OBJECTIVES: Advances in total joint arthroplasty (TJA) blood management protocols over the past decade have resulted in a precipitous decline in the incidence of transfusion. However, these advances may not be proportionate – with certain institutions still having higher incidence of transfusion relative to their peers. This study examined whether these declines varied by procedure, patient, or hospitalization characteristics.

METHODS: This retrospective study used the Premier Perspective® hospital database (2010-2015). Patients selection criteria included: inpatient visit for primary total hip arthroplasty (P-THA), primary total knee arthroplasty (P-TKA), revision THA (R-THA) or revision TKA (R-TKA); aged 18+; no history of fracture; and no concurrent hip and knee procedures. Significance of time trends within cohorts were analyzed with the Cochran-Armitage Test.

RESULTS: A total of 314,779 P-THA patients, 605,702 P-TKA patients, 38,399 R-THA patients, and 54,144 R-TKA patients met selection criteria. Overall incidence of transfusion declined significantly between 2010 and 2015, from 22.1% to 7.1% for P-THA, 18.1% to 3.2% for P-TKA, 30.6% to 18.5% for R-THA, and 19.8% to 9.8% for R-TKA (all P<.001). The percent reduction from 2010 to 2015 varied by hospital size; larger hospitals (400+ beds) demonstrated greater improvements vs. small hospitals (0-199 beds). Percent reduction for large vs. small hospitals was 73.5% vs. 60.3% for P-THA; P-TKA: 85.0% vs. 80.5%; R-THA: 40.2% vs. 23.4%; and R-TKA: 54.3% vs. 37.5%, respectively. Transfusion incidence reductions observed in community hospitals were greater than academic centers for P-THA (70.4% vs. 64.1%), R-THA (45.4% vs. 33.2%), and R-TKA (51.1% vs. 49.6%); P-TKA was nearly equal (82.1% vs. 82.3%).

CONCLUSIONS: This study demonstrates that there was a considerable decline in TJA transfusion incidence between 2010 and 2015. However, these declines were not shared equally by procedure type, facility size, or academic status. While significant advances have been made, there remains a large opportunity for improvement.