Nareg H. Roubinian, MD, MPHTM; Edward L. Murphy, MD, MPH; Dustin G. Mark, MD; Darrell J. Triulzi, MD; Jeffrey L. Carson, MD; Catherine Lee, PhD; Patricia Kipnis, PhD; Steven Kleinman, MD; Vincent X. Liu, MD; Gabriel J. Escobar, MD
Note: Dr. Roubinian had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Acknowledgment: The authors thank Dr. Jason Lee and the other members of the KPNC Blood Management Advisory Group for facilitating access to blood bank data used in the study. They also thank John Greene, MS (KPNC Division of Research), for assistance with electronic health record programming.
Grant Support: By grant R01HL126130 from the National Heart, Lung, and Blood Institute (NHLBI).
Disclosures: Drs. Roubinian and Kleinman report grants from National Institutes of Health (NIH) during the conduct of the study. Dr. Triulzi reports grants from NHLBI during the conduct of the study. Dr. Carson reports leadership of an NIH-funded clinical trial (MINT [Myocardial Ischemia and Transfusion]) evaluating transfusion thresholds in patients with acute myocardial infarction. Dr. Liu reports grants from NIH/National Institute of General Medical Sciences during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-3253.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Proctor & Gamble, Pfizer, and Johnson & Johnson.
Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Available from Dr. Lee (e-mail, Catherine.firstname.lastname@example.org).
Corresponding Author: Nareg H. Roubinian, MD, MPHTM, Kaiser Permanente Northern California Division of Research, 2000 Broadway, Oakland, CA 94612; e-mail, Nareg.H.Roubinian@kp.org.
Current Author Addresses: Drs. Roubinian, Mark, Lee, Liu, and Escobar: Kaiser Permanente Northern California Division of Research, 2000 Broadway, Oakland, CA 94612.
Dr. Murphy: University of California, San Francisco, 270 Masonic Avenue, San Francisco, CA 94118.
Dr. Triulzi: Institute for Transfusion Medicine, 3636 Boulevard of the Allies, Pittsburgh, PA 15213.
Dr. Carson: Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, New Brunswick, NJ 08901.
Dr. Kipnis: Kaiser Permanente Northern California Division of Research, 1800 Harrison Street, 7th Floor, Oakland, CA 94612.
Dr. Kleinman: University of British Columbia, 1281 Rockcrest Avenue, Victoria, British Columbia V9A 4W4, Canada.
Author Contributions: Conception and design: N.H. Roubinian, E.L. Murphy, V. Liu, G.J. Escobar.
Analysis and interpretation of the data: N.H. Roubinian, D.G. Mark, D.J. Triulzi, C. Lee, S. Kleinman, V. Liu, G.J. Escobar.
Drafting of the article: N.H. Roubinian, E.L. Murphy, D.G. Mark, J.L. Carson.
Critical revision for important intellectual content: N.H. Roubinian, D.G. Mark, D.J. Triulzi, J.L. Carson, C. Lee, P. Kipnis, S. Kleinman, V. Liu, G.J. Escobar.
Final approval of the article: N.H. Roubinian, E.L. Murphy, D.G. Mark, D.J. Triulzi, J.L. Carson, C. Lee, P. Kipnis, S. Kleinman, V. Liu, G.J. Escobar.
Provision of study materials or patients: N.H. Roubinian.
Statistical expertise: D.G. Mark, C. Lee, P. Kipnis.
Obtaining of funding: N.H. Roubinian, E.L. Murphy, G.J. Escobar.
Administrative, technical, or logistic support: G.J. Escobar.
Collection and assembly of data: N.H. Roubinian, G.J. Escobar.
Randomized clinical trial findings support decreased red blood cell (RBC) transfusion and short-term tolerance of in-hospital anemia. However, long-term outcomes related to changes in transfusion practice have not been described.
To describe the prevalence of anemia at and after hospital discharge and associated morbidity and mortality events.
Retrospective cohort study.
Integrated health care delivery system with 21 hospitals serving 4 million members.
445 371 surviving adults who had 801 261 hospitalizations between January 2010 and December 2014.
Hemoglobin levels and RBC transfusion, rehospitalization, and mortality events within 6 months of hospital discharge. Generalized estimating equations were used to examine trends over time, accounting for correlated observations and patient-level covariates.
From 2010 to 2014, the prevalence of moderate anemia (hemoglobin levels between 7 and 10 g/dL) at hospital discharge increased from 20% to 25% (P < 0.001) and RBC transfusion declined by 28% (39.8 to 28.5 RBC units per 1000 patients; P < 0.001). The proportion of patients whose moderate anemia had resolved within 6 months of hospital discharge decreased from 42% to 34% (P < 0.001), and RBC transfusion and rehospitalization within 6 months of hospital discharge decreased from 19% to 17% and 37% to 33%, respectively (P < 0.001 for both). During this period, the adjusted 6-month mortality rate decreased from 16.1% to 15.6% (P = 0.004) in patients with moderate anemia, in parallel with that of all others.
Possible unmeasured confounding.
Anemia after hospitalization increased in parallel with decreased RBC transfusion. This increase was not accompanied by a rise in subsequent RBC use, rehospitalization, or mortality within 6 months of hospital discharge. Longitudinal analyses support the safety of practice recommendations to limit RBC transfusion and tolerate anemia during and after hospitalization.
National Heart, Lung, and Blood Institute.
Roubinian NH, Murphy EL, Mark DG, Triulzi DJ, Carson JL, Lee C, et al. Long-Term Outcomes Among Patients Discharged From the Hospital With Moderate Anemia: A Retrospective Cohort Study. Ann Intern Med. [Epub ahead of print 18 December 2018]170:81–89. doi: 10.7326/M17-3253
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Published: Ann Intern Med. 2019;170(2):81-89.
Published at www.annals.org on 18 December 2018
Hematology/Oncology, Hospital Medicine, Red Cell Disorders.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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