Impact of a PRUDENT© Red Blood Cell Transfusion Strategy in Pediatric HSCT and Oncology Patients

Results from the CHB Experience 2009-11

© 2009 All rights reserved. For permission please contact the Physician’s Organization Quality Department.

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Background Blood products are increasingly recognized as a

resource to target1. Transfusions are high risk2. Unnecessary use creates shortage of scarce and costly

resource3. Increasing evidence that tolerating anemia (e.g. Hct 7-

9g/dl) in critically ill, stable patients does not adversely impact their outcomes

4. Reducing blood product use may decrease risks of volume overload, transfusion reactions and immunologic consequences

Blood products have become a focus of many clinicians across Children’s Hospital Boston

Growing body of evidence that optimizing blood product use may be beneficial**

Inappropriate (imprudent) use could place our patient at risk

**Kipps, 2010; Salvin 2010; Karam, 2010; Bateman, 2008

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Calendar Year2009

Total Number of CHB admissions 18, 852

Hospital admissions associated with RBC transfusion -(n) 2,404 (13.0)

Age at admissions associated with RBC transfusions (Years) -median (IQR)

4 (0,12)

Length of stay associated with RBC products (Days) - median (IQR) 8 days (5, 22)

Number of hospital admissions associated with RBC products and ICU admissions - median (IQR)

686(21.4)

Number patients with admissions associated with RBCs and mortality – n(%)

128(6.9)

Total CHB billed RBC product charges $6,262,829

CHB Use of RBC Products (PHIS)

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PRBC Transfusions by Location

8 South

Amb Transfusion

OR6N7S

6W

11.6%

2.4%

3.7%

4.6%

5.6%

7.7%

1.9%

10.2%8.3%

11.5%

13.7%

18.8% 8 South

Amb Transfusion

OR

7 South

6 North

6 West

Cardiac Surgery

Dana Farber Ped

Therapy Apheres

7 North

Cardiac Cath

*Other

6W –

(HSCT

Unit)

Amb Transfusion

OR

7South –

MSICU

6 N

orth

–

(Onc

)6 W

est

8 Sou

th

(CIC

U)

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Background PRUDENT©

QI initiative at Children’s Hospital Boston Focus on identifying areas of physician decision

making that shape effectiveness and value of care “Pediatric Resource Use: Determination of

Effective and Necessary Targets” Analysis of baseline use of a targeted resource Used RBCs as model

Wise decision making and medical choices Use of resources when they should be used

(appropriate use) Avoidance of overuse and/or misuse

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RBC Transfusion Practices Evaluated by HSCT Unit and Oncology

Preliminary evidence/culture change from “Transfusion Requirements in Critical Care Pilot Study”, JAMA 1995 Multicenter, prospective,randomized(Canada) 69 patients in tertiary ICUs, 16yo or older Hgb maintained at 7-9 (2.5 U/pt) or 10-12 (4.8 U/pt) 48% reduction in transfusions in “conservative” group No difference in mortality, organ dysfunction

Meta-analysis by Marik, Crit Care Med 2008 45 observational studies, 272,000 adult ICU patients Primary endpoint was mortality 42/45 studies: risks of rbc transfusion outweighed the

benefit; benefit outweighed risk in 1 study of elderly MI patients

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Presentation to Division(Dr. Lehmann on 2/5/09) Transfusion strategies for patients on pediatric ICU”,

LaCroix, NEJM 2007 637 patients “noninferiority” trial HgB at 7 vs 9.5 44% fewer transfusions in conservative group No change in outcomes

** Hence, Reasons to be Concerned with RBC Transfusions at CHB Efficacy Toxicity Cost

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Impact of a PRUDENT© Red Blood Cell Strategy In Children Undergoing HSCT

Baseline Characteristics of Pre-Practice Change and Post-Practice Change CHB Bone Marrow Transplant Patients

Variable Pre-Practice Change(1/1/08-12/31/08)

(N=66)

Post-Practice Change(3/1/09-2/28/10)

(N=75)

P-value

Male sex- n (%) 29 (43.9%) 55 (73.3%) 0.004

Age (Years), median (IQR) 6 (2, 12.25) 6 (3, 13)

Diagnosis- n (%):Non-Malignant Hematology

Lymphoma and Solid TumorNeuroblastoma

Hematologic Malignancies

6 (9.1%)22 (33.3%)

4 (6.1%)34 (51.6%)

12 (16.0%)28 (37.3%)

7 (9.3%)28 (37.3%)

0.31

Type of Transplant- n (%):Auto

SiblingBM-URD

Other Family URCord

22 (33.3%)13 (19.7%)31 (47.0%)

0 (0%)0 (0%)

26(34.7%)15 (20.0%)30 (40.0%)

2 (2.7%)2 (2.7%)

0.87

Collaboration with 7S (MSICU)Written policy change in Feb 2009

“Routine” transfusion for Hgb <7 g/dl (vs. 9 g/dl)

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Impact of a PRUDENT© Red Blood Cell Strategy In Children Undergoing HSCT

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Impact of a PRUDENT© Red Blood Cell Strategy In Children Undergoing HSCT

CHB Bone Marrow Transplant Transfusion Practice by Pre-Practice Change and Post-Practice Change Groups

Variable Pre-Practice Change

(1/1/08-12/31/08)(N=66)

Post-Practice Change

(3/1/09-2/28/10)(N=75)

P-value

Patients Transfused- n(%) 65 (98.5%) 72 (96%) 0.38

Total # RBC Transfusion Units 392 307

RBC Transfusion Units per Patient, median (IQR)

4 (3,8) 3 (2,5) 0.002

Transfusion Days* 286 243

Transfusion Days per Patient, median (IQR)

4 (2,5) 3 (2,5) 0.01

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Impact of a PRUDENT© Red Blood Cell Strategy In Children Undergoing HSCT

Transfusion Thresholds of Children Undergoing HSCTPre-Practice Change (01/01/08-12/31/08) vs. Post-Practice Change (03/01/09-02/28/09)

13.2% 6.2% 11.9%

89.5%

61.7%

2.1%

1.7%2.1%

7.0%

4.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Post-Practice Change

Pre-Practice Change

Percent

≤ 6.9 7.0-7.3 7.4 and 7.5 7.6 and 7.9≥ 8.0

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Outcomes of a PRUDENT© Red Blood Cell Strategy In Children Undergoing HSCT

Pre-Intervention and Post-Intervention CHB Bone Marrow Transplant Patient Outcomes

Variable Pre-Practice Change(1/1/08-12/31/08)

(N=66)

Post-Practice Change(3/1/09-2/28/10)

(N=75)

P-value

Time to Engraftment (Days), median (IQR)

20 (12, 25) 18 (12,24) 0.71

Length of Stay (Days), median (IQR)

37(30, 46) 37 (29, 52) 0.69

100-Day Mortality (days)- n (%):

Relapse Related Transplant Related

17 (25.8%)

9 (13.6%)8 (12.1%)

13 (17.3%)

6 (8.0%)7 (9.3%)

0.22

Blood Product Related Charges $3624 ($2265, $6040) $2185 ($1812, $3997) 0.0040

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Diffusion to 06 North – Inpatient Oncology

Comparison of Lowest Hgb Thresholds by Calendar Year on 06 North

240

111

135

73

34

34

51

102

51

275

0% 20% 40% 60% 80% 100%

2010

2009

≤ 6.9

7.0-7.3

7.4 -7.5

7.6-7.9

≥ 8.0

Written policy change in Jan 2010 “Routine” transfusion Hgb <7 g/dl

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PRBC Transfusions by Location

8 South

Amb Transfusion

OR6N7S

6W

11.6%

2.4%

3.7%

4.6%

5.6%

7.7%

1.9%

10.2%8.3%

11.5%

13.7%

18.8% 8 South

Amb Transfusion

OR

7 South

6 North

6 West

Cardiac Surgery

Dana Farber Ped

Therapy Apheres

7 North

Cardiac Cath

*Other

6W –

(HSCT

Unit)

Amb Transfusion

OR

7South –

MSICU

6 N

orth

–

(Onc

)6 W

est

8 Sou

th

(CIC

U)

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MSICU- 07 South

BMT- 06 WestOncology- 06 North

ORCardiac ICU- 08 South

Solid Organ Tx-10 South

Safety Evaluation- ICU Transfers

Cost Modeling

PRUDENT© Activities

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