Red blood cell transfusions for elective hip and knee arthroplasty: opportunity to improve quality of care and documentation

S S Cook, C B Cangialose, D M Sieburg, S M Kieszak, R Boudreau, L H Hoffman, K S Elward, D J Ballard
Clinical Performance and Quality Health Care 1999, 7 (1): 5-16

OBJECTIVES: To assess current practice for red blood cell transfusion relative to the American College of Physicians guideline for red blood cell transfusion; to determine comparative rates and relative appropriateness of autologous versus allogeneic blood use; and, to assess cost implications of current transfusion practices.

DESIGN: Computerized quality-of-care algorithm applied retrospectively to medical-record and blood-bank data.

SETTING: Twenty-six hospitals in Colorado, Connecticut, Georgia, Oklahoma, and Virginia.

PATIENTS: Medicare beneficiaries (2,137) who were hospitalized in 1993 for two elective surgical procedures: total hip arthroplasty and total knee arthroplasty. Of the 1,195 patients who received a preoperative or postoperative transfusion, 728 were excluded from the analysis because the hospital medical record did not contain the clinical documentation necessary to apply the American College of Physicians guideline to each unit transfused. The remaining 467 patients comprised the sample.

RESULTS: For 467 patients who underwent these two procedures and received a total of 651 units of preoperative or postoperative blood, there were 256 excess units transfused. Two hundred four of these units were autologous, and 52 were allogeneic. These excess units accounted for $48,200 of the total $121,000 direct cost of transfused units.

CONCLUSIONS: These findings demonstrate that current medical records lack the documentation necessary to evaluate transfusion practice for the majority of Medicare beneficiaries undergoing elective hip and knee arthroplasty. The direct costs of preoperative and postoperative blood transfusion for these two procedures could be reduced by nearly 40% through adherence to the American College of Physicians guideline. The majority of this cost saving would be realized through reduction in unnecessary collection and use of autologous blood.

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