What’s New in the Patient Safety World
June 2015
Economics and Blood Transfusion
Over the last decade
there has been increasing evidence of the potential harms associated with blood
transfusions. Transfusions have been associated with increased risk of infections,
SIRS (systemic inflammatory response syndrome), and other complications. While
clinical factors need to be considered in any decision about whether to
transfuse, use of a hemoglobin (Hb) threshold or
trigger is still commonly used. Studies have demonstrated that use of more
restrictive Hb triggers (8 g/dL)
do not adversely impact patient outcomes and this has been reflected in
multiple new guidelines regarding transfusion (see our April 2012 What’s New in
the Patient Safety World column “New
Transfusion Guidelines from the AABB”).
Now a new study from
Johns Hopkins (Ejaz 2015), which has been a leader in improving
transfusion practices (see our June 2013 What’s New in the Patient Safety World
column “Hopkins
Blood Ordering Initiative”), shows that substantial variation in
transfusion practices persists, with potentially inappropriate transfusion
practices leading to considerable consumption of resources. Ejaz
and colleagues looked at PRBC transfusions in patients undergoing major
abdominal surgery at Johns Hopkins over almost a 4-year period. They defined
“liberal” Hb trigger as transfusion of PRBCs for an
intraoperative Hb level of 10 g/dL
or greater or a postoperative Hb level of 8 g/dL or greater. Overall, they found that 11.4% of units
were transfused using a liberal trigger. They then calculated the estimated
costs of such “liberal” transfusions, using an acquisition cost of $220/unit
and an activity-based cost of $760/unit (the latter representing the mean cost
from another study that calculated the cumulative costs for each step involved
in delivering 1 unit of PRBC’s from a donor to a recipient, including
technical, administrative, and clinical costs). They estimated that the total
overall PRBC transfusion costs may have been reduced by $27,360 to $94,516 per
year by adhering to the more restrictive transfusion triggers.
Note that the current study only assessed the acquisition costs of the blood and the estimated costs involved in getting the blood to patients (technical, administrative, and clinical costs). It did not include any additional costs that might have resulted from complications of the transfusion (eg. surgical complications, infection, longer length of stay, etc.). Patients in their study who received transfusions had more perioperative complications and longer lengths of stay even after adjusting for multiple clinical variables. So, given what we know about the potential downsides of unnecessary transfusion, the costs in the current study may be an underestimate of the true total cost of unnecessary transfusion.
The Ejaz study also revealed that the use of “liberal” transfusion varied significantly by type of surgery and by individual surgeon. Significantly, of the 92 participating surgeons the 9 surgeons least compliant with their institutional guidelines accounted for 80% of the total overall estimated excess transfusion costs.
We’ll bet your organization has a similar opportunity to improve both patient outcomes and the financial bottom line by instituting the more restrictive transfusion guidelines and auditing adherence to them.
Prior columns on potential detrimental effects related to red blood cell transfusions:
- March 2011 “Downside of Transfusions in Surgery”
- February 2012 “More
Bad News on Transfusions”
- January 2012 “Need
for New Transfusion Criteria?”
- April 2012 “New
Transfusion Guidelines from the AABB”
- February 2013 “More
Evidence Favoring Restriction of Transfusions”
- June 2013 “Hopkins
Blood Ordering Initiative”
- May 2014 “Blood
Transfusion and Infection Risk”
References:
Ejaz A, Frank SM, Spolverato G, et al. Potential Economic Impact of Using a Restrictive Transfusion Trigger Among Patients Undergoing Major Abdominal Surgery. JAMA Surg 2015; Published online May 06, 2015
http://archsurg.jamanetwork.com/article.aspx?articleid=2277732
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