Economic Impact of Restrictive Blood Transfusion in Abdominal Surgery

Original Investigation Research

Invited Commentary

Use of Restrictive Transfusion in Abdominal Surgery Should Evidence-Based Medicine Replace Art of Medicine? Danny Chu, MD

Ejaz et al1 elegantly demonstrated in a single-institution study that significant monetary savings may be realized if surgeons were to adhere to a restrictive transfusion policy based on concrete intraoperative and postoperative hemoglobin values. There is little doubt that blood transfuRelated article page 625 sion exposes patients to potential risks of bloodborne pathogens.2 Studies have also demonstrated worse short-term outcomes attributable to blood transfusion itself in critically ill patients.3 Recently, a multicenter, prospective, randomized clinical trial demonstrated no long-term mortality difference between liberal and restrictive transfusion strategies. 4 In light of the current controversy and changing climate of health care reform, Ejaz and colleagues are to be commended for spearheading this timely and provocative study. ARTICLE INFORMATION Author Affiliation: Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania. Corresponding Author: Danny Chu, MD, Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, UPMC Heart and Vascular Institute, 200 Lothrop St, C-700, Pittsburgh, PA 15213 (chud @upmc.edu). Published Online: May 6, 2015. doi:10.1001/jamasurg.2015.111.

However, many such studies are retrospective in nature, using administrative databases, and have thus suffered from selection bias and lack of clinical granularity. While the transfusion trigger using hemoglobin levels may guide the need for transfusion, these guidelines should be taken with some caution and surgeons must use all clinical data to make the final determination on the need for transfusion. At the same time, liberal transfusion strategies based solely on relatively low hemoglobin levels in completely asymptomatic healthy patients may expose them to unnecessary risks and possibly worse outcomes. Because it is nearly impossible to design a prospective randomized clinical trial of blood transfusion triggers incorporating all possible clinical scenarios owing to ethical concerns, surgeons should carefully weigh all the risks and benefits of blood transfusion guided by evidence and use their best clinical judgment. Ultimately, evidence-based medicine should complement, not replace, the art of medicine.

Conflict of Interest Disclosures: None reported.

ill: current clinical practice in the United States. Crit Care Med. 2004;32(1):39-52.

REFERENCES

4. Carson JL, Sieber F, Cook DR, et al. Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial [published online December 9, 2014]. Lancet. doi:10.1016/S01406736(14)62286-8.

1. Ejaz A, Frank SM, Spolverato G, Kim Y, Pawlik TM. Potential economic impact of using a restrictive transfusion trigger among patients undergoing major abdominal surgery [published online May 6, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.81. 2. Picker SM. Current methods for the reduction of blood-borne pathogens: a comprehensive literature review. Blood Transfus. 2013;11(3):343-348. 3. Corwin HL, Gettinger A, Pearl RG, et al. The CRIT Study: anemia and blood transfusion in the critically

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(Reprinted) JAMA Surgery July 2015 Volume 150, Number 7

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Use of Restrictive Transfusion in Abdominal Surgery: Should Evidence-Based Medicine Replace Art of Medicine?

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