Determinants of Blood Transfusions after Cardiac Surgery

描述(申请人提供)：全国接受冠状动脉搭桥术(CABG)的患者中，近一半接触到红细胞(RBC)产品。在急性失血的情况下，大量(3+单位)的输血可以用来挽救患者的生命，但有证据表明，即使在调整了病例组合后，即使是少量(1-2单位)的红细胞用于解决氧气输送不良的问题，患者的死亡风险也会增加16%，发病率也会增加27%。考虑到心脏手术使用了全国血液供应总量的20%-25%，而且红十字会报告称，他们的36个地区中有32个地区的RBC产品不到一天的供应量，以满足医院的需求，因此适当分配RBC产品至关重要。简而言之，重要的是 鉴于1-2单位红细胞与发病率、死亡率和资源利用的关系，提高我们对1-2单位红细胞的决策方式和背景的理解。越来越多的证据表明，一些输血可能是可自由支配的。在密歇根州，近40%的冠脉搭桥术患者暴露在1-2单位的红细胞中，尽管绝对率在不同机构之间存在32%的差异。对于输血的适应症、设置和红细胞压积触发因素缺乏共识，这可能是由于输血实践中特定中心的差异。鉴于这种不确定性，输血率可能是组织(如规程、决策者类型、缺乏有关输血做法的绩效反馈)和提供者(如关于输血的益处/危害的知识、信念和输血倾向)因素差异的结果。减少不必要输血率的干预措施首先需要确定一组决定因素(在组织或提供者水平上)，这些决定因素不能完全解释观察到的跨地区医疗中心红细胞利用率的差异。我们将利用密歇根州胸科和心血管外科医生质量合作协会(MSTCVS-QC)的预期数据和基础设施，该协会是密歇根州所有33个心脏外科项目的联盟，以：(1)对密歇根州的医院和临床提供者进行调查，以描述心脏手术期间1-2单位红细胞输注的决定因素，以及(2)确定导致输血变异性的主要组织和提供者特征。这项研究的结果将为一项旨在降低心脏手术中红细胞输注率的行为调整研究奠定基础。

DESCRIPTION (provided by applicant): Nearly half of patients undergoing coronary artery bypass grafting (CABG) nationwide are exposed to red blood cell (RBC) products. While large volumes (3+ units) of transfusions may be delivered to a given patient to preserve life in cases of acute blood loss, evidence suggests that even small amounts (1-2 units) of RBCs often transfused to address poor oxygen delivery are associated with a 16% increase in a patient's risk of mortality and a 27% increase in morbidity, even after case mix adjustment. It is vitally important to allocate RBC products appropriately, given both that cardiac surgery utilizes between 20-25% of the total national blood supply, and the Red Cross reports that 32 of their 36 regions had less than a day's supply available to meet hospital needs. In short, it is important to improve our understanding of how and in what context decisions are made regarding 1-2 units of RBCs, given its association with morbidity, mortality and resource utilization. Growing evidence suggests that some transfusions may be discretionary. In the state of Michigan, nearly 40% of CABG patients are exposed to 1-2 units of RBCs, although the absolute rate varies 32% across institutions. Center-specific variation in transfusion practices is likely attributed to thelack of consensus regarding the indications, setting and hematocrit trigger for transfusions. Given this uncertainty, transfusion rates may be the consequence of differences in organizational (e.g. protocols, types of decision-makers, lack of performance feedback regarding transfusion practice) and provider (e.g. knowledge, beliefs concerning the benefit/harm of transfusions, and inclination to transfuse) factors. Interventions to reduce the rate of unnecessary transfusions first require identifying the set of determinants (at the organizational or provider level) that mot fully explain the observed variation in RBC utilization across regional medical centers. We will use the prospective data and infrastructure of the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC), a consortium of all 33 cardiac surgical programs in Michigan, to: (1) Develop, pilot, and implement surveys to hospitals and clinical providers within the state of Michigan to describe determinants of 1-2 units of RBC transfusions during cardiac surgery, and (2) Identify the primary organizational and provider characteristics contributing to variability in transfusions. Results from this study will set the sage for a behavioral modification study aimed at reducing the rate of RBC transfusions in the setting of cardiac surgery.