Taming the Blood Beast With Better Utilization

Rapid yearly increases in blood product cost motivates hospital labs to educate physicians

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CEO SUMMARY: For hospital labs, explosive increases in the cost of blood products is a budget buster. At St. Vincent Indianapolis Hospital, a multi-year blood management program is paying big dividends. Patient safety has improved, even as utilization of blood dropped by 7,000 units per year. Annual savings from this innovative blood management program now total $4 million. One key element behind this success was for the lab to engage and educate physicians in a multi-disciplinary approach.

BURNING A BIG HOLE IN THE BUDGETS of hospital laboratories across the nation are the costs of transfusion services and blood banking.

Hospital and health system laboratories are facing a perfect storm of rising expenses. Over the past decade, each year brought hefty price increases for blood products. At the same time, labs were expected to intensify management of transfusion services and the blood bank, with the goal of improving patient safety and reducing unnecessary use of blood products.

Blood Product Management

“It’s no surprise that blood products and transfusion services are becoming management priorities for hospital laboratories,” stated anesthesiologist Timothy Hannon, M.D., MBA, Medical Director of the Blood Management Program at St. Vincent Indianapolis Hospital in Indianapolis, Indiana. He is also President and CEO of Strategic Healthcare Group LLC, a blood management consulting firm.

“For the moment, set aside the huge costs associated with the use of blood products,” continued Hannon. “New research and ongoing studies provide a powerful case in favor of much tighter guidelines for use of blood products by physicians.

“There are two primary aspects to the blood product management challenges facing hospital labs today,” observed Hannon. “First, a significant portion of the blood units used in treatment today are likely wasted because many physicians do not understand the current clinical practices which govern how many units to have on hand, and how they should be administered to the patient during treatment. Beyond this knowledge gap, most hospitals don’t have a workable surgical blood ordering schedule.

“Every pathologist is familiar with the situation of certain physicians who regularly order too many units,” he said. “After surgery, it is not possible to put those unused units back into the blood bank. This is pure waste of an expensive and life-sustaining product.

“Second, clinical practices associated with the use of blood products are evolving rapidly,” explained Hannon. “On the plus side, this new knowledge allows us to be more evidence-based when treating patients. The benefit is improved out- comes for the patient with fewer instances of negative or harmful consequences associated with the administration of blood products to the patient.

“However, this good news comes with a challenge for pathologists and laboratory scientists,” added Hannon. “Many physicians are unaware of these changing standards in clinical practice. It often falls to the laboratory to take a lead role in educating physicians about current standards of practice, which are much more conservative than in the past.”

“Third, national data indicates a wide variation in practice,” he noted. “This is true for different regions of the United States. It is also true of the individual physicians within a single hospital or health system.

“This variation was demonstrated in a report published in Anesthesiology in 1998,” he said. “Blood use in primary coronary artery bypass grafts (CABG) was studied in 24 hospitals. It was determined that 92% of CABG patients received blood at one of the study hospitals, while only 27% of CABG patients received blood at another hospital.

Four-Fold Difference

“Primary CABG is first-time heart surgery,” explained Hannon. “It is basically the same surgery, whether it is performed in San Diego or Indianapolis or New York. Yet, there is a four-fold difference in transfusion rates!

“What’s even more disturbing to me as a physician is that—within an institution— there is also wide variation in practice, with some physicians being very liberal, others being very conservative,” he said.

Hannon noted that a 10-year follow up study in 2008, published in Transfusion, showed even wider variations in red blood cell usage in cardiac surgery among 16 developed countries. Usage rates ranged from about 10% to 100%.

“That degree of variation in what should be a fairly standardized practice is symptomatic of a poorly-controlled process,” observed Hannon, who then pointed out that the variation is not just in cardiac surgery. Studies of blood use done in other fields, such as orthopedics, trauma, and oncology, have found equally broad variations in practice.

“There is another interesting phenomenon,” commented Hannon. “During the past 10 years, blood use has increased in the United States, while blood use has stabilized or even dropped in most other developed countries. Currently, blood use in the U.S. is 15% percent higher than use in Europe and 44% higher than in Canada on a per capita basis.”

Change In Blood Use

Hannon also called attention to the fact that transfusion has shifted to a different set of patients. “At my hospital, St. Vincent’s, in 2001 our number one consumer of blood products was cardiac surgery. It used almost 35% of our blood, with oncology using 22%.

“Today, in 2010, those numbers have flipped,” he noted. “Our number one user of blood is oncology, while cardiac surgery is a distant second. Primarily, this change is due to our intense and ongoing efforts in recent years to encourage better blood conservation in surgical patients, along with the increasing use of blood products in medical and oncology therapy.

“For labs, it means that blood management efforts cannot focus exclusively on the peri-operative area,” Hannon said. “There must be strategies for both surgical and medical patients, along with the outpatients. At our hospital, 20-25% of transfusions are now given to outpatients, meaning this is another target-rich opportunity.”

Frequent Complications

Hannon noted that over-use of blood is related to the perception of physicians that blood transfusions are safe and have few side effects. “While the chances for infectious viral transmission are low—about 1 in 2 million—other non-infectious complications occur much more frequently,” he stated.

As an example, Hannon referred to a 1999 study in Transfusion which found that, as the number of units of blood given increases, the risk for pneumonia and serious bacterial infections also increases.

Length Of Blood Storage

“Some of these complications are associated with the length of blood storage, since ‘older blood’ has been associated with poorer outcomes,” he explained. “The threshold for increased risk of complications appears to come from blood stored longer than 14 days, although the evidence to date is not definitive and formal studies are just being constructed.”

For pathologists and laboratory administrators who are ready to tackle the twin challenges of increased cost of blood products and variation in practice within their hospital or health system, Hannon has advice based on the successful blood management program at 747-bed St. Vincent Indianapolis, which he designed and implemented.

“Since launching our blood management program in 2001,” recalled Hannon. “we’ve achieved a 30% sustainable reduction in hospital transfusions. That means we use 7,000 fewer units of blood each year and that generates $4 million in savings annually at our hospital!

Appropriate Blood Use

“An effective blood management program needs to address two issues,” he offered. “One issue is how we decide to give blood to an individual patient. The second issue is to reduce the number of patients who are transfused in the hospital through proactive management strategies, since we know that the greater the number of units of blood, the greater the total cost of care and the greater risk of transfusion-related complications.

“Frankly, I don’t care if my hospital uses more blood than another hospital, as long as the blood is used wisely, appropriately, and in an evidence-based manner,” he said. “The heart of stewardship of this community resource is appropriate utilization. Unfortunately, the current practice habits of many physicians means that the deck is stacked against appropriate use.”

Hannon’s consulting firm, Strategic Healthcare Group, has reviewed more than 3,000 patient charts in a number of hospitals over the past three years. “Our composite score for appropriate use of blood products for all of those hospitals is about 50%,” he stated. “This evidence supports my argument that, any time a unit leaves the hospital blood bank, it’s a coin-toss as to whether the decision to use that blood is appropriate.”

Other studies of blood product use confirm Hannon’s observation. Similar or even worse results were identified when hospitals were audited for the appropriateness of blood use. An audit of routine transfusion orders at Brigham and Women’s Hospital in Boston found that 73% of orders were inappropriate. Another recent audit of two New York City hospitals showed 62% of transfusion orders were inappropriate.

Overuse Of Blood

“Don’t forget that, beyond the patient safety aspect, such overuse of blood has serious consequences for local blood sup- plies as well as for a hospital’s bottom line,” commented Hannon.

Hannon advises that hospital laboratories need to understand the total costs associated with the use of each unit of blood. “The purchase price of the blood used in a transfusion is only one portion of the overall cost,” he stated. “The cost skyrockets when you factor in staff time used for ordering blood, managing blood storage, administering and documenting transfusions, and treating adverse effects.

“Typically, a $220 unit of blood costs about $2,100 to administer,” noted Hannon. “This is why better blood management translates into better patient safety and substantially lower costs.

“In fact, it is reasonable for any hospital to see a 10% to 30% savings in the cost of transfusion services and blood products during the first year of a concentrated program to improve utilization,” he added. “These savings come in tandem with improvements in patient outcomes and patient safety as physicians use blood products more appropriately.”

Based on the 10-year experience with the blood management program at St. Vincent Hospital, as well as direct experience with 40 other hospitals and health systems, Hannon has several recommendations on how to organize a blood utilization improvement program.

Educating Physicians

“Education is the cornerstone of the improvement program,” Hannon noted. “Physicians and everyone on staff need up-to-date education on the current risks, benefits, and alternatives to allogeneic transfusions. Use of evidence-based guidelines is another important element. Clinicians understand the importance of following these standards of practice.

“One of the most effective vehicles for orchestrating change is to organize a representative multi-disciplinary blood utilization committee within the hospital,” he went on. “This group should be given the authority to exercise oversight over utilization of blood products. It can also be the catalyst for identifying best practices and introducing these into use.

“In conjunction with these activities, it is important to build active patient safety systems involving blood component therapy,” Hannon commented. “One effective way to improve patient safety is to create cross-functional teams of laboratory and clinical staff to improve the quality, efficiency and safety of transfusion practices.

“Among other things, these cross-functional teams should review work flow and work processes to identify and address sources of waste and errors,” he added. “All of these activities improve the stewardship of the community blood supply.”

The multi-year success at St. Vincent Indianapolis Hospital at improving physician utilization of blood products, along with the substantial cost savings, provides other hospital laboratories with a useful road map on how to achieve similar improvements within their own organization.

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Studies on Blood Use Reveal Positive and Negative Results

CURRENT STUDIES INDICATE THAT a significant portion of blood products are likely wasted, doing little good for the patients who receive them and, in some cases, creating harm.

A landmark study published in the New England Journal of Medicine (JAMA) in 1999, “Transfusion Requirements in Critical Care,” compared liberal and restrictive approaches to transfusion in critically ill patients. The researchers randomly assigned 418 patients to a restrictive strategy, in which red cells were transfused if the hemoglobin concentration dropped below 7.0 g per deciliter, and 420 patients to a liberal strategy, in which transfusions were given when the hemoglobin concentration fell below 10.0 g per deciliter.

Outcomes for the two groups were not significantly different. But in one sub-group— those who were under 50 years of age and less acutely ill—less blood transfused was associated with significantly lower death rates at 30 days.

The restrictive strategy also decreased the average number of red-cell units transfused by 54%, saving a significant amount of blood as well as other valuable resources. The study concluded, “A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction and unstable angina.”

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