Avoidable Blood Use Bleeding Hospitals Dry

In an era of bloodless medicine and bloodless surgery, hospitals are using increasing amounts of blood, or certainly not using less blood. The Society of Thoracic Surgeons (STS) tracks an ever growing list of clinical metrics from open heart surgery patients. The STS data set reveals that patients who undergo relatively bloodless open heart procedures have better outcomes and lower mortality rates. ICU patients maintained at hemoglobin levels of 7 gm/dL have similar outcomes to those maintained at 10 gm/ dL, yet have length of stays one day less.However, virtually all hospitals have been unable to promote anemic blood use.

Bloodless centers, numbering less than 5 percent of American hospitals, treat many patients such as Jehovah’s Witness patients with practically no blood. Patients with pre-existing anemia and coagulopathy are often treated without blood transfusion prior to or during surgery, when only a few years ago none of these patients would have been considered surgical candidates without transfusion. Yet even some bloodless programs admit that blood use by non-bloodless physicians in their own facilities is unnecessary.

Why is blood use so pervasive in American health care when evidence points to so many harmful effects? Increased myocardial injury, congestive heart failure, immune suppression, respiratory failure and a host of other conditions alongside traditional infectious risks have all been reported. Perhaps our cultural perception that “Blood Saves Lives” is responsible. “The doctors are doing everything for Mom. They are even giving her blood,” is frequently heard.

No simple cause or solution may be found. In an era when 30 to 50 percent of blood transfusions are likely unnecessary, physicians have little awareness of modern transfusion principles. They practice from rote memory or fear of the unknown, using archaic rules. Such rules are frequently passed along through misguided mentorship devoid of objective data pointing to rational practice.

A major problem has been that double-blind randomized prospective controlled studies demonstrating best transfusion medicine practices are very difficult to construct. Evidence that blood transfusions are not good for patients is mounting and it would be easy to speculate that if blood were a new drug, it would not be approved by the FDA.

Fortunately advancements in blood component substitutes continue, so that one day many cases treated by transfusion may be managed by pharmacologic means. Recombinant Factor VII (Novo-7), costing several thousand dollars per dose, is just one such example of pharmacotherapy. While the cost of such agents appears superficially extreme, the ability to heal patients more rapidly makes such costs rational when the total cost of patient care is considered.

Currently 60 to 80 percent of patients receiving blood transfusion receive at least one unit of medically unnecessary blood; many receive multiple units of non-beneficial blood. When total costs are factored in, including therapy for untoward events and extended length of stay, a unit of blood costs $1500 per unit, not just the $250 or more to purchase the unit, while unnecessary blood use may lead to thousands of dollars in avoidable patient care costs per patient.

Unnecessary and even inappropriate blood use likely stems from multiple other factors, including failure of adequate peer review by the transfusion committee. Most hospitals report that transfusion review processes rarely find instances of inappropriate blood use even though a major portion of blood use is non-beneficial. There are multiple causes for the failure to recognize or report unnecessary blood use and each hospital should search out solutions to this problem. One answer is to perform objective external chart review on redacted chart documents in a standardized manner so that each hospital chart, each physician and each hospital is comprehensively evaluated in a standardized process applied universally across the nation. The capacity to review all hospital records exists and the prospect of reviewing health care records redacted of identifying information holds the promise of eliminating internal reviewer bias and other shortcomings of internal utilization and medical peer review.