Predictors and Economic Impact of Red Blood Cell Transfusion in Cardiac Surgery: A Simulated Cost Reduction Model for Preoperative Anemia Management
DOI:
https://doi.org/10.20344/amp.23502Keywords:
Anemia/prevention and control, Cardiac Surgical Procedures, Costs and Cost Analysis, Erythrocyte Transfusion/economics, Hospital Costs, Length of StayAbstract
Introduction: Red blood cell (RBC) transfusions are frequent in cardiac surgery and are associated with higher morbidity, mortality, prolonged hospitalization, and increased healthcare costs. Several patient- and procedure-related factors have been identified as transfusion predictors. Studying these predictors in specific populations allows more accurate risk stratification and tailored clinical decision-making. RBC transfusions represent a significant economic burden for healthcare systems due to increased resource utilization and hospital costs overall. The aim of this study was to identify independent risk factors of RBC transfusion, evaluate its economic impact, and estimate potential cost savings from eliminating preoperative anemia.
Methods: We conducted a retrospective cohort study at a tertiary hospital in Portugal, including 661 adults who underwent elective cardiac surgery between April 2020 and April 2021. The primary outcome was the need for at least one RBC transfusion during hospitalization. Secondary outcomes included 30-day mortality, infection, acute kidney injury, prolonged mechanical ventilation, intensive care unit stay, hospital length of stay (LOS), and hospital costs. Independent risk factors were identified using multivariable logistic regression. An economic analysis compared costs between transfused and non-transfused patients. To estimate potential cost reductions, a simulation model was developed assuming the elimination of preoperative anemia and applying the observed transfusion patterns of non-anemic patients to the entire cohort.
Results: Red blood cell transfusion occurred in 41.3% of patients. The identified predictors were preoperative anemia (OR 3.67; 2.00 - 6.74), female sex (OR 2.06; 1.22 - 3.48), higher EuroSCORE II (OR 1.15; 1.03 - 1.29), longer cardiopulmonary bypass time (OR 1.01; 1.00 - 1.02) and lower intraoperative nadir hemoglobin (OR 0.48; 0.40 - 0.58), after adjusting for postoperative hemorrhage. Transfused patients had longer hospital stays (median 10 vs 8 days) and higher costs (median increase of €2264.44). After adjustment for infection and prolonged ventilation, transfusion was no longer independently associated with LOS. Eliminating preoperative anemia could prevent 47 transfusions, reduce 94 hospital days, and save €106 429 over 13 months overall.
Conclusion: Red blood cell transfusion was associated with longer hospital stays, likely due to higher infection rates and prolonged mechanical ventilation. Correcting preoperative anemia could potentially reduce transfusion rates and related hospital costs in cardiac surgery.
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Tempe DK, Khurana P. Optimal blood transfusion practice in cardiac surgery. J Cardiothorac Vasc Anesth. 2018;32:2743-5.
Krishna MN, Nagaraja PS, Singh NG, Nanjappa SN, Kumar KN, Prabkhar V, et al. Evaluation of risk scores in predicting perioperative blood transfusions in adult cardiac surgery. Ann Card Anaesth. 2019;22:73-8.
Lee E, Hart D, Ruggiero A, Dowling O, Ausubel G, Preminger J, et al. The relationship between transfusion in cardiac surgery patients and adverse outcomes. J Cardiothorac Vasc Anesth. 2024;38:1492-8.
Abreu A, Máximo J, Almeida C, Lourenço A, Leite-Moreira A. The additive effects of anaemia and transfusion on long-term survival after coronary artery bypass surgery. Eur J Cardiothorac Surg. 2024;65:ezad403.
Koch C, Li L, Figueroa P, Mihaljevic T, Svensson L, Blackstone EH. Transfusion and pulmonary morbidity after cardiac surgery. Ann Thorac Surg. 2009;88:1410-8.
Jakobsen CJ, Ryhammer PK, Tang M, Andreassen JJ, Mortensen PE. Transfusion of blood during cardiac surgery is associated with higher long-term mortality in low-risk patients. Eur J Cardiothorac Surg. 2012;42:114-20.
LaPar DJ, Hawkins RB, McMurry TL, Isbell JM, Rich JB, Speir AM, et al. Preoperative anemia versus blood transfusion: which is the culprit for worse outcomes in cardiac surgery? J Thorac Cardiovasc Surg. 2018;156:66-74.e2.
Ad N, Massimiano PS, Rongione AJ, Taylor B, Schena S, Alejo D, et al. Number and type of blood products are negatively associated with outcomes after cardiac surgery. Ann Thorac Surg. 2022;113:748-56.
Sultan I, Bianco V, Brown JA, Kilic A, Habertheuer A, Aranda-Michel E, et al. Long-term impact of perioperative red blood cell transfusion on patients undergoing cardiac surgery. Ann Thorac Surg. 2021;112:546-54.
Woldendorp K, Manuel L, Srivastava A, Doane M, Bassin L, Marshman D. Perioperative transfusion and long-term mortality after cardiac surgery: a meta-analysis. Gen Thorac Cardiovasc Surg. 2023;71:323-30.
Koch CG, Li L, Duncan AI, Mihaljevic T, Cosgrove DM, Loop FD, et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med. 2006;34:1608-16.
Trentino KM, Leahy MF, Sanfilippo FM, Farmer SL, Hofmann A, Mace H, et al. Associations of nadir haemoglobin level and red blood cell transfusion with mortality and length of stay in surgical specialties: a retrospective cohort study. Anaesthesia. 2019;74:726-34.
Warner MA, Hanson AC, Schulte PJ, Sanz JR, Smith MM, Kauss ML, et al. Preoperative anemia and postoperative outcomes in cardiac surgery: a mediation analysis evaluating intraoperative transfusion exposures. Anesth Analg. 2024;138:728-37.
Galas FR, Almeida JP, Fukushima JT, Osawa EA, Nakamura RE, Silva CM, et al. Blood transfusion in cardiac surgery is a risk factor for increased hospital length of stay in adult patients. J Cardiothorac Surg. 2013;8:54.
Saporito A, La Regina D, Hofmann A, Ruinelli L, Merler A, Mongelli F, et al. Perioperative inappropriate red blood cell transfusions significantly increase total costs in elective surgical patients, representing an important economic burden for hospitals. Front Med. 2022;9:956128.
Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini DG. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation. 2007;116:2544-52.
Morton J, Anastassopoulos KP, Patel ST, Lerner JH, Ryan KJ, Goss TF, et al. Frequency and outcomes of blood products transfusion across procedures and clinical conditions warranting inpatient care: an analysis of the 2004 healthcare cost and utilization project nationwide inpatient sample database. Am J Med Qual. 2010;25:289-96.
Casselman FP, Lance MD, Ahmed A, Ascari A, Blanco-Morillo J, Bolliger D, et al. 2024 EACTS/EACTAIC Guidelines on patient blood management in adult cardiac surgery in collaboration with EBCP. Eur J Cardiothorac Surg. 2025;67:ezae352.
Alghamdi AA, Davis A, Brister S, Corey P, Logan A. Development and validation of Transfusion Risk Understanding Scoring Tool (TRUST) to stratify cardiac surgery patients according to their blood transfusion needs. Transfusion. 2006;46:1120-9.
Ranucci M, Castelvecchio S, Frigiola A, Scoletta S, Giomarelli P, Biagioli B. Predicting transfusions in cardiac surgery: the easier, the better: the Transfusion Risk and Clinical Knowledge score. Vox Sanguinis. 2009;96:324-32.
Klein AA, Collier T, Yeates J, Miles LF, Fletcher SN, Evans C, et al. The ACTA PORT-score for predicting perioperative risk of blood transfusion for adult cardiac surgery. Br J Anaesth. 2017;119:394-401.
Biancari F, Brascia D, Onorati F, Reichart D, Perrotti A, Ruggieri VG, et al. Prediction of severe bleeding after coronary surgery: the WILL-BLEED Risk Score. Thromb Haemost. 2017;117:445-56.
Mathews R, Peterson ED, Chen AY, Wang TY, Chin CT, Fonarow GC, et al. In-hospital major bleeding during ST-elevation and non-ST-elevation myocardial infarction care: derivation and validation of a model from the ACTION Registry®-GWTG™. Am J Cardiol. 2011;107:1136-43.
Subherwal S, Bach RG, Chen AY, Gage BF, Rao SV, Newby LK, et al. Baseline risk of major bleeding in non-ST-segment-elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of unstable angina patients Suppress ADverse outcomes with early implementation of the ACC/AHA Guidelines) bleeding score. Circulation. 2009;119:1873-82.
Vuylsteke A, Pagel C, Gerrard C, Reddy B, Nashef S, Aldam P, et al. The papworth bleeding risk score: a stratification scheme for identifying cardiac surgery patients at risk of excessive early postoperative bleeding. Eur J Cardiothorac Surg. 2011;39:924-30.
Räsänen J, Ellam S, Hartikainen J, Juutilainen A, Halonen J. Sex differences in red blood cell transfusions and 30-day mortality in cardiac surgery: a single center observational study. J Clin Med. 2023;12:7674.
Zhou R, Qian D, Li H, Wang Z, Shi S, Shen F, et al. Clinical presentation and in-hospital outcomes of intraoperative red blood cell transfusion in non-anemic patients undergoing elective valve replacement. Front Cardiovasc Med. 2022;9:1053209.
Hajjar LA, Vincent JL, Galas FR, Nakamura RE, Silva CM, Santos MH, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010;304:1559-67.
Wester ML, Sampon F, Olsthoorn JR, Soliman-Hamad MA, Houterman S, Maas AH, et al. Gender is independently associated with red blood cell and platelet transfusion in patients undergoing coronary artery bypass grafting: data from the Netherlands Heart Registration. J Cardiothorac Vasc Anesth. 2024;38:924-30.
Ter Woorst J, Sjatskig J, Soliman-Hamad MA, Akca F, Haanchoten M, van Straten A. Evolution of perioperative blood transfusion practice after coronary artery bypass grafting in the past two decades. J Card Surg. 2020;35:1220-7.
Cavalli LB, Pearse BL, Craswell A, Anstey CM, Naidoo R, Rapchuk IL, et al. Determining sex-specific preoperative haemoglobin levels associated with intraoperative red blood cell transfusion in cardiac surgery: a retrospective cohort study. Br J Anaesth. 2023;131:653-3.
Dickinson TA, Wu X, Sturmer DL, Goldberg J, Fitzgerald DC, Paone G, et al. Net prime volume is associated with increased odds of blood transfusion. J Extra Corpor Technol. 2019;51:195-200.
Sandoughdaran S, Sarzaeem MR, Bagheri J, Jebelli M, Mandegar MH. Predictors of blood transfusion in patients undergoing coronary artery bypass grafting surgery. Int Cardiovasc Res J. 2013;7:25-8.
Tanaka KA, Alejo D, Ghoreishi M, Salenger R, Fonner C, Ad N, et al. Impact of preoperative hematocrit, body mass index, and red cell mass on allogeneic blood product usage in adult cardiac surgical patients: report from a statewide quality initiative. J Cardiothorac Vasc Anesth. 2023;37:214-20.
Unal D, Senayli Y, Polat R, Spahn DR, Toraman F, Alkis N, et al. Peri-operative blood transfusion in elective major surgery: incidence, indications and outcome - an observational multicentre study. Blood Transfus. 2020;18:261-79.
Roubinian NH, Murphy EL, Swain BE, Gardner MN, Liu V, Escobar GJ. Predicting red blood cell transfusion in hospitalized patients: role of hemoglobin level, comorbidities, and illness severity. BMC Health Serv Res. 2014;14:213.
Craver C, Belk KW, Myers GJ. Measurement of total hemoglobin reduces red cell transfusion in hospitalized patients undergoing cardiac surgery: a retrospective database analysis. Perfusion. 2018;33:44-52.
Ranucci M. Perioperative haemostasis and coagulation management in cardiac surgery: a European survey. Eur J Anaesthesiol. 2007;24:1-13.
Shevde K, Pagala M, Tyagaraj C, Udeh C, Punjala M, Arora S, et al. Preoperative blood volume deficit influences blood transfusion requirements in females and males undergoing coronary bypass graft surgery. J Clin Anesth. 2002;14:512-7.
Abreu A, Máximo J, Leite-Moreira A. Long-term survival of female versus male patients after coronary artery bypass grafting. PLoS One. 2022;17:e0275035.
Padmanabhan H, Siau K, Curtis J, Ng A, Menon S, Luckraz H. Preoperative anemia and outcomes in cardiovascular surgery: systematic review and meta-analysis. Ann Thorac Surg. 2019;108:1840-8.
Klein AA, Collier TJ, Brar MS, Evans C, Hallward G, Fletcher SN, et al. The incidence and importance of anaemia in patients undergoing cardiac surgery in the UK - the first Association of Cardiothoracic Anaesthetists national audit. Anaesthesia. 2016;71:627-35.
Pereira RM, Magueijo D, Guerra NC, Correia CJ, Rodrigues A, Nobre Â, et al. Activated clotting time value as an independent predictor of postoperative bleeding and transfusion. Interdiscip Cardiovasc Thorac Surg. 2024;38:ivae092.
Blajchman MA. Immunomodulation and blood transfusion. Am J Ther. 2002;9:389-95.
Kuduvalli M, Oo AY, Newall N, Grayson AD, Jackson M, Desmond MJ, et al. Effect of peri-operative red blood cell transfusion on 30-day and 1-year mortality following coronary artery bypass surgery. Eur J Cardiothorac Surg. 2005;27:592-8.
Trentino KM, Farmer SL, Swain SG, Burrows SA, Hofmann A, Ienco R, et al. Increased hospital costs associated with red blood cell transfusion. Transfusion. 2015;55:1082-9.
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