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BackgroundEfforts to reduce blood product use have the potential to avoid transfusion-related complications and reduce health care costs. The purpose of this investigation was to determine whether a multi-institutional effort to reduce blood product use affects postoperative events after cardiac surgical operations and to determine the influence of perioperative transfusion on risk-adjusted outcomes.MethodsA total of 14,259 patients (2006-2010) undergoing nonemergency, primary, isolated coronary artery bypass grafting operations at 17 different statewide cardiac centers were stratified according to transfusion guideline era: pre-guideline (n = 7059, age = 63.7 ± 10.6 years) versus post-guideline (n = 7200, age = 63.7 ± 10.5 years). Primary outcomes of interest were observed differences in postoperative events and mortality risk-adjusted associations as estimated by multiple regression analysis.ResultsOverall intraoperative (24% vs 18%, P

Although associations between transfusion and inferior outcomes have been documented, there is a lack of blood transfusion standardization in cardiac surgery. At the Inova Heart and Vascular Institute, a multidisciplinary, criterion-driven algorithm for transfusion management was implemented. We examined the effect of our blood conservation protocol on transfusion rates and outcomes after cardiac surgery and on stability of transfusion over time.Patients undergoing first-time cardiac surgery from 2006 (full year before protocol) were compared with those in 2009 (after protocol) and propensity score matched to improve balance. Data were prospectively collected. Stability of transfusion incidence also was compared (2005-2006 vs 2008-2014).After matching, 890 patients from each year were included. Use of blood products decreased from 54% in 2006 to 25% in 2009 (P .001). Patients in 2009 had a lower incidence of postoperative renal failure (2.6% vs 4%, P = .04), reoperations for bleeding (2% vs 4%, P = .004), and readmissions at less than 30 days (6% vs 12%, P .001). No differences were found for operative mortality, deep sternal wound infection, or permanent strokes. Patients in 2009 had greater improvement in physical (P = .001) and mental (P = .02) quality of life than patients in 2006. Reduction of blood products led to significant cost savings for packed erythrocytes (P .001) and platelets (P .001). After protocol implementation, transfusion incidence remained 30% or less, with less than 28% in most years.A multidisciplinary blood conservation program can significantly control blood transfusion rates, improve outcomes, and be sustained over time. Efforts are needed to implement evidence-based protocols to standardize and decrease blood use in cardiac surgery to improve outcomes and reduce cost.

The membrane glycoprotein encoded by the env gene of either the polycythemia- or anemia-inducing spleen focus-forming virus (SFFVp or SFFVa, respectively) is responsible for the induction of erythroleukemia in mice. It has been shown that the SFFVp glycoprotein, gp55, interacts with the erythropoietin receptor (EPO-R) and promotes EPO-independent proliferation of an EPO-R-expressing hematopoietic cell line, Ba/F3 (Li et al., Nature 343:762, 1990). We show here that when residues within the transmembrane (TM) sequence of an SFFVp gp55 are altered based on the sequences of the anemia-inducing gp55s by a methionine-to-isoleucine (M-I) substitution, a di-leucine deletion (dLL), or both, the resulting mutants display an attenuated phenotype that resembles an SFFVa: they induce milder erythroproliferative disease without polycythemia in vivo and are unable to promote EPO-independent cell proliferation in vitro. The dLL mutation directly interferes with EPO-R binding by decreasing the affinity of gp55 for the receptor. On the other hand, the M-I mutation hampers the full mitogenic activation of EPO-R while having no effect on receptor binding and asserts a dominant negative effect over the wild-type SFFVp gp55. Two other sequence changes within the TM sequence did not affect the biological activities of the SFFVp gp55. These results indicate that the TM sequence of the SFFV env glycoprotein plays a prominent role in SFFV-induced erythroleukemogenesis through its influence on the mitogenic activation of EPO-R.

The release of 2 landmark reports by the Institute of Medicine titled, “To Err Is Human: Building a Safer Health System” and “Crossing the Quality Chasm” were instrumental in the identification of safety and quality issues. Since their release, federal and state programs of public reporting of performance measures have attempted to close the quality gap of care that is inappropriate, not timely, or lacking an evidence base. Cardiac surgery has long been the focus of public scrutiny, and now, as we move from an era of managed care to public reporting, reimbursement for cardiac surgery procedures will be tied to performance. However, the question is whether public reporting and pay for performance will ultimately improve the quality of patient care, safety, and provide the consumer with enough information to make surgeon and institutional choices. Will the cost and focus of achieving perfection with performance standards overshadow any real improvement in clinical outcomes?