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The proportion of variation in perioperative transfusion decisions in Canada attributable to the hospital

[La proportion de variation dans les pratiques transfusionnelles périopératoires au Canada imputable aux hôpitaux]

Nadine Shehata, MD MSc^*,,, Kumanan Wilson, MD MSc^,, C. David Mazer, MD^||, George Tomlinson, PhD, David Streiner, PhD^¶,**, Paul Hébert, MD MHSc (Epidemiology) and Gary Naglie, MD^,,

^* From the Division of Hematology, St. Michael’s Hospital, University of Toronto, Toronto; the
Canadian Blood Services, the
Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto; the
Division of General Internal Medicine, University Health Network; Toronto; the
^|| Department of Anesthesia, St. Michael’s Hospital and University of Toronto, Toronto; the
^¶ Baycrest Centre for Geriatric Care, the
^** Departments of Psychiatry and Health Policy Management and Evaluation, University of Toronto, Toronto; the
Ottawa Health Research Institute Clinical Epidemiology Programme,Ottawa; and the
Geriatrics Program, Toronto Rehabilitation Institute, Toronto, Ontario, Canada.

Address correspondence to: Dr. Nadine Shehata, St. Michael’s Hospital, 30 Bond Street, Queen Wing, 2-065c, Toronto, Ontario M5B 1W8, Canada. Phone: 416-864-5128; Fax: 416-864-5127; E-mail: shehatan{at}smh.toronto.on.ca Conflicts of interest: None declared.

Purpose: Hospital variation in transfusion practices has been described previously but the proportion of variation attributable to the hospital has not. The objective of this report was to quantify hospital variation in red cell transfusion decisions perioperatively for patients undergoing coronary artery bypass surgery (CABG).

Methods: We used a cross-sectional study design using pretested self-administered mailed questionnaires sent to all anesthesiologists and cardiac surgeons involved in CABG in Canada.

Results: Responses were received from anesthesiologists from all 32 hospital sites and from cardiac surgeons from 30/32 sites (94%). There was variation attributable to the hospital in transfusion triggers selected (P < 0.0001). For patients who had uncomplicated CABG surgery, the range of transfusion triggers among hospitals for the intraoperative and postoperative case scenarios were 61 to 80 g·L^–1 and 64 to 80 g·L^–1, respectively. The hospital accounted for 20% of the variation in the transfusion practice intraoperatively and postoperatively. The remainder of the variation was attributable to the individual physician. Academic affiliation and the number of surgical cases performed at the hospital were not significant factors impacting on the transfusion triggers selected

Conclusion: This is the first study to quantify the variation in red cell transfusion practices according to individual physicians and the hospital. The variation attributed to the hospital is significant. The explanation for the variation in transfusion decisions that relate to the hospital needs to be explored further in order to help optimize transfusion practice.