Large Variation in Blood Transfusion Use after Colorectal Resection: A Call to Action

BACKGROUND: Perioperative blood transfusions are associated with an increased risk of adverse postoperative outcomes through immunomodulatory effects. OBJECTIVE: The purpose of this study was to identify factors associated with variation in blood transfusion use after elective colorectal resection and associated postoperative infectious complications DESIGN: This was a retrospective cohort study. SETTINGS: The study included elective colorectal resections in New York State from 2001 to 2013. PATIENTS: The study cohort consists of 125,160 colorectal resections. Patients who were admitted nonelectively or who were admitted before the date of surgery were excluded. MAIN OUTCOME MEASURES: Receipt of a perioperative allogeneic red blood cell transfusion and the secondary end points of postoperative pneumonia, surgical site infection, intra-abdominal abscess, and sepsis were measured. RESULTS: The overall rate of perioperative blood transfusion for the study cohort was 13.9%. The unadjusted blood transfusion rates ranged from 2.4% to 58.7% for individual surgeons and 2.9% to 32.8% for individual hospitals. After controlling for patient-, surgeon-, and hospital-level factors in a 3-level mixed-effects multivariable model, significant variation was still present across both surgeons (p < 0.0001) and hospitals (p < 0.0001), with a 16.8-fold difference in adjusted blood transfusion rates across surgeons and a 13.2-fold difference in adjusted blood transfusion rates across hospitals. Receipt of a blood transfusion was also independently associated with pneumonia (OR = 3.23 (95% CI, 2.92-3.57)), surgical site infection (OR = 2.27 (95% CI, 2.14-2.40)), intra-abdominal abscess (OR = 2.72 (95% CI, 2.41-3.07)), and sepsis (OR = 4.51 (95% CI, 4.11-4.94)). LIMITATIONS: Limitations include the retrospective design and the possibility of miscoding within administrative data. CONCLUSIONS: Large surgeon-and hospital-level variations in perioperative blood transfusion use for patients undergoing colorectal resection are present despite controlling for patient-, surgeon-, and hospital-level factors. In addition, receipt of a blood transfusion was independently associated with an increased risk of postoperative infectious complications. These findings support the creation and implementation of perioperative blood transfusion protocols aimed at limiting unwarranted variation.