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AnemiaPhase 3FOCUSNCT00071032

Safety and Effectiveness of Two Blood Transfusion Strategies in Surgical Patients With Cardiovascular Disease

A Phase 3 study testing Liberal (10 g/dL) Transfusion Strategy and Restrictive (Symptomatic) Transfusion Strategy in people with Anemia and Hematologic Diseases, run by Rutgers, The State University of New Jersey at 1 site in United States.

Completed

Finished. The study has ended and is not enrolling. Results may be posted on the official record.

Official record
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Trial summary

The purpose of this study is to compare liberal red blood cell transfusion therapy with restrictive red blood cell transfusion therapy in surgical patients with cardiovascular disease or risk factors. Read more about this study

Who is it for?
Ages 50 years and older
What is being tested?
Liberal (10 g/dL) Transfusion Strategy and Restrictive (Symptomatic) Transfusion Strategy
Could I receive a placebo?
No, everyone receives an active treatment
How many people
2,016 participants
Where
1 siteUnited States
Study dates
Jul 2003to May 2009
Phase
Phase 3
Are there results?
Yes, posted in the registrySummary in the doctors' view

Key requirements

Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.

  • Ages 50 years and older
  • All sexes
  • No healthy volunteers
  • Adult, Older adult

Who may be able to join

  • Has undergone surgical repair for a hip fracture
  • Has a postoperative Hgb level below 10 g/dL within three days of surgery
  • Diagnosis of cardiovascular disease (e.g., coronary artery disease, congestive heart failure, stroke or transient ischemic attack, or peripheral vascular disease) or cardiovascular risk factors (e.g., diabetes mellitus, hypertension, hypercholesterolemia, tobacco use, or creatinine levels greater than 2.0 mg/dL)

Who cannot join

  • Unable to walk prior to hip fracture
  • Declines blood transfusions
  • Suffered multiple traumas
  • Pathologic fracture of the hip due to malignancy
  • Clinically recognized acute myocardial infarction within the 30 days prior to study entry
  • Previously participated in the trial and fractured the other hip
  • Symptoms associated with anemia (e.g., ischemic chest pain) or actively bleeding at the time of randomization

Trial locations and contacts

1 site in 1 country.

United States1 site
  • University Medicine & Dentistry of NJ

    New Brunswick, New Jersey, 08903

Other trials in United States

About this study

Official title: Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair (FOCUS)

The purpose of this study is to compare liberal red blood cell transfusion therapy with restrictive red blood cell transfusion therapy in surgical patients with cardiovascular disease or risk factors.

Read the detailed description

BACKGROUND:

Red blood cell transfusions are an extremely common medical intervention in both the United States and worldwide; over 14 million units of blood are transfused in the United States. Between 60 and 70 percent of all blood is transfused in the surgical setting. Despite the common use of red blood cell transfusions, the threshold for transfusion has not been adequately evaluated and is very controversial. A decade ago, the standard of care was to administer a peri-operative transfusion whenever the hemoglobin (Hgb) level fell below 10 g/dl (the "10/30 rule"). Concerns about the safety of blood, especially with respect to HIV and hepatitis, and the absence of data to support a 10 g/dl threshold led to the current standard of care, which is to administer blood transfusions based on the presence of symptoms, and not a specific Hgb/hematocrit level. However, there have not been any randomized clinical trials done with surgical patients that have tested the efficacy and safety of withholding blood until the patient develops symptoms, or the "10/30" approach to transfusion. Patients with underlying cardiovascular disease are at greatest risk of adverse effects from reduced Hgb levels.

DESIGN NARRATIVE:

This is a multi-center randomized trial to test the effectiveness of a transfusion strategy that maintains postoperative Hgb levels above 10 g/dl (liberal transfusion) in improving patient outcome. This will be compared to the restrictive (symptomatic) transfusion strategy in which blood transfusion is withheld until the patient develops symptoms of anemia or Hgb less than 8 g/dL. Participants will be randomly assigned to one of the two transfusion strategies. The liberal (10 g/dl) threshold strategy will use enough red blood cell units to maintain Hgb levels at or above 10 g/dl through hospital discharge. Restrictive (Symptomatic) transfusion strategy patients will receive red blood cell transfusions for symptoms of anemia, although transfusion is also permitted, but not required, if the Hgb level falls below 8 g/dl. Outcomes will include functional recovery (primary outcome: ability to walk 10 feet across a room without human assistance or death 60 days post-randomization), lower extremity activities of daily living and instrumental activities of daily living, survival up to 60-days and long-term, disposition (i.e., nursing home placement), and postoperative complications (e.g., myocardial infarction, unstable angina, or death in hospital, pneumonia, wound infection, thromboembolism, stroke).

Ambulation at 60 days is known to be highly predictive of ultimate functional outcome as well as of mortality at one year. Because inability to walk has such important implications for quality of life, and because it is a common problem, it far outweighs the small risk of viral infection or other complications from transfusion in elderly patients.

The trial will also evaluate the effect of transfusion threshold on postoperative risk of acute cardiac ischemia. The strategy will be to enhance surveillance for ischemic events by increasing the number of EKG and serum troponin measurements beyond those already called for in the original FOCUS protocol.

There is an ancillary study to the trial (R01 HL085706) to examine delirium as an outcome in a subsample of 139 patients. We will assess short-term (in hospital) and longer-term (after 30 days) severity of delirium.

Being tested
Liberal (10 g/dL) Transfusion Strategy, Restrictive (Symptomatic) Transfusion Strategy
Keywords
Blood Disease, blood transfusion
Medical subject headings
Anemia, Hematologic Diseases, Cardiovascular Diseases, Heart Diseases, Myocardial Infarction, Thromboembolism, Pneumonia, Stroke

What participants receive

What participants receive. In a randomised study each person is assigned to one group by chance.

  • Liberal (10 g/dL) Transfusion StrategyBiological

    This transfusion strategy will maintains postoperative Hgb levels above 10 g/dL. This threshold strategy will use enough red blood cell units to maintain Hgb levels at or above 10 g/dL through hospital discharge or up to 30 days after randomization.

  • Restrictive (Symptomatic) Transfusion StrategyBiological

    Transfusion is withheld until the patient develops symptoms from anemia (i.e., chest pain or ECG changes thought to be ischemic, congestive heart failure, unexplained tachycardia or hypotension unresponsive to fluids) or until the hemoglobin level falls below 8 g/dL. Transfusion is permitted, but is not mandatory, if the hemoglobin level falls below 8 g/dL.

Study groups in NCT00071032
Study groupRoleWhat they receive
Liberal (10 g/dL) Transfusion StrategyExperimentalTransfusion strategy that maintains postoperative Hgb levels above 10 g/dL.
Receives: Biological: Liberal (10 g/dL) Transfusion Strategy
2Active comparatorSymptomatic transfusion strategy, a more conservative strategy, in which blood transfusion is withheld until the patient develops symptoms of anemia.
Receives: Biological: Restrictive (Symptomatic) Transfusion Strategy

What is being measured

The primary outcome is the main question the study is designed to answer.

  1. Inability to Walk 10 Feet or Across a Room Without Human Assistance or Death

    ascertained via telephone follow-up

    Measured: 60 days after randomization

Secondary outcomes (15)
  1. Myocardial Infarction, Unstable Angina, or Death for Any Reason

    Measured: In-hospital

  2. Mortality at 30 Days

    Measured: 30 days

  3. Mortality at 60 Days

    Measured: 60 Days

  4. Composite Outcomes (a) Death, Myocardial Infarction, or Pneumonia and b) Death, Myocardial Infarction, Pneumonia, Thromboembolism, or Stroke

    Measured: In-hospital

  5. Myocardial Infarction

    Measured: In-hospital

  6. Postoperative Complications (e.g., Wound Infection, Thromboembolism, Stroke)

    Measured: In hospital

  7. Disposition Status (i.e., Nursing Home Placement)

    Nursing Home Residence

    Measured: 60 days

  8. Function - Lower Extremity Activities of Daily Living,at 30 Days

    Using the Functional Status Index, score range 0 to 11, higher scores indicate greater dependency

    Measured: 30 days

  9. Function - Instrumental Activities of Daily Living, at 30 Days

    Using the Older Americans Resources and Services Functional Assessment Questionnaire, score range from 0 to 4, higher scores indicating greater dependency

    Measured: 30 days

  10. Function - Fatigue/Energy, at 30 Days

    Using the Functional Assessment of Chronic Illnesses Therapy-Fatigue, score range from 0 to 52, higher scores indicating greater level of energy

    Measured: 30 days

  11. Function - Lower Extremity Activities of Daily Living. at 60 Days

    Scale range 0 to 11, higher scores indicate greater dependency

    Measured: 60 Days

  12. Function - Instrumental Activities of Daily Living, at 60 Days

    Scale range 0 to 11, higher scores indicate greater dependency

    Measured: 60 Days

  13. Function - Fatigue/Energy, at 60 Days

    Scale ranging from 0 to 52, higher scores indicating greater level of energy

    Measured: 60 Days

  14. Length of Stay in Hospital for United States Participants

    Measured: Days from randomization to discharge

  15. Length of Stay in Hospital for Canadian Participants

    Measured: Days from randomization to discharge

Timeline

From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.

  1. First posted13 Oct 2003 (estimated)
  2. Study startJul 2003
  3. Primary completionMay 2009
  4. Study completionMay 2009

Resources

More details

For doctors and researchers: how the study is designed, who runs it, and its registry IDs.

Study design
Study type
Interventional
Phase
Phase 3
Primary purpose
Treatment
Allocation
Randomised
Intervention model
Parallel groups
Masking
Single blind
Who is masked
Outcomes assessor
Enrolment
2,016 participants (actual)
IDs, dates and publications
ClinicalTrials.gov ID
NCT00071032
Sponsor's protocol ID
159
Other IDs
U01HL073958-06, U01HL073958, U01HL074815
Acronym
FOCUS
Status last verified
Oct 2020
First submitted
9 Oct 2003
Last updated
16 Nov 2020
Data monitoring committee
Yes

Publications

  • Carson JL, Terrin ML, Magaziner J, Chaitman BR, Apple FS, Heck DA, Sanders D; FOCUS Investigators. Transfusion trigger trial for functional outcomes in cardiovascular patients undergoing surgical hip fracture repair (FOCUS). Transfusion. 2006 Dec;46(12):2192-206. doi: 10.1111/j.1537-2995.2006.01056.x. No abstract available.

    PubMed 17176334
  • Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, Nemo G, Dragert K, Beaupre L, Hildebrand K, Macaulay W, Lewis C, Cook DR, Dobbin G, Zakriya KJ, Apple FS, Horney RA, Magaziner J; FOCUS Investigators. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011 Dec 29;365(26):2453-62. doi: 10.1056/NEJMoa1012452. Epub 2011 Dec 14.

    PubMed 22168590
  • Carson JL, Stanworth SJ, Dennis JA, Fergusson DA, Pagano MB, Roubinian NH, Turgeon AF, Valentine S, Trivella M, Doree C, Hebert PC. Transfusion thresholds and other strategies for guiding red blood cell transfusion. Cochrane Database Syst Rev. 2025 Oct 20;10(10):CD002042. doi: 10.1002/14651858.CD002042.pub6.

    PubMed 41114449
  • Zhang J, Chen Z, He Y. Comparison of liberal versus restrictive transfusion strategies after hip surgery in patients with coronary artery disease: a post hoc analysis of the FOCUS trial. BMC Cardiovasc Disord. 2024 Sep 18;24(1):498. doi: 10.1186/s12872-024-04151-z.

    PubMed 39294606
  • Meng L, Wang X, Carson JL, Schlussel Y, Shapses SA. Vitamin D Binding Protein and Postsurgical Outcomes and Tissue Injury Markers After Hip Fracture: A Prospective Study. J Clin Endocrinol Metab. 2023 Dec 21;109(1):e18-e24. doi: 10.1210/clinem/dgad502.

    PubMed 37633261
  • Carson JL, Stanworth SJ, Dennis JA, Trivella M, Roubinian N, Fergusson DA, Triulzi D, Doree C, Hebert PC. Transfusion thresholds for guiding red blood cell transfusion. Cochrane Database Syst Rev. 2021 Dec 21;12(12):CD002042. doi: 10.1002/14651858.CD002042.pub5.

    PubMed 34932836
  • Carson JL, Sieber F, Cook DR, Hoover DR, Noveck H, Chaitman BR, Fleisher L, Beaupre L, Macaulay W, Rhoads GG, Paris B, Zagorin A, Sanders DW, Zakriya KJ, Magaziner J. Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial. Lancet. 2015 Mar 28;385(9974):1183-9. doi: 10.1016/S0140-6736(14)62286-8. Epub 2014 Dec 9.

    PubMed 25499165

Questions about this trial

What is this clinical trial studying?

A Phase 3 study testing Liberal (10 g/dL) Transfusion Strategy and Restrictive (Symptomatic) Transfusion Strategy in people with Anemia and Hematologic Diseases, run by Rutgers, The State University of New Jersey at 1 site in United States.

The full registered description is in the About this study section and the official record.

Who may be eligible to take part?

The sponsor lists 3 inclusion and 7 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.

Is this clinical trial currently recruiting?

The record says: finished, as of the sponsor's last update on 16 Nov 2020. Status can change between updates, so confirm with the study contact before making plans.

Where is the study taking place?

The record lists 1 site in United States. Whether a site is taking part right now should be confirmed with that site. See every site.

What are the possible benefits and risks?

They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.

What does this phase mean?

Phase 3 studies compare the treatment with the current standard treatment or a placebo in a large group, to confirm how well it works and watch for side effects.

Not every study follows the same path, and some studies (observational studies, device studies) have no phase.

Are results available for this study?

Yes. Results are posted in the registry (first posted 28 Aug 2014). A summary is in the For doctors view, and the full results are on ClinicalTrials.gov.

How can a doctor refer a patient or contact the research team?

The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.

What does the primary outcome measure?

Inability to Walk 10 Feet or Across a Room Without Human Assistance or Death (time frame: 60 days after randomization). It is what the study was designed to measure, not a finding.

Where can I read the original study information?

On the ClinicalTrials.gov record for NCT00071032, which also lists 7 linked publications.

Does a listing mean the treatment is approved or proven to work?

No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.

How often is this information updated?

AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 16 Nov 2020.

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