CORR Insights®: Minorities Are Less Likely to Receive Autologous Blood Transfusion for Major Elective Orthopaedic Surgery

Where Are We Now? Menendez and Ring performed a retrospective cross-sectional analysis of the Nationwide Inpatient Sample database and found that black, Hispanic, uninsured, publicly insured, and low- to medium-income patients were less likely to receive autologous blood transfusion for major elective orthopaedic surgery than white, insured, and higher-income patients. When controlled for insurance and income levels, racial minorities still tended to have lower use of autologous blood for elective orthopaedic surgery. This observation supports the findings of an earlier study by Segal et al. [14] who also noted socio-demographic disparities in the use of autologous blood. This manuscript brings to light two topics of interest: (1) The appropriate use of autologous blood donation for elective orthopedic surgery, and (2) racial, ethnical, and socioeconomic disparities in the delivery of health care. Although presurgical autologous blood donation was first advocated in 1937 [4], its use did not peak until the early 1990s in response to the knowledge that the HIV virus could be transmitted through allogenic blood. There has since been a steady decline in the use of preoperative autologous donation related to the increased safety of allogenic blood, concerns for cost-effectiveness, large percentage of wastage, and evidence that despite decreasing allogenic transfusion rates, there is an overall increase exposure to all red cell transfusions [2, 6]. However, there are still concerns with allogeneic blood including hemolytic, febrile, or allergic reactions, alloimmunization, increased infection rates, and depletion of allogeneic blood supplies [5, 15]. Discrepancies in the delivery of health care are well documented including regional variations and differences related to racial, ethnic, and socioeconomic status [1, 8-10]. Barriers to equalizing health care delivery can be attributed to patient factors such as language barriers, health literacy, access (related to costs, transportation, or time commitments), cultural or religious beliefs, or distrust in health care providers. As health care providers, we try to exemplify unbiased treatment for all patients. However, we also have barriers related to time constraints and system resources that may alter our ability to provide equal care. For example, discussions related to blood management options may be shortened for patients requiring translation services and less detailed for patients with decreased health literacy. There is conflicting evidence regarding racial differences in patient-physician communications related to biomedical issues or rapport-building dialogue [7, 12]. Therefore, the reasons for disparities in health care remain unclear, and some research suggests they are not solely explained by differences in health care access, clinical need, or differences in communication. Where Do We Need To Go? Evidence-based, cost-effective, and unbiased delivery of health care should be our ultimate goal. Reaching these goals requires answering these two basic questions: 1) What racial differences led to the inequality of autologous blood transfusion for major elective orthopedic surgery and 2) Is this discrepancy related to under use of autologous blood donation by minorities or overuse by nonminorities? To help answer these questions, there needs to be further clarification on the appropriate use of autologous blood donation and on racial differences in health care decision making. Menendez and Ring were able to show the association between insurance, income and racial class and autologous blood use but could not establish cause. Therefore, further research into the racial and cultural aspects of autologous blood donation is warranted. Autologous blood donation still has utility for elective orthopedic procedures but algorithms vary on their recommendation of blood management strategies. For example, predonation of autologous blood has been recommended if the risk of blood transfusion is greater than 10% to 50% [3, 11]. However, transfusion rates for THA vary from 2% to 70% [5]. With variable recommendations for procedures with variable blood loss, standardization is difficult. How Do We Get There? The topic of discrepancies in the delivery of health care is, appropriately, a focus of more and more research. Large databases help to identify and answer important questions; the next step is to design future studies to answer these questions. These studies ideally will be prospective clinical trials incorporating population surveys or examinations of the physician-patient interaction to further address health care disparities in the use of autologous blood donation. As new evidence is revealed, we will need to assimilate it into our practices. We also need to focus on culturally and racially sensitive approaches to improving the health literacy of our patients, and on well-designed decision-making tools that take into account important differences in the values espoused by the diverse patient populations we treat. Healthcare providers will need to be not only educated in technical advances, but also informed of the racial and cultural preferences concerning the acceptance of new technology. Incorporating these new decision-making tools into the electronic medical record will further help improve their consistency of use.