Peri-operative blood transfusion as a quality indicator of surgical care in bladder cancer: Beyond the Abstract

In this large, population-based study, we have for the first time explored practice patterns and outcomes related to peri-operative blood transfusion (PBT) for patients with bladder cancer treated with radical cystectomy in routine clinical care. We undertook this cohort study to evaluate the incidence and risk factors associated with PBT and cystectomy, as well as its association with outcomes, in order to explore its utility as a quality indicator of cystectomy. 

Previous studies have emphasized significant variation in the management of muscle invasive bladder cancer (MIBC) with sub-optimal outcomes for those outside of high-volume, specialized centers. Optimization of surgical care delivery for patients with MIBC in the general population includes the development and implementation of markers of quality of care utilizing reliable and valid indicators. 

PBT is a commonly studied quality of care indicator in both oncologic and non-oncologic surgical cases. As surgical blood loss is a modifiable factor that may reflect surgical technique and extended operative time, rates of PBT have been advocated as robust quality indicators. Although PBT at the time of cystectomy has been linked with early morbidity there is contradictory evidence for an association of PBT and late cancer outcomes.

Several important findings have emerged from our population-based study in Ontario, Canada.  First, we have observed a high rate of transfusion in routine clinical practice. Secondly, we demonstrate that PBT is associated with multiple patient- and disease-related factors, as well as provider volume. Thirdly, PBT appears to be strongly associated with early morbidity and mortality that would appear to confirm that PBT is a marker of a more complex peri-operative course. Finally, receiving a PBT was associated with worse 5-year OS and CSS in routine clinical care, despite controlling for important confounders. These findings suggest to us that documentation of allogenic blood transfusion during an admission for cystectomy is indeed a valid quality indicator of surgical care for patients with MIBC.

Clearly, RC is a technically challenging undertaking. As a result, intra-operative blood loss and, therefore, subsequent RBC transfusions, are robust quality indicators because they are ‘specific and measurable elements of practice that can be used to assess quality of care’. Moreover, this element of care is also modifiable because it is often surgeon or anaesthesiologist determined. As a result, it is one of the few modifiable factors that we have available for both short- and long-term outcomes. The need for a transfusion can also be altered by technical modifications such as minimizing blunt dissection, ensuring intra-operative haemostasis, maintaining normothermia and of course utilization of increased intra-abdominal pressures during laparoscopy. Non-technical approaches to reduce blood loss are also helpful and include pre-operative improvement of haemoglobin levels (iron and erythropoietin), minimizing redundant blood tests (pre- and post-operative), reducing central venous pressures, employing blood cell salvage devices and following evidence-based guidelines for lower transfusion triggers.

Our study confirms that administrative documentation of transfusion was associated with both early outcomes as well as long-term survival and importantly this association is persistent despite adjustment for provider volumes. These data suggest that PBT may be a valid indicator of surgical care of MIBC in the general population and reporting of transfusion rates should be considered by hospitals or regional cancer control bodies.

Written By: D. Robert Siemens, MD, FRCSC, Department of Urology, Queen’s University, Kingston, Ontario, Canada

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