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Wide Variation in Blood Transfusion Use

Wide Variation in Blood Transfusion Use

Current clinical guidelines from three medical societies suggest that the hemoglobin threshold for blood transfusions during surgery should be 7 g/dl or 8 g/dl. These guidelines also note that patients don’t need a transfusion when hemoglobin levels are above 10 g/dl. However, when hemoglobin levels fall between these thresholds, there is little consensus on the best course of action. Although four landmark studies published over the past 5 years suggest that it’s safe to wait until hemoglobin levels fall to 7 g/dl or 8 g/dl before transfusing, wide variation and excessive use of blood transfusions have been reported. Advances in viral testing in recent years have made blood transfusion safer, but risks still exist for these patients, including lung injury, immune suppression, and viral transmission. Blood is also in scarce supply and expensive. Wide Variation of Hemoglobin Thresholds In an issue of Anesthesiology, my colleagues and I had a study published that sought to confirm the wide range of hemoglobin thresholds used by surgeons and anesthesiologists. Over 18 months, we collected data on more than 48,000 surgical patients at Johns Hopkins Hospital. Within the institution, there was a variation of up to 3 g/dl in hemoglobin thresholds among surgeons and anesthesiologists, when compared with their peers. Virtually all providers used thresholds above the ones recommended in guidelines, and none used thresholds below the recommended range. Surprisingly, sicker patients—generally those under-going cardiac surgeries—had the lowest hemoglobin thresholds, whereas those undergoing surgery for pancreatic cancer, orthopedic issues, and aortic aneurysms received blood transfusions at higher thresholds. The amount of blood transfused did not correlate with how sick the patients were or...
Predicting Avoidable 30-Day Readmissions

Predicting Avoidable 30-Day Readmissions

Throughout the United States, readmission rates are increasingly being used for benchmarking across hospitals. Some hospital readmissions may be avoidable, which in turn has led to the levying of financial penalties on hospitals with high risk-adjusted rates. Recent studies have estimated that the 30-day readmission rate for Medicare beneficiaries is almost 20%, and these occurrences cost the U.S. healthcare system as much as $17 billion annually. Several prediction scores have been developed, but few accurately and efficiently predict 30-day readmission risk in general medical patients, explains Jacques Donzé, MD, MSc. “The models that are currently available often do not distinguish between avoidable and unavoidable readmissions, have poor discriminatory power, or use complex scores that aren’t calculable before hospital discharge. Interventions to reduce readmissions are often expensive to implement. To improve efficiency, the highest intensity interventions should be targeted to patients who are most likely to benefit.” A New Prediction Model for 30-Day Readmission In JAMA Internal Medicine, Dr. Donzé and colleagues had a study published that derived and validated a prediction model for potentially avoidable 30-day hospital readmissions in medical patients. The model used administrative and clinical data that was readily available prior to discharge. “Our purpose was to help clinicians target transitional care interventions most efficiently,” Dr. Donzé says. “The goal was to develop a score to predict potentially avoidable readmissions. In other words, we wanted to predict which patients may be most likely to benefit from intensive interventions.” The HOSPITAL score is able to indicate readmission risk before a patient is discharged. This allows clinicians to target a timely transitional care intervention. In their retrospective analysis, Dr....
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