Why Excessive Blood Transfusion Utilization is a Widespread Problem
Excessive transfusion utilization is a major, widespread problem associated with high rates of morbidity, mortality, and avoidable spending. But there are evidence-based restrictive guidelines and blood programs in place in some institutions that can change clinician patterns and generate significant clinical value.
The blood transfusion problem in the United States has been recognized for quite a long time. Dr. Aryeh Shandar, clinical professor of anesthesiology, medicine, and surgery at Mt. Sinai’s Icahn School of Medicine in New York, summarized it thus: “Blood transfusion is far riskier than what people believe, and is responsible for billions in wasted healthcare dollars every year.” A New England Journal of Medicine article in 1999 was the first to question the efficacy of blood transfusion, and there are now dozens of clinical trials in the literature that indicate that less is more in terms of saving lives and improving outcomes, as well as preventing wasted dollars.
“Blood transfusion is far riskier than what people believe, and is responsible for billions in wasted healthcare dollars every year.”
Despite that, there continues to be a problem in terms of adopting new guidelines. There is a wide variation in ordering transfusions, which is not uncommon in medicine. One study shows that it takes about 17 years in medicine for physicians to adopt new guidelines. Today’s practicing physicians were trained largely based on old guidelines, which indicated a more liberal transfusion trigger. New triggers relate to a hemoglobin (Hgb) of 7 or below. Before, Hgb of 8 – 12 was an acceptable trigger, depending on the setting. Also, the past guidelines indicated starting with two units of blood. Some physicians have these adopted newer guidelines; others have not. The harms that come from this go way beyond the classic transfusion reaction, which is why the costs are so enormous. Put all of this together, and what you have is a tremendous opportunity to drive adoption of these new programs and guidelines, and save lives, decrease harms, and generate savings.
Guideline adoption is still a monumental issue, but let’s quantify the problem. Recent data shows that almost half of transfusions are deemed inappropriate in the US. When we look at the morbidity and mortality impact of liberal transfusion, the risk of mortality when transfusion is not restricted is about 26% higher in the hospital. Total mortality — including after hospitalization — is 20% higher. The risk of rebleeding is 36% higher, and acute coronary syndrome is 56% higher for a patient who’s had a more liberal transfusion practice than a restrictive one. Similarly, pulmonary edema is 52% higher, and bacterial infections are 14% higher.
A study from The Advisory Board of 345 hospitals looking at hip and knee joint replacements shows the vast difference in these hospitals in what percentage of their patients they’re transfusing. It spans anywhere from 5% of patients to 100% of patients. And, The Advisory Board calculated that, on average, if a hospital tackled just the hip and knee joint replacement topic in terms of restrictive blood transfusion management, it could save $1 million a year. And that is not just the cost of the blood alone; that’s because of mortality, length of stay, and other adverse events.
To learn more, download “Advanced Lab Analytics for Patient Blood Management Programs“.