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Organizational Contributors to the Variation in Red Blood Cell Transfusion Practices in Cardiac Surgery: Survey Results From the State of Michigan

Camaj, Anton MD, MS*; Zahuranec, Darin B. MD, MS; Paone, Gaetano MD, MHSA; Benedetti, Barbara R. BA§; Behr, Warren D. BS; Zimmerman, Marc A. PhD; Zhang, Min PhD#; Kramer, Robert S. MD**; Penn, Jason CCP††; Theurer, Patricia F. BSN§; Paugh, Theron A. CCP§‡‡; Engoren, Milo MD§§; DeLucia, Alphonse III MD‖‖; Prager, Richard L. MD§‡‡; Likosky, Donald S. PhD§‡‡on behalf of the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative

doi: 10.1213/ANE.0000000000002277
Blood Management: Original Clinical Research Report

BACKGROUND: While large volumes of red blood cell transfusions are given to preserve life for cardiac surgical patients, indications for lower volume transfusions (1–2 units) are less well understood. We evaluated the relationship between center-level organizational blood management practices and center-level variability in low volume transfusion rates.

METHODS: All 33 nonfederal, Michigan cardiac surgical programs were surveyed about their blood management practices for isolated, nonemergent coronary bypass procedures, including: (1) presence and structure of a patient blood management program, (2) policies and procedures, and (3) audit and feedback practices. Practices were compared across low (N = 14, rate: 0.8%–10.1%) and high (N = 18, rate: 11.0%–26.3%) transfusion rate centers.

RESULTS: Thirty-two (97.0%) of 33 institutions participated in this study. No statistical differences in organizational practices were identified between low- and high-rate groups, including: (1) the membership composition of patient blood management programs among those reporting having a blood management committee (P= .27–1.0), (2) the presence of available red blood cell units within the operating room (4 of 14 low-rate versus 2 of 18 high-rate centers report that they store no units per surgical case, P= .36), and (3) the frequency of internal benchmarking reporting about blood management audit and feedback practices (low rate: 8 of 14 versus high rate: 9 of 18; P= .43).

CONCLUSIONS: We did not identify meaningful differences in organizational practices between low- and high-rate intraoperative transfusion centers. While a larger sample size may have been able to identify differences in organizational practices, efforts to reduce variation in 1- to 2-unit, intraoperative transfusions may benefit from evaluating other determinants, including organizational culture and provider transfusion practices.

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From the *Michigan Medicine, Ann Arbor, Michigan; Department of Neurology, University of Michigan, Ann Arbor, Michigan; Division of Cardiac Surgery, Henry Ford Hospital, Detroit, Michigan; §Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan; Blood Management and Conservation, Bronson Methodist Hospital, Kalamazoo, Michigan; Department of Health Behavior and Health Education, School of Public Health and #Department of Biostatistics, University of Michigan, Ann Arbor, Michigan; **Division of Cardiothoracic Surgery, Maine Medical Center, Portland, Maine; ††Department of Perfusion, Bronson Methodist Hospital, Kalamazoo, Michigan; ‡‡Department of Cardiac Surgery and §§Department of Anesthesiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan; and ‖‖Department of Cardiothoracic Surgery, Bronson Methodist Hospital, Bronson, Michigan.

Accepted for publication April 10, 2017.

Funding: Support for the MSTCVS Quality Collaborative is provided by the Blue Cross and Blue Shield of Michigan and Blue Care Network as part of the BCBSM Value Partnerships program. D.S.L. is supported in part by Grant Numbers R01HS022535 and R03HS022909 from the Agency for Healthcare Research and Quality (AHRQ). A.C. is supported by Grant Number 5TL1TR000435 from the National Institutes of Health (NIH). D.B.Z. is supported by Grant KAG038731 (NIH). The opinions expressed in this document are those of the authors and do not reflect the official position of the AHRQ, NIH, or the US Department of Health and Human Services. This project was funded in part under grant number R03HS022909 from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Donald S. Likosky, PhD, Section of Health Services Research and Quality, Department of Cardiac Surgery (5346 CVC), Michigan Medicine, Ann Arbor, MI 48109. Address e-mail to

© 2017 International Anesthesia Research Society
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