Determinants of Blood Transfusions after Cardiac Surgery

描述（由申请人提供）：全国近一半接受冠状动脉旁路移植术（CABG）的患者暴露于红细胞（RBC）产品。虽然在急性失血的情况下，可以向给定患者输送大量（3+单位）输血以挽救生命，但有证据表明，即使经常输注少量（1-2个单位）RBC以解决氧气输送不良，也会导致患者死亡风险增加16%，发病率增加27%，即使在病例组合调整后。适当分配红细胞产品至关重要，因为心脏手术使用了全国血液供应总量的20-25%，红十字会报告说，他们36个地区中有32个地区的供应量不足一天，以满足医院的需求。总之，重要的是 提高我们对如何以及在什么情况下做出关于1-2单位RBC的决定的理解，因为它与发病率，死亡率和资源利用有关。越来越多的证据表明，一些输血可能是随意的。在密歇根州，近40%的CABG患者暴露于1-2个单位的RBC，尽管各机构的绝对比率差异为32%。输血实践中的中心特异性差异可能归因于对输血的适应症、设置和红细胞压积触发缺乏共识。鉴于这种不确定性，输血率可能是组织（例如，方案、决策者类型、缺乏关于输血实践的绩效反馈）和提供者（例如，关于输血益处/危害的知识、信念和输血倾向）因素差异的结果。降低不必要输血率的干预措施首先需要确定一组决定因素（在组织或提供者层面），这些决定因素不能完全解释在区域医疗中心观察到的RBC利用率变化。我们将使用密歇根州胸心血管外科医师质量协作协会的前瞻性数据和基础设施（MSTCVS-QC），一个由密歇根州所有33个心脏外科项目组成的联盟，旨在：（1）在密歇根州的医院和临床提供者中开展、试点和实施调查，以描述心脏手术期间1-2个单位RBC输注的决定因素，以及（2）识别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矫正研究奠定基础。

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.