During surgeries where a large amount of blood is lost, such as cardiac operations, patients usually are transfused when hemoglobin levels drop. It's become standard operating procedure.
But mounting evidence suggests that many transfusions are not necessary, are expensive, and can be dangerous.
Johns Hopkins Hospital in Baltimore, MD has found a wide variation in the use of transfusions and frequent use of transfused blood in patients who didn't need it, primarily because there is no consensus on guidelines, and many anesthesiologists (the members of surgery teams who usually perform transfusions) assume there is no harm in replacing lost blood.
According to the Centers for Disease Control, about 5 million patients account for an estimated 15 million transfusions. The American Red Cross estimates that a total of 30 million blood components are transfused each year in the U.S, with the average red blood cell transfusion being about three units (pints) .
The cost of blood is difficult to estimate because of the multiple steps involved in going from "vein to vein" (collecting, testing, storing, and transporting). One estimate pegs the figure at about $1,000 per unit of blood. The current national average price for a unit of red blood cells from the American Red Cross is approximately $217. The prices charged by hospitals varies by type of patient (e.g., private vs public) and reimbursement arrangements (e.g.,itemized vs bundled). Suffice it to say the hospitals seem to make a small profit when providing blood to private patients and lose money when doing so to public patients. In either case, the cost to patients also includes cost of administering the transfusion.
However, according to the Hopkins study and other investigations, transfused patients do no better -- and may do worse -- if given transfusions prematurely or unnecessarily. "Blood conservation is one of the few areas in medicine where outcomes can be improved, risk reduced and costs saved all at the same time," says Steven Frank, MD, who directed the Hopkins study, "In most cases it is better not to give a patient more blood than is needed." The exceptions include trauma and hemorrhage where infusing blood quickly can be lifesaving.
Typically, when a patient's hemoglobin level falls below six or seven grams per deciliter (14 is considered normal), a patient will benefit from a transfusion, and that if the levels are above 10, a patient does not need a transfusion. But when blood levels are in-between, there has been little agreement on what to do, although retrospective analyses confirms that physicians can safely wait until hemoglobin levels fall to seven or eight before transfusing, even in some of the sickest patients.
Blood transfusion, which introduces the equivalent of a foreign substance into the body, initiates a series of complex immune reactions. Patients often develop antibodies to transfused red blood cells making it more difficult to find a match if future transfusions are needed. Transfused blood also has a suppressive effect on the immune system, which increases the risk of infections and the body's (over) reaction to infection, called sepsis. Dr. Frank also cites a study showing a 42 percent increased risk of cancer recurrence in patients having cancer surgery who received transfusions.
Another issue is the quality of donated blood. Often chemicals in donated blood suppress the patient's immune system, making it harder to fight off infections. Also within hours of being collected, red blood cells stiffen up, making them less able to squeeze down narrow blood vessels and supply oxygen to vital organs.
In addition, a study published in the August 2015 issue of the New England Journal of Medicine found that patients who received blood that was more than two weeks old were almost 70 percent more likely to die within a year than patients who received fresher blood. This was the case whether the blood came from the patient or another donor.
Exacerbating the problem is that the supply of blood is dependent entirely on blood donors (it cannot be manufactured), and when donations decrease – usually during summer and winter months -- the reduced supply increases the costs of transfusions and limits the blood available for truly needy patients.
Also, blood is a perishable product. Red blood cells have a shelf life of only 42 days and platelets just five days, so they must be replenished constantly, making the judicious use of blood all the more imperative.
Clearly, the situation calls for significant change. In the absence of universally accepted guidelines, peer review becomes the default process. However, in most cases, peer review is either not used or, when it is, the findings often support existing practice, and when they don't, they are ignored.
Thus, external – not internal– peer review is needed. This is the opinion of David Jadwin, D.O. His solution is External Review as a Service (ERaaS™), developed by his Columbia Healthcare Analytics. According to Dr. Jadwin, "The advantage of EraaS™ over internal processes ls that physicians can study their case management in hindsight and learn how to better provide patient care, with blood use, diagnosis or any non-blood therapy, rather than just being told to do something different."
Peer review has waned in recent decades and it is difficult for physicians to perform peer review objectively of colleagues with who they have political, social and economic relationships. Says Dr. Jadwin, "The key to transforming health care – and blood use as one example – is to enable physicians to perform peer review in a blind, standardized manner for facilities other than their own, and provide case-based educational feedback to physicians whenever they might have provided better care. This strategy for a peer review network enables not only physicians to learn from their errors but many physicians to learn from the errors of other physicians and produce accelerated learning opportunities."
Dr. Jadwin also notes that "blood use generally depends upon the type of surgery. Most trauma-related surgery patients receive blood transfusions. There is a concerted attempt to minimize or not use blood for heart surgery and elective orthopedic surgery through "bloodless" techniques. Strategies can be employed to optimize patients prior to surgery, such as amply correcting pre-existing anemia. Also, using IV iron for anemic obstetrical patients may reduce the ultimate need for blood transfusions when heavy post-partum blood loss occurs."
Dr. Jadwin's position is supported by research conducted by Aryeh Shander, MD and his colleagues at Englewood (NJ) Hospital and Medical Center, which showed that 75 percent of all patients in hospitals were anemic. Phlebotomy – taking of blood samples – exacerbated the blood-condition of these patients and eventually required transfusions. Avoidable transfusions and the trouble they cause are what Dr. Shander calls the "quiet epidemic." For this reason, both the Joint Commission and the Patient Safety Movement have called for more judicious use of blood transfusions.
Thus far, ERaaS™ has been adopted or tested at 29 hospitals. Overall, the service has shown that 30 percent of or more of hospitals transfusions were found to be non-beneficial. At Marin County Hospital in Greenbrae, CA ERaaS™ reduced blood component use by 30 percent within 90 days saving the hospital more than $860,000 over four quarters in direct blood supply cost and several multiples of that amount in total patient care costs.
"This experience, " says Dr. Jadwin, "confirms that external review is the most effective way to reduce unnecessary and potential harmful transfusions. We are hopeful that the number of hospitals using this objective, culture-changing process will increase substantially in the near future."
Until better guidelines and external review are more widely adopted, to avoid unnecessary blood transfusions, Columbia Healthcare Analytics recommends that patients should:
1. Make sure anemia is identified and treated.
2. Get regular physician examinations and blood tests to make sure you have a normal, healthy hemoglobin level. Anemia (low hemoglobin) is a prevalent, pernicious health problem that often goes undetected and under treated.
3. If a patient has anemia, they should get a comprehensive laboratory and medical evaluation to determine the type and source of anemia.
4. If a patient has "iron deficiency"anemia, IV iron therapy may be more effective than traditional oral iron tablets, and IV iron therapy should be seriously considered.
5. If a patient is scheduled to have major surgery, seek treatment in a facility with an established patient blood management (bloodless surgery) program.
6. Select a surgeon with a low complication rate. ProPublica publishes complication data by surgeon and hospital for a number of surgical conditions.
7. Patients should have a detailed conversation with their physician about risks, benefits and alternatives to blood transfusion, and ensure that their physician understands that the patient wishes to have blood transfusions only when absolutely necessary (restrictive blood use), if at all.
The Cleveland Clinic also has this advice on blood transfusions:
Be sure you are off medicines that cause bleeding. Before surgery, you should temporarily stop medicines that cause bleeding, such as Coumadin® (warfarin). Aspirin tends to be well tolerated for most patients who are having first-time heart surgery, but with re-operative procedures, it may be best to stop medications that contain aspirin (those with drug caution code ASA). If you are taking new platelet inhibitors, be sure to talk to your doctor about stopping them many days before surgery to prevent bleeding.
Ask about surgical approach to reduce blood loss. There are other things that factor into having a blood transfusion that you should discuss with your surgeon. These are things that are done during heart surgery to reduce blood loss. The approach to surgery is important. We have found over the years, minimally invasive surgery causes less bleeding and chance for blood transfusion. In addition, meticulous surgical technique will result in less bleeding. Also, we return blood to patients that they lose during surgery. We collect the blood during surgery, which is sucked up into a special canister, washed of anything that may have gotten into the blood, and then returned to the patient.
Ask about limiting amount of blood taken for lab work. We noticed that some patients were becoming even more anemic after surgery because of the amount of blood taken during blood draws for lab work. So we have cut down on need for blood transfusions after surgery by limiting how much blood we take. We now use smaller blood draws and decrease the volume of blood taken from each patient.
Finally, patients should ask if they are candidates for bloodless surgery, where no blood products or transfusions are involved in the operation. This has become a growing alternative, prompted by objections by religious groups (e.g., Jehovah's Witness) and by fears of (HIV) contamination.
Ozga is president of Medical Business Exchange and author of "How Safe Is YOUR Hospital?"