Jesse Zuckerman, MD, is a general surgery resident at the University of Toronto.
It is crucial to target the users of transfusions—surgeons and hospitals—with tools that can be used to change practice and limit transfusion to patients who actually need it.
Red blood cell transfusions are common in patients who have surgery for gastrointestinal (GI) cancer. GI cancer patients are at high risk for requiring transfusions because of their underlying malignancy, poor nutrition and previous chemotherapies. But, like any medical intervention, transfusions are not risk-free.
Research over the past 30 years has consistently shown an association between transfusions and poorer outcomes following surgery, including postoperative morbidity and mortality, cancer recurrence and increased costs.
Guidelines and programs from the American Association of Blood Banks, the National Institute for Health and Care Excellence, and several others recommend limiting transfusion use to patients who truly need it. Even with this guidance, substantial variation in transfusion practice continues.
Research links higher transfusion rates with poor outcomes
My colleagues and I wanted to understand the relationship between variation in transfusion use among individual surgeons and hospitals and its impact on surgical outcomes in GI cancer surgery.
For the study that we presented during Digestive Disease Week 2021, we analyzed 59,964 records for patients undergoing elective GI cancer resection from 2007 to 2019 involving 81 hospitals and 616 surgeons. We found adjusted frequency rates for red blood cell transfusions varied widely, from 7.4% to 36.4%for surgeons, and 8.4% to 30% for hospitals. Higher surgeon and hospital transfusion rates were independently associated with higher rates of morbidity and mortality. Adjusting for the surgeons’ case mix, for every 10% increase in their rate of transfusion, the rate of 90-day morbidity and mortality both increased by 4% and 0.3%, respectively. Similar differences in morbidity were observed among hospitals.
These results highlight the importance of efforts aimed at minimizing use of red blood cell transfusions and reducing variation in transfusion practices. It is crucial to target the users of transfusions—surgeons and hospitals—with tools that can be used to change practice and limit transfusion to patients who actually need it.
Practice change can be slow
It takes a long time to change practice. The first trial on restrictive transfusions was published in 1999, and guidelines encouraging restrictive transfusion practices have been around for over a decade. While there has been some change, variation continues for a variety of reasons:
It is often easier to transfuse than to optimize patients before surgery. Optimizing anemia status before GI cancer surgery takes time. While time is not always available, surgery can often be postponed, allowing time to prepare the patient. We should make it easier for physicians to prevent transfusions than to prescribe them.
Misperceptions linger about possible benefits of transfusion. Early studies suggested that transfusions may generate an immunomodulatory response. Since the mechanisms for inferior outcomes with transfusions are not entirely clear or accepted, the persistent doubt in transfusion-related immunomodulation may remain an obstacle to changes in practice. Many physicians still do not accept the potentially detrimental effects of transfusion. Surveys have shown that up to half of surgeons doing GI surgery are unlikely to investigate for anemia before surgery, and many don’t believe in the potential implications of providing perioperative transfusion.
Interventions to Reduce Transfusion Variation
Interventions at different levels can help change practice. Educational materials, guidelines or workshops can be provided at the unit level. Hospitals can provide decision supports with order sets or order entries that need blood lab approval before a transfusion can be performed.
Health systems can create system-level change through departmental policies or establishing protocols or algorithms along with financial incentives. In addition, health systems can monitor and provide performance feedback for physicians and institutions, providing them with necessary information to modify their practice. Those performing below evidence-based standards can then evaluate their processes of care and identify opportunities for improvement.
Health care leaders can concretely improve the quality of care by maintaining performance metrics of transfusions for physicians and institutions. This key measure will enhance both individual and organizational accountability by monitoring critical benchmarks that will help to produce lasting changes in practice.
Author and Funding Information
Jesse Zuckerman, MD, is a general surgery resident at the University of Toronto. Dr. Zuckerman presented findings of the study, “The contribution of surgeon and hospital variation in transfusion practice to outcomes for patients undergoing gastrointestinal cancer surgery: A population-based analysis,” abstract 326, during Digestive Disease Week, on May 22, at 10 a.m. EDT. This study received funding from the following: Ministry of Health and Long-Term Care Clinician Investigator Program, Sunnybrook Alternative Funding Plan Innovation Grant, Canadian Institute of Health Research Canada Graduate Scholarship, Canadian Institute of Health Research New Investigator Award, and Canadian Institutes of Health Research Project Grant (FRN #154131).