Objective: Increasing evidence, including publication of the Transfusion Requirements in Critical Care trial in 1999, supports a lower hemoglobin threshold for RBC transfusion in ICU patients. However, little is known regarding the influence of this evidence on clinical practice over time in a large population-based cohort.
Design: Retrospective population-based cohort study.
Setting: Thirty-five Maryland hospitals.
Patients: Seventy-three thousand three hundred eighty-five nonsurgical adults with an ICU stay greater than 1 day between 1994 and 2007.
Measurements and Main Results: The unadjusted odds of patients receiving an RBC transfusion increased from 7.9% during the pre-Transfusion Requirements in Critical Care baseline period (1994–1998) to 14.7% during the post-Transfusion Requirements in Critical Care period (1999–2007). A logistic regression model, including 40 relevant patient and hospital characteristics, compared the annual trend in the adjusted odds of RBC transfusion during the pre- versus post-Transfusion Requirements in Critical Care periods. During the pre-Transfusion Requirements in Critical Care period, the trend in the adjusted odds of RBC transfusion did not differ between hospitals averaging > 200 annual ICU discharges and hospitals averaging ≤ 200 annual ICU discharges (odds ratio, 1.07 [95% CI, 1.01–1.13] annually and 1.03 [95% CI, 0.99–1.07] annually, respectively; p = 0.401). However, during the post-Transfusion Requirements in Critical Care period, the adjusted odds of RBC transfusion decreased over time in higher ICU volume hospitals (odds ratio, 0.96 [95% CI, 0.93–0.98] annually) but continued to increase in lower ICU volume hospitals (odds ratio, 1.10 [95% CI, 1.08–1.13] annually), p < 0.001.
Conclusions: In this population-based cohort of ICU patients, the unadjusted odds of RBC transfusion increased in both higher and lower ICU volume hospitals both before and after Transfusion Requirements in Critical Care publication. After adjusting for relevant characteristics, the odds continued to increase in lower ICU volume hospitals in the post-Transfusion Requirements in Critical Care period, but it decreased in higher ICU volume hospitals. This suggests that evidence supporting restrictive RBC transfusion thresholds may not be uniformly translated into practice in different hospital settings.
1Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University, Atlanta, GA.
2Division of Pulmonary/Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
3Division of Pulmonary and Critical Care Medicine, Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD.
4Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD.
5Department of Pathology, Johns Hopkins University, Baltimore, MD.
6Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
* See also p. 2449.
Dr. Murphy was supported by an institutional training grant from the NIH (T32 HL007534). Dr. Pronovost was supported by a K24 award from the NIH. Dr. Berenholtz was supported by the National Institutes of Health, Agency for Healthcare Research and Quality, Health Research and Education Trust, The Commonwealth Fund, Centers for Disease Control and Prevention, and Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality for unrelated research; has equity ownership in Docusys; and receives honoraria and travel expenses from various hospitals and hospital associations for consulting. Dr. Netzer received funding from the National Institutes of Health. Dr. Ness consulted for TerumoBCT and Fenwal Labs. The remaining authors have disclosed that they do not have any potential conflicts of interest.
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