e155(1) C OPYRIGHT Ó 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Allogenic Blood Transfusion Following Total Hip Arthroplasty: Results from the Nationwide Inpatient Sample, 2000 to 2009 Anas Saleh, MD, Travis Small, DO, Aiswarya Lekshmi Pillai Chandran Pillai, MBBS, MS, Nicholas K. Schiltz, BS, Alison K. Klika, MS, and Wael K. Barsoum, MD Investigation performed at the Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
Background: The large-scale utilization of allogenic blood transfusion and its associated outcomes have been described in critically ill patients and those undergoing high-risk cardiac surgery but not in patients undergoing elective total hip arthroplasty. The objective of this study was to determine the trends in utilization and outcomes of allogenic blood transfusion in patients undergoing primary total hip arthroplasty in the United States from 2000 to 2009. Methods: An observational cohort of 2,087,423 patients who underwent primary total hip arthroplasty from 2000 to 2009 was identified in the Nationwide Inpatient Sample. International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes 99.03 and 99.04 were used to identify patients who received allogenic blood products during their hospital stay. Risk factors for allogenic transfusions were identified with use of multivariable logistic regression models. We used propensity score matching to estimate the adjusted association between transfusion and surgical outcomes. Results: The rate of allogenic blood transfusion increased from 11.8% in 2000 to 19.0% in 2009. Patient-related risk factors for receiving an allogenic blood transfusion include an older age, female sex, black race, and Medicaid insurance. Hospital-related risk factors include rural location, smaller size, and non-academic status. After adjusting for confounders, allogenic blood transfusion was associated with a longer hospital stay (0.58 ± 0.02 day; p < 0.001), increased costs ($1731 ± $49 [in 2009 U.S. dollars]; p < 0.001), increased rate of discharge to an inpatient facility (odds ratio, 1.28; 95% confidence interval, 1.26 to 1.31), and worse surgical and medical outcomes. In-hospital mortality was not affected by allogenic blood transfusion (odds ratio, 0.97; 95% confidence interval, 0.77 to 1.21). Conclusions: The increase in allogenic blood transfusion among total hip arthroplasty patients is concerning considering the associated increase in surgical complications and adverse events. The risk factors for transfusion and its impact on costs and inpatient outcomes can potentially be used to enhance patient care through optimizing preoperative discussions and effective utilization of blood-conservation methods. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
T
otal hip arthroplasty is associated with substantial perioperative blood loss averaging 1000 to 2000 mL1-3 and a drop of 4.0 ± 1.5 g/dL (mean and standard deviation) in the hemoglobin level4,5. With this blood loss, allogenic blood transfu-
sion is common in total hip arthroplasty. It was estimated that from 1996 to 1997, 16% of patients undergoing total hip arthroplasty received an allogenic blood transfusion compared with 11% of those undergoing total knee arthroplasty in the United States1.
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:e155(1-10)
d
http://dx.doi.org/10.2106/JBJS.M.00825
e155(2) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 18 S E P T E M B E R 17, 2 014
AL LO G E N I C BLO OD TR A N S F U S I O N FOL LOW I N G T O TA L H I P A R T H R O P L A S T Y
d
d
d
TABLE I Demographics and Hospital Characteristics for Primary Total Hip Arthroplasty (THA) Patients Receiving or Not Receiving an Allogenic Blood Transfusion, United States 2000-2009 (Weighted) Patients Receiving a Transfusion
All THA Patients Parameter Patients Age (yr)
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Allogenic Blood Transfusion Following Total Hip Arthroplasty: Results from the Nationwide Inpatient Sample, 2000 to 2009 Anas Saleh, MD, Travis Small, DO, Aiswarya Lekshmi Pillai Chandran Pillai, MBBS, MS, Nicholas K. Schiltz, BS, Alison K. Klika, MS, and Wael K. Barsoum, MD Investigation performed at the Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
Background: The large-scale utilization of allogenic blood transfusion and its associated outcomes have been described in critically ill patients and those undergoing high-risk cardiac surgery but not in patients undergoing elective total hip arthroplasty. The objective of this study was to determine the trends in utilization and outcomes of allogenic blood transfusion in patients undergoing primary total hip arthroplasty in the United States from 2000 to 2009. Methods: An observational cohort of 2,087,423 patients who underwent primary total hip arthroplasty from 2000 to 2009 was identified in the Nationwide Inpatient Sample. International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes 99.03 and 99.04 were used to identify patients who received allogenic blood products during their hospital stay. Risk factors for allogenic transfusions were identified with use of multivariable logistic regression models. We used propensity score matching to estimate the adjusted association between transfusion and surgical outcomes. Results: The rate of allogenic blood transfusion increased from 11.8% in 2000 to 19.0% in 2009. Patient-related risk factors for receiving an allogenic blood transfusion include an older age, female sex, black race, and Medicaid insurance. Hospital-related risk factors include rural location, smaller size, and non-academic status. After adjusting for confounders, allogenic blood transfusion was associated with a longer hospital stay (0.58 ± 0.02 day; p < 0.001), increased costs ($1731 ± $49 [in 2009 U.S. dollars]; p < 0.001), increased rate of discharge to an inpatient facility (odds ratio, 1.28; 95% confidence interval, 1.26 to 1.31), and worse surgical and medical outcomes. In-hospital mortality was not affected by allogenic blood transfusion (odds ratio, 0.97; 95% confidence interval, 0.77 to 1.21). Conclusions: The increase in allogenic blood transfusion among total hip arthroplasty patients is concerning considering the associated increase in surgical complications and adverse events. The risk factors for transfusion and its impact on costs and inpatient outcomes can potentially be used to enhance patient care through optimizing preoperative discussions and effective utilization of blood-conservation methods. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
T
otal hip arthroplasty is associated with substantial perioperative blood loss averaging 1000 to 2000 mL1-3 and a drop of 4.0 ± 1.5 g/dL (mean and standard deviation) in the hemoglobin level4,5. With this blood loss, allogenic blood transfu-
sion is common in total hip arthroplasty. It was estimated that from 1996 to 1997, 16% of patients undergoing total hip arthroplasty received an allogenic blood transfusion compared with 11% of those undergoing total knee arthroplasty in the United States1.
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:e155(1-10)
d
http://dx.doi.org/10.2106/JBJS.M.00825
e155(2) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 18 S E P T E M B E R 17, 2 014
AL LO G E N I C BLO OD TR A N S F U S I O N FOL LOW I N G T O TA L H I P A R T H R O P L A S T Y
d
d
d
TABLE I Demographics and Hospital Characteristics for Primary Total Hip Arthroplasty (THA) Patients Receiving or Not Receiving an Allogenic Blood Transfusion, United States 2000-2009 (Weighted) Patients Receiving a Transfusion
All THA Patients Parameter Patients Age (yr)
