Are lower levels of red blood cell transfusion more cost-effective than liberal levels after cardiac surgery? Findings from the TITRe2 randomised controlled trial

Journal article

Objective: To assess the incremental cost and cost-effectiveness of a restrictive versus a liberal red blood cell transfusion threshold for after cardiac surgery patients.
Design: A within-trial cost-effectiveness analysis with a three month time horizon, based on a multi-centre superiority randomised controlled trial from the perspective of the National Health Service (NHS) and personal social services in the United Kingdom (UK).
Setting: 17 specialist cardiac surgery centres in UK NHS hospitals.
Participants: 2003 patients aged over 16 years undergoing non-emergency cardiac surgery with a post-operative haemoglobin of less than 9g/dL.
Interventions: Restrictive (transfuse if haemoglobin <7.5g/dL) or liberal (transfuse if haemoglobin <9g/dL) threshold during hospitalisation after surgery.
Main outcome measures: Health related quality of life measured using the EQ-5D-3L to calculate quality-adjusted life years (QALYs).
Results: The total costs from surgery up to 3 months were £17,945 and £18,127 in the restrictive and liberal groups (mean difference is -£182, 95% CI -£1108 to £744). The cost difference was largely attributable to the difference in the cost of red blood cells. Mean QALYs to 3 months were 0.18 in both groups (restrictive minus liberal difference is 0.0004, 95% CI -0.0037 to 0.0045). The point estimate for the base-case cost-effectiveness analysis suggested that the restrictive group was slightly more effective and slightly less costly than the liberal group and, therefore, cost-effective. However, there is great uncertainty around these results partly due to the negligible differences in QALYs gained.
Conclusions: We conclude that there is no clear difference in the cost-effectiveness of restrictive and liberal thresholds for red blood cell transfusion after cardiac surgery.

Authors: Stokes, E; Wordsworth, S; Bargo, D; TITRe2 Investigators

• Publication status: Published
• Peer review status: Peer reviewed
• Publisher: BMJ Publishing Group
• Journal: BMJ Open
• Volume: 6
• Pages: e011311
• Publication date: 2016-08-01
• Acceptance date: 2016-06-30
• DOI: 10.1136/bmjopen-2016-011311
• EISSN: 2044-6055
• ISSN: 2044-6055
• Keywords: cost-effectiveness; blood transfusion; cardiac surgery