title: Effect of a restrictive transfusion strategy on transfusion-attributable severe acute complications and costs in the US ICUs: a model simulation.
abstract: BACKGROUND
  Nearly half of all patients in the Intensive Care Unit (ICU) receive red blood cell (pRBC) transfusions (TFs), despite their associated complications. Restrictive transfusion strategy (Hemoglobin [Hb] < 7 g/dL) has been shown to reduce TF exposure. We estimated the potential annual reduction in transfusion-attributable severe acute complications (TSACs) and costs across the US ICUs with the adoption of restrictive strategy.
  
  
  METHODS
  A model, utilizing inputs from published studies, was constructed. Step 1 calculated potential number of patients appropriate for this strategy. In step 2, total number of pRBC units avoided with the restrictive trigger was extrapolated to the annual TFs in the US ICUs. Step 3 quantified excess acute complications and the number of pRBC units TF/1 TSAC in the TRICC trial. Step 4 transformed restrictive strategy-related avoidance of pRBC units to a reduction in TSACs, and step 5 quantified the associated cost savings.
  
  
  RESULTS
  Of the 4.4 million annual ICU admissions, 1,020,800 comprised the at-risk population. The total of 1,295,126 units of pRBC ($643/unit) could be saved with the restrictive strategy. Based on the data from the TRICC trial, dividing the 49 excess complications in the liberal group into the calculated excess of pRBCs transfused (1,624 units) yielded the rate of 33 pRBC units per one complication. Thus, dividing 1,295,126 units saved by 33 units/1 TSAC, the base-case analysis showed that 39,246 TSACs could potentially be avoided annually in the US ICUs, with the cost savings of $821,109,826.
  
  
  CONCLUSIONS
  This model demonstrates that a restrictive transfusion strategy in appropriate at risk ICU patients is dominant and could result in improved quality of care and cost savings. Given the potential savings of 40,000 TSACs and nearly $1 billion, it is incumbent upon the intensivist community to promote more ubiquitous adoption of a clinically appropriate restrictive transfusion strategy in the ICU.
authors.affiliation: University of Massachusetts, 715 North Pleasant Street, Amherst, MA 01003, USA. MZilberb@schoolph.umass.edu
authors.forename: Marya D
authors.initials: MD
authors.lastname: Zilberberg
authors.forename: Andrew F
authors.initials: AF
authors.lastname: Shorr
mesh_terms: D000328:Adult; D000368:Aged; D015706:Bibliometrics; D003198:Computer Simulation; D017046:Cost Savings / Q000379:methods*; D017707:Erythrocyte Transfusion / Q000009:adverse effects* / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D006291:Health Policy; D006801:Humans; D007049:Iatrogenic Disease / Q000453:epidemiology / Q000517:prevention & control*; D007362:Intensive Care Units / Q000191:economics / Q000592:standards*; D008297:Male; D008875:Middle Aged; D017059:Models, Econometric; D009010:Monte Carlo Method; D016134:Organizational Policy; D011785:Quality Assurance, Health Care / Q000379:methods*; D018570:Risk Assessment / Q000379:methods; D014481:United States / Q000453:epidemiology