Introduction of national guidelines for restrictive blood transfusion threshold for hip fracture patients: a consecutive cohort study based on complete follow-up in national databases

Bjarke Viberg, Per Hviid Gundtoft, Jesper Schønnemann, Lasse Pedersen, Lis Røhl Andersen, Kjell Titlestad, Carsten Fladmose Madsen, Jens Lauritsen, Søren Overgaard

Publikation: Bidrag til tidsskriftTidsskriftartikelForskningpeer review

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Resumé

BACKGROUND: Randomized controlled trials have demonstrated that a restrictive red blood cell (RBC) transfusion strategy lowers transfusion frequency without affecting mortality. However, the external validity of these trials has not been tested in a large cohort. The purpose was to estimate the effect of introducing a National Clinical Guideline (NCG) for a restrictive hemoglobin transfusion threshold on transfusion frequency and mortality in hip fracture patients > 65 years old.

METHODS: A consecutive cohort study of hip fracture patients > 65 years old residing in the southern region of Denmark was conducted using prospectively gathered data from registers during two separate 1-year time periods. The first period from October 1, 2012, to September 30, 2013, included 1494 patients and used a liberal transfusion threshold, whereas the second period from October 1, 2015, to September 30, 2016, including 1414 participants used a restrictive threshold from the NCG. Participant data for age, sex, body mass index, Charlson Comorbidity Index, time to surgery, and death were retrieved from the Danish Interdisciplinary Registry of Hip Fractures and were merged with RBC transfusion and medication data extracted from the Danish Transfusion and Odense Pharmacoepidemiological Databases, respectively. Cox proportional hazards models were used to test relative mortality risk for the restrictive group compared with the liberal group at 30 and 90 days.

RESULTS: Overall RBC transfusions decreased from 42 to 30% (p < 0.001). The 30-day mortality rate (95% CI) was 9% (8;11) in the restrictive group and 13% (11;14) in the liberal group (p < 0.008), whereas the adjusted relative mortality risk was 0.72 (0.57;0.91). The 90-day mortality rate was 15% (13;17) in the restrictive group and 19% (17;21) in the liberal group, whereas the adjusted relative mortality risk was 0.78 (0.65;0.94).

CONCLUSION: These data suggest that the introduction of an NCG on restrictive blood transfusion leads to lower transfusion frequency in hip fracture patients > 65 years old. Even though this reduction is associated with decreased mortality at both 30 and 90 days, it may be explained by other issues than restrictive transfusion strategy. There has been an improvement in the mortality of hip fracture patients in Denmark, and we suggest that a restrictive transfusion strategy does not lead to increased mortality.

OriginalsprogEngelsk
Artikelnummer116
TidsskriftJournal of Orthopaedic Surgery and Research
Vol/bind13
Antal sider8
ISSN1749-799X
DOI
StatusUdgivet - 18. maj 2018

Fingeraftryk

Cohort Studies
Databases
Guidelines
Erythrocyte Transfusion
Denmark
Proportional Hazards Models
Registries
Comorbidity
Body Mass Index
Randomized Controlled Trials

Citer dette

@article{25b84c9ce26f4b20bd121af1aa695f9e,
title = "Introduction of national guidelines for restrictive blood transfusion threshold for hip fracture patients: a consecutive cohort study based on complete follow-up in national databases",
abstract = "BACKGROUND: Randomized controlled trials have demonstrated that a restrictive red blood cell (RBC) transfusion strategy lowers transfusion frequency without affecting mortality. However, the external validity of these trials has not been tested in a large cohort. The purpose was to estimate the effect of introducing a National Clinical Guideline (NCG) for a restrictive hemoglobin transfusion threshold on transfusion frequency and mortality in hip fracture patients > 65 years old.METHODS: A consecutive cohort study of hip fracture patients > 65 years old residing in the southern region of Denmark was conducted using prospectively gathered data from registers during two separate 1-year time periods. The first period from October 1, 2012, to September 30, 2013, included 1494 patients and used a liberal transfusion threshold, whereas the second period from October 1, 2015, to September 30, 2016, including 1414 participants used a restrictive threshold from the NCG. Participant data for age, sex, body mass index, Charlson Comorbidity Index, time to surgery, and death were retrieved from the Danish Interdisciplinary Registry of Hip Fractures and were merged with RBC transfusion and medication data extracted from the Danish Transfusion and Odense Pharmacoepidemiological Databases, respectively. Cox proportional hazards models were used to test relative mortality risk for the restrictive group compared with the liberal group at 30 and 90 days.RESULTS: Overall RBC transfusions decreased from 42 to 30{\%} (p < 0.001). The 30-day mortality rate (95{\%} CI) was 9{\%} (8;11) in the restrictive group and 13{\%} (11;14) in the liberal group (p < 0.008), whereas the adjusted relative mortality risk was 0.72 (0.57;0.91). The 90-day mortality rate was 15{\%} (13;17) in the restrictive group and 19{\%} (17;21) in the liberal group, whereas the adjusted relative mortality risk was 0.78 (0.65;0.94).CONCLUSION: These data suggest that the introduction of an NCG on restrictive blood transfusion leads to lower transfusion frequency in hip fracture patients > 65 years old. Even though this reduction is associated with decreased mortality at both 30 and 90 days, it may be explained by other issues than restrictive transfusion strategy. There has been an improvement in the mortality of hip fracture patients in Denmark, and we suggest that a restrictive transfusion strategy does not lead to increased mortality.",
keywords = "Hip fracture, Liberal, Mortality, Restrictive, Transfusion",
author = "Bjarke Viberg and Gundtoft, {Per Hviid} and Jesper Sch{\o}nnemann and Lasse Pedersen and Andersen, {Lis R{\o}hl} and Kjell Titlestad and Madsen, {Carsten Fladmose} and Jens Lauritsen and S{\o}ren Overgaard",
year = "2018",
month = "5",
day = "18",
doi = "10.1186/s13018-018-0828-8",
language = "English",
volume = "13",
journal = "Journal of Orthopaedic Surgery and Research",
issn = "1749-799X",
publisher = "BioMed Central",

}

Introduction of national guidelines for restrictive blood transfusion threshold for hip fracture patients : a consecutive cohort study based on complete follow-up in national databases. / Viberg, Bjarke; Gundtoft, Per Hviid; Schønnemann, Jesper; Pedersen, Lasse; Andersen, Lis Røhl; Titlestad, Kjell; Madsen, Carsten Fladmose; Lauritsen, Jens; Overgaard, Søren.

I: Journal of Orthopaedic Surgery and Research, Bind 13, 116, 18.05.2018.

Publikation: Bidrag til tidsskriftTidsskriftartikelForskningpeer review

TY - JOUR

T1 - Introduction of national guidelines for restrictive blood transfusion threshold for hip fracture patients

T2 - a consecutive cohort study based on complete follow-up in national databases

AU - Viberg, Bjarke

AU - Gundtoft, Per Hviid

AU - Schønnemann, Jesper

AU - Pedersen, Lasse

AU - Andersen, Lis Røhl

AU - Titlestad, Kjell

AU - Madsen, Carsten Fladmose

AU - Lauritsen, Jens

AU - Overgaard, Søren

PY - 2018/5/18

Y1 - 2018/5/18

N2 - BACKGROUND: Randomized controlled trials have demonstrated that a restrictive red blood cell (RBC) transfusion strategy lowers transfusion frequency without affecting mortality. However, the external validity of these trials has not been tested in a large cohort. The purpose was to estimate the effect of introducing a National Clinical Guideline (NCG) for a restrictive hemoglobin transfusion threshold on transfusion frequency and mortality in hip fracture patients > 65 years old.METHODS: A consecutive cohort study of hip fracture patients > 65 years old residing in the southern region of Denmark was conducted using prospectively gathered data from registers during two separate 1-year time periods. The first period from October 1, 2012, to September 30, 2013, included 1494 patients and used a liberal transfusion threshold, whereas the second period from October 1, 2015, to September 30, 2016, including 1414 participants used a restrictive threshold from the NCG. Participant data for age, sex, body mass index, Charlson Comorbidity Index, time to surgery, and death were retrieved from the Danish Interdisciplinary Registry of Hip Fractures and were merged with RBC transfusion and medication data extracted from the Danish Transfusion and Odense Pharmacoepidemiological Databases, respectively. Cox proportional hazards models were used to test relative mortality risk for the restrictive group compared with the liberal group at 30 and 90 days.RESULTS: Overall RBC transfusions decreased from 42 to 30% (p < 0.001). The 30-day mortality rate (95% CI) was 9% (8;11) in the restrictive group and 13% (11;14) in the liberal group (p < 0.008), whereas the adjusted relative mortality risk was 0.72 (0.57;0.91). The 90-day mortality rate was 15% (13;17) in the restrictive group and 19% (17;21) in the liberal group, whereas the adjusted relative mortality risk was 0.78 (0.65;0.94).CONCLUSION: These data suggest that the introduction of an NCG on restrictive blood transfusion leads to lower transfusion frequency in hip fracture patients > 65 years old. Even though this reduction is associated with decreased mortality at both 30 and 90 days, it may be explained by other issues than restrictive transfusion strategy. There has been an improvement in the mortality of hip fracture patients in Denmark, and we suggest that a restrictive transfusion strategy does not lead to increased mortality.

AB - BACKGROUND: Randomized controlled trials have demonstrated that a restrictive red blood cell (RBC) transfusion strategy lowers transfusion frequency without affecting mortality. However, the external validity of these trials has not been tested in a large cohort. The purpose was to estimate the effect of introducing a National Clinical Guideline (NCG) for a restrictive hemoglobin transfusion threshold on transfusion frequency and mortality in hip fracture patients > 65 years old.METHODS: A consecutive cohort study of hip fracture patients > 65 years old residing in the southern region of Denmark was conducted using prospectively gathered data from registers during two separate 1-year time periods. The first period from October 1, 2012, to September 30, 2013, included 1494 patients and used a liberal transfusion threshold, whereas the second period from October 1, 2015, to September 30, 2016, including 1414 participants used a restrictive threshold from the NCG. Participant data for age, sex, body mass index, Charlson Comorbidity Index, time to surgery, and death were retrieved from the Danish Interdisciplinary Registry of Hip Fractures and were merged with RBC transfusion and medication data extracted from the Danish Transfusion and Odense Pharmacoepidemiological Databases, respectively. Cox proportional hazards models were used to test relative mortality risk for the restrictive group compared with the liberal group at 30 and 90 days.RESULTS: Overall RBC transfusions decreased from 42 to 30% (p < 0.001). The 30-day mortality rate (95% CI) was 9% (8;11) in the restrictive group and 13% (11;14) in the liberal group (p < 0.008), whereas the adjusted relative mortality risk was 0.72 (0.57;0.91). The 90-day mortality rate was 15% (13;17) in the restrictive group and 19% (17;21) in the liberal group, whereas the adjusted relative mortality risk was 0.78 (0.65;0.94).CONCLUSION: These data suggest that the introduction of an NCG on restrictive blood transfusion leads to lower transfusion frequency in hip fracture patients > 65 years old. Even though this reduction is associated with decreased mortality at both 30 and 90 days, it may be explained by other issues than restrictive transfusion strategy. There has been an improvement in the mortality of hip fracture patients in Denmark, and we suggest that a restrictive transfusion strategy does not lead to increased mortality.

KW - Hip fracture

KW - Liberal

KW - Mortality

KW - Restrictive

KW - Transfusion

U2 - 10.1186/s13018-018-0828-8

DO - 10.1186/s13018-018-0828-8

M3 - Journal article

C2 - 29776419

VL - 13

JO - Journal of Orthopaedic Surgery and Research

JF - Journal of Orthopaedic Surgery and Research

SN - 1749-799X

M1 - 116

ER -