary transfusions in otherwise routine, uncomplicated coronary artery bypass graft procedures.

(JAMA. 1991;265:86-90)

REFERENCES

1 +
Lawrence L.  Detailed diagnoses and procedures for patients discharged from short stay hospitals, United States, 1984 . Vital and Health Statistics, Series 13: Data From the National Health Survey, No. 86 . Hyattsville, Md: National Center for Health Statistics; 1986;:169. DHHS publication (PHS) 86-1747.
2 +
Killip T.  Twenty years of coronary bypass surgery . N Engl J Med. 1988;;319:366-368.
3 +
Kaariainen L, Paloheimo J, Klemola E, Makela T, Koivuniemi A.  Cytomegalovirus-mononucleosis: isolation of the virus and demonstration of subclinical infections after fresh blood transfusion in connection with open-heart surgery . Ann Med Exp Biol Fenn. 1966;;44:297-301.
4 +
Aymard JD.  Post-transfusion non-A, non-B hepatitis after cardiac surgery: prospective analysis of donor blood anti-HBC antibody as a predictive indicator of the occurrence of non-A, non-B hepatitis in recipients . Vox Sang. 1986;;51:236-238.
5 +
Stevens CE, Aach RD, Hollinger FB, et al.  Hepatitis B virus antibody in blood donors and the occurrence of non-A, non-B hepatitis in transfusion recipients: an analysis of the transfusion-transmitted viruses study . Ann Intern Med. 1984;;101: 733-738.
6 +
Maggart M, Stewart S.  The mechanisms and management of noncardiogenic pulmonary edema following cardiopulmonary bypass . Ann Thorac Surg. 1987;;43:231-236.
7 +
Cohen NA, Munoz A, Reitz BA, et al.  Transmission of retroviruses by transfusion of screened blood in patients undergoing cardiac surgery . N Engl J Med. 1989;;320:1172-1176.
8 +
Thaler M, Shamiss A, Orgad S, et al.  The role of blood from HLA-homozygous donors in fatal transfusion-associated graft vs host disease after open heart surgery . N Engl J Med. 1989;;321:25-28.
9 +
 National Institutes of Health Consensus Conference. Perioperative red cell transfusion . JAMA . 1988;;260:2700-2705.
10 +
 National Institutes of Health Consensus Conference. Fresh-frozen plasma: indications and risks . JAMA . 1985;;253:551-553.
11 +
 National Institutes of Health Consensus Conference. Platelet transfusion therapy . JAMA . 1987;;257:1777-1780.
12 +
Goodnough LT, Shuck JM.  Review of risks, options, and informed consent for blood transfusion in elective surgery . Am J Surg. 1990;;159:602-609.
13 +
Program Guidelines for Transfusion Medicine Academic Award, First Competition . Bethesda, Md: National Institutes of Health (National Heart, Lung, and Blood Institute); (March 30) , 1982;.
14 +
Goodnough LT, Bravo J, Hsueh Y, Keating L, Brittenham GM.  Red blood cell volume in autologous and homologous blood units: implications for risk/benefit assessment for autologous blood 'crossover' and directed blood transfusion . Transfusion . 1989;;29:821-822.
15 +
SAS User's Guide: Basics, Version 5 Edition . Cary, NC: SAS Institute Inc; 1985;:1181-1191.
16 +
Debanne SM, Rowland DY.  The conservative chi-square test for sparse data . Proceedings of the American Statistical Association, Business and Economic Statistics Section . Baltimore, Md: American Statistical Association; 1983;.
17 +
Cosgrove DM, Loop FD, Lytle BW, et al.  Determinants of blood utilization during myocardial revascularization . Ann Thorac Surg. 1985;;40: 380-384.
18 +
Spector I, Corn M, Ticktin HE.  Effect of plasma transfusions on the prothrombin time and clotting factors in liver disease . N Engl J Med. 1966;;275:1027-1032.
19 +
Chassin MR, Brook RH, Park RE, et al.  Variations in the use of medical and surgical services by the Medicare population . N Engl J Med. 1989;;290:285-290.
20 +
Vayda E.  A comparison of surgical rates in Canada and in England and Wales . N Engl J Med. 1973;;289:1224-1229.
21 +
McPherson K, Wennberg JE, Hovind OB, Clifford P.  Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway . N Engl J Med. 1982;;307:1310-1314.
22 +
Chassin MR, Kosecoff J, Winslow CM, et al.  Does inappropriate use explain geographic variations in the use of health care services? JAMA . 1987;;258:2533-2537.
23 +
Friedman BA, Burns TL, Schork MA.  An analysis of blood transfusion of surgical patients by sex: a quest for the transfusion trigger . Transfusion . 1980;;20:179-188.
24 +
Toy PTYC, Strauss RG, Stehling LC, et al.  Predeposited autologous blood for elective surgery: a national multicenter study . N Engl J Med. 1987;;316:517-520.
25 +
Love TR, Hendren WG, O'Keefe DD, Daggett WM.  Transfusion of predonated autologous blood in elective cardiac surgery . Ann Thorac Surg. 1987;;43:508-512.
26 +
Kruskall MS, Glazer EE, Leonard SS, et al.  Utilization and effectiveness of a hospital autologous preoperative blood donor program . Transfusion. 1986;;26:335-340.
27 +
Owings DV, Kruskall MS, Thurer RL, Donovan LM.  Autologous blood donations prior to elective cardiac surgery: safety and effect on subsequent blood use . JAMA . 1989;;262:1963-1968.
28 +
Simon TL, Akl BF, Murphy W.  Controlled trial of routine administration of platelet concentrates in cardiopulmonary bypass surgery . Ann Thorac Surg. 1984;;37:359-364.
29 +
Harding JA, Shakoor MA, Grindon AJ.  Platelet support for cardiopulmonary bypass surgery . J Thorac Surg. 1975;;70:350-353.

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1 +
Lawrence L.  Detailed diagnoses and procedures for patients discharged from short stay hospitals, United States, 1984 . Vital and Health Statistics, Series 13: Data From the National Health Survey, No. 86 . Hyattsville, Md: National Center for Health Statistics; 1986;:169. DHHS publication (PHS) 86-1747.
2 +
Killip T.  Twenty years of coronary bypass surgery . N Engl J Med. 1988;;319:366-368.
3 +
Kaariainen L, Paloheimo J, Klemola E, Makela T, Koivuniemi A.  Cytomegalovirus-mononucleosis: isolation of the virus and demonstration of subclinical infections after fresh blood transfusion in connection with open-heart surgery . Ann Med Exp Biol Fenn. 1966;;44:297-301.
4 +
Aymard JD.  Post-transfusion non-A, non-B hepatitis after cardiac surgery: prospective analysis of donor blood anti-HBC antibody as a predictive indicator of the occurrence of non-A, non-B hepatitis in recipients . Vox Sang. 1986;;51:236-238.
5 +
Stevens CE, Aach RD, Hollinger FB, et al.  Hepatitis B virus antibody in blood donors and the occurrence of non-A, non-B hepatitis in transfusion recipients: an analysis of the transfusion-transmitted viruses study . Ann Intern Med. 1984;;101: 733-738.
6 +
Maggart M, Stewart S.  The mechanisms and management of noncardiogenic pulmonary edema following cardiopulmonary bypass . Ann Thorac Surg. 1987;;43:231-236.
7 +
Cohen NA, Munoz A, Reitz BA, et al.  Transmission of retroviruses by transfusion of screened blood in patients undergoing cardiac surgery . N Engl J Med. 1989;;320:1172-1176.
8 +
Thaler M, Shamiss A, Orgad S, et al.  The role of blood from HLA-homozygous donors in fatal transfusion-associated graft vs host disease after open heart surgery . N Engl J Med. 1989;;321:25-28.
9 +
 National Institutes of Health Consensus Conference. Perioperative red cell transfusion . JAMA . 1988;;260:2700-2705.
10 +
 National Institutes of Health Consensus Conference. Fresh-frozen plasma: indications and risks . JAMA . 1985;;253:551-553.
11 +
 National Institutes of Health Consensus Conference. Platelet transfusion therapy . JAMA . 1987;;257:1777-1780.
12 +
Goodnough LT, Shuck JM.  Review of risks, options, and informed consent for blood transfusion in elective surgery . Am J Surg. 1990;;159:602-609.
13 +
Program Guidelines for Transfusion Medicine Academic Award, First Competition . Bethesda, Md: National Institutes of Health (National Heart, Lung, and Blood Institute); (March 30) , 1982;.
14 +
Goodnough LT, Bravo J, Hsueh Y, Keating L, Brittenham GM.  Red blood cell volume in autologous and homologous blood units: implications for risk/benefit assessment for autologous blood 'crossover' and directed blood transfusion . Transfusion . 1989;;29:821-822.
15 +
SAS User's Guide: Basics, Version 5 Edition . Cary, NC: SAS Institute Inc; 1985;:1181-1191.
16 +
Debanne SM, Rowland DY.  The conservative chi-square test for sparse data . Proceedings of the American Statistical Association, Business and Economic Statistics Section . Baltimore, Md: American Statistical Association; 1983;.
17 +
Cosgrove DM, Loop FD, Lytle BW, et al.  Determinants of blood utilization during myocardial revascularization . Ann Thorac Surg. 1985;;40: 380-384.
18 +
Spector I, Corn M, Ticktin HE.  Effect of plasma transfusions on the prothrombin time and clotting factors in liver disease . N Engl J Med. 1966;;275:1027-1032.
19 +
Chassin MR, Brook RH, Park RE, et al.  Variations in the use of medical and surgical services by the Medicare population . N Engl J Med. 1989;;290:285-290.
20 +
Vayda E.  A comparison of surgical rates in Canada and in England and Wales . N Engl J Med. 1973;;289:1224-1229.
21 +
McPherson K, Wennberg JE, Hovind OB, Clifford P.  Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway . N Engl J Med. 1982;;307:1310-1314.
22 +
Chassin MR, Kosecoff J, Winslow CM, et al.  Does inappropriate use explain geographic variations in the use of health care services? JAMA . 1987;;258:2533-2537.
23 +
Friedman BA, Burns TL, Schork MA.  An analysis of blood transfusion of surgical patients by sex: a quest for the transfusion trigger . Transfusion . 1980;;20:179-188.
24 +
Toy PTYC, Strauss RG, Stehling LC, et al.  Predeposited autologous blood for elective surgery: a national multicenter study . N Engl J Med. 1987;;316:517-520.
25 +
Love TR, Hendren WG, O'Keefe DD, Daggett WM.  Transfusion of predonated autologous blood in elective cardiac surgery . Ann Thorac Surg. 1987;;43:508-512.
26 +
Kruskall MS, Glazer EE, Leonard SS, et al.  Utilization and effectiveness of a hospital autologous preoperative blood donor program . Transfusion. 1986;;26:335-340.
27 +
Owings DV, Kruskall MS, Thurer RL, Donovan LM.  Autologous blood donations prior to elective cardiac surgery: safety and effect on subsequent blood use . JAMA . 1989;;262:1963-1968.
28 +
Simon TL, Akl BF, Murphy W.  Controlled trial of routine administration of platelet concentrates in cardiopulmonary bypass surgery . Ann Thorac Surg. 1984;;37:359-364.
29 +
Harding JA, Shakoor MA, Grindon AJ.  Platelet support for cardiopulmonary bypass surgery . J Thorac Surg. 1975;;70:350-353.

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