Hospitals can do a lot to reduce how much blood their surgeons use for transfusions, especially since blood products are scarce, carry risk of adverse events and are extremely costly, says the fall edition of Economic Outlook, a report by the hospital purchasing and quality alliance, Premier.
Premier looked at 7.4 million case-mix adjusted patients with common DRGs discharged from 464 hospitals over four years. Its analysts did the math and found an enormous variation among hospitals across the country.
It also realized that if all 464 hospitals in the Premier study instituted blood utilization practices similar to those hospitals in the top 25%, they could save $165 million annually in blood purchasing costs, and avoid using 802,716 units without changing patient outcomes.
And that's just in the top 10 patient diagnoses, excluding avoided costs of testing, storage, transportation, administration and the increased cost of care when patients' adverse reactions to blood units require longer lengths of stay.
They also would avoid an uncertain number of unintended consequences that occur when patients develop serious adverse reactions to transfused blood.
Premier is expected to announce its findings in a press briefing in New York Tuesday.
"Blood utilization represents the eighth highest savings opportunity for hospitals, a savings of about $1.06 million per hospital per year," Premier says.
The Premier analysis, which the organization says is unique, found that the biggest savings were found in patients with septicemia, followed closely by those undergoing major joint replacement or reattachment surgeries, those having cardiac valve and other major cardiac procedures, and patients with infections.
To a lesser extent, blood use could be avoided in patients who were being treated for gastrointestinal hemorrhage, and infections.
Different Set of Protocols
Five years ago, Bon Secours Healthcare System, based in Marriottsville, MD, realized it might be spending too much on blood products after comparing its use and cost with that of other hospitals in the Premier system.
Drilling down, it explored transfusion practices just among 12 heart surgeons, who practice at Bon Secours hospitals in New York, Kentucky, Maryland, South Carolina, and Virginia.
Because each surgeon had a different set of protocols, there was a wide variation in the volume, thresholds, and frequency of use of blood from one surgeon to the next, says Marlon Priest, MD, the system's executive vice president and chief medical officer.
Why do doctors specializing in heart surgery all work under different rules?
"We trained at various periods of time. We all have our own practices and local facilities all have their own cultures," Priest says. "By creating a conversation among the five programs, we can step back and ask the question: Why is my blood utilization different than yours for the same type of patient?' "
"So we asked our physicians who took care of these patients to make a difference in the best interests of the patient," he says. "We said, let's look at data and outcomes and see if we can't find what's in the literature to use this precious commodity better.
After four years of implementing best practices in transfusion medicine, Priest says, Bon Secours' surgeons were able to reduce the need for blood from an average of 6.2 units per heart surgery patient to 2.2 units. Since each unit costs about $1,100 to administer, that's an average saving of $4,400 per patient.
Priest says this saving was achieved largely because surgeons were less likely to transfuse certain low-risk patients than they were before. But additionally, more patients were transfused with less blood.
"The surgeons became more comfortable that they could safely transfuse patients to a lower level (of hemoglobin or hematocrit) than they once were," Priest says.
By Premier's analysis, administering blood transfusions is the single most commonly billed procedure hospitals provide, with 15 million blood product transfusions each year, at a cost of $10 billion to $15 billion.
Part of the reason for such wide variation is the lack of universally agreed guidelines for when surgeons should transfuse. Different professional organizations recommend different protocols, and policies differ on the use of presurgical erythropoietin, a drug that can stimulate the growth of red blood cells in hope of avoiding the need for a transfusion.
Premier recommends that hospitals initiate six practices to lower the use of blood:
1. Use of a multi-disciplinary blood stewardship team
2. Collaboration with clinicians and supply chain executives to find alternative products and procedures
3. Implementation evidence-based transfusion guidelines
4. Education and clinical decision support to inform clinicians of guidelines in real time
5. Development of processes to monitor adherence to guidelines and provide
feedback to clinicians
6. Monitoring and measuring the impact of improvement
Premier's efforts to get hospitals to use less blood is one of several campaigns to reduce the use of blood. Another, the "Hemovigilance Module," is a joint effort of the American Association of Blood Banks, and the Centers for Disease Control and Prevention.
Increasingly, researchers are finding that even practices instituted by surgeons for Jehovah's Witness patients, whose religion prohibits any transfusion, do not carry such serious risks previously believed.