An investigation on Virginia Cardiac Surgery Quality Initiative (VCSQI) to determine whether a multi-institutional effort to reduce blood-product use through the implementation of transfusion guidlines affects postoperative events following cardiac operations and to determine the influence of intraoperative and postoperative product transfusion on risk-adjusted outcomes.

1. VCSQI (Virginia Cardiac Surgery Quality
Initiative)

2. VCSQI (Virginia Cardiac Surgery Quality
Initiative)
DJ LaPar (University of Virginia, Charlottesville)
American Association of Thoracic Surgery 2012 Annual Meeting
• An investigation to determine whether a multi-institutional effort to reduce
blood-product use through the implementation of transfusion guidelines affects
postoperative events following cardiac operations and to determine the
influence of intraoperative and postoperative product transfusion on risk-
adjusted outcomes
• Population and design:
14 259 patients (2006–2010) undergoing nonemergent, primary, isolated
CABG operations at 17 statewide cardiac centers were stratified according to
transfusion guideline era: preguideline vs postguideline
• Primary outcomes of interest:
Observed differences in postoperative events and mortality risk-adjusted
associations as estimated by multiple regression analysis
CABG=coronary artergy bypass graft

3. VCSQI: Results (transfusion-related risks)
• Intraoperative transfusions were used in 24% of cardiac surgeries in the
preguidelines period and 17.7% after the guidelines were in place (p<0.001)
• Postoperative transfusions fell from 39.1% to 32.8% (p<0.001)
• Decreased use of packed red blood cells accounted for most of both differences
• Major complications* and mortality went up significantly with intraoperative and
postoperative transfusions whether used before or after protocol implementation
Odds ratio (OR, 95% CI) for effect of transfusion type and guidelines era (pre- vs
postimplementation) on risk-adjusted outcomes
Endpoint Guidelines era Intraoperative transfusion Postoperative transfusion
Major complications 0.97 (0.88–1.08)† 1.25 (1.12–1.41) 4.50 (4.03–5.03)
30-day mortality 0.53 (0.37–0.74) 1.86 (1.35–2.55) 4.61 (3.19–6.68)
(Including pneumonia, prolonged ventilation, renal failure, and hemodialysis
†p=0.64; all other ORs p<0.001

4. VCSQI: Results (cost)
• At the patient level, the mortality-adjusted overall cost of an intraoperative
transfusion rose by $4408 from before to after guidelines implementation
• The increase in cost reached $10 479 for a postoperative transfusion
• Total and average hospital costs went down significantly
Odds ratio (OR, 95% CI) for effect of transfusion type and guidelines era (pre- vs
postimplementation) on risk-adjusted outcomes*
Parameter 2006–2008 ($) 2008–2010 ($)
Statewide total hospital costs 261 million 212 million
Median total hospital costs 30 487 26 197
Median ICU/CCU costs 6355 5710
*p<0.001 for all differences by guidelines era
ICU=intensive care unit; CCU=coronary care unit

5. VCSQI: Commentary*
"I hope that [the analysis] is now extended, based on this experience at the state
level, to the national level, because the implications at the national level both on
the cost analysis and the outcomes would be significant."
- Dr Edward D Verrier
*All comments from Lives, money saved by protocol-guided transfusion use at cardiac surgery
(http://www.theheart.org/article/1393357.do)

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