Hospitals Seek to Limit Blood Transfusions as a Cost-Saving Measure

In a previous life, I was a blood banker and, assisted by colleagues, named and helped to popularize the maximum surgical blood order schedule (MSBOS) in 1976 (see: The maximum surgical blood order schedule and surgical blood use in the United States; An analysis of surgical blood use in United States hospitals with application to the maximum surgical blood order schedule).  Simply put, the MSBOS is a list of the maximum number of units of blood that a surgeon can order pre-operatively to be crossmatched and stored in an operating room refrigerator prior to a surgical procedure.

The primary goal of the MSBOS is to reduce blood wastage. It achieves this goal in two ways. First of all, surgeons will sometimes transfuse crossmatched blood on-hand in the OR even in marginal cases. Secondly, crossmatched but untransfused blood returned to the blood bank has used up some of its valuable shelf life, thus reducing its intrinsic value.

The adoption of a MSBOS program two effects -- it increases the effective blood supply for those patients with a legitimate need for it and also reduces the cost of operating a hospital blood bank by reducing the discard rate for outdated blood. A recent article reinforced this point about how a reduction in blood transfusion can both cut hospital costs (see: Hospitals Seek to Limit Use of Transfusions: New Efforts to Recycle Blood and Treat Anemia Are Aimed at Cutting Costs and Risks). Below are excerpts from it with boldface emphasis mine:

Questions to ask your doctor or surgeon about blood transfusions.

Will I need a transfusion? If so, why?
What are the risks involved with blood trans fusions?
What are the risks if I choose to minimize or avoid blood transfusions?
Will I need iron, vitamins or medications to increase my blood count for this surgery?
If I do need a transfusion, how will it affect my recovery time?

(later in the same article)

The University of Pittsburgh Medical Center, which has 16 hospitals in Western Pennsylvania and spends about $122 million a year on its blood labs, began a program to lower blood use at its flagship Presbyterian Hospital in 2002. By 2005 the amount of blood provided per hospital admission dropped by 18%, resulting in savings of about $1.8 million a year, says Ed Corona, corporate director of laboratory services. He says the program is being adopted system-wide. Jonathan Waters, head of the UPMC's blood-management program and another co-chairman of the Joint Commission task force, says doctors sometimes fail to evaluate patients before surgery to detect any pre-operative anemia that could be treated with drugs or intravenous iron. He says about half of elderly joint-replacement patients are anemic and need a blood transfusion. "It's very simple to check a patient's hemoglobin level when they are scheduling surgery, but often surgeons don't do it," Dr. Waters says. "It requires a paradigm shift in how we practice medicine." Hemoglobin is responsible for transporting oxygen to organs.

Blood transfusion is the most common type of organ transplantation performed yearly in the United States. If I had the power to do so, I would require all surgeons to read the following statement to all patients preceding surgery:

During surgery, I may be forced to transfuse blood to you. There is a cost associated with blood transfusion, both in terms of the product and the possible transmission of various diseases to you. I will test you for anemia prior to surgery and will pre-operatively treat you with drugs or intavenous iron to reduce your need for blood transfusion. The body can also adapt physiologically to substantial blood loss so I probably will not need to transfuse you even after moderate blood loss.

The likelihood of such a specific discussion occurring between surgeon and patient is relatively small because most surgeons do not like to discuss operative complications in detail with patients. An appropriate substitute for such a discussion would be for the patient to ask the questions listed above pertaining to intra-operative and post-operative blood transfusion. This will draw the surgeon into a discussion of the issue and achieve the same goal.

Comments

[Mark Holland]

This is the perfect blog for anyone who wants to know about this topic. You know You definitely put a new spin on a subject thats been written about for years. Great stuff, just great!

[Mark Holland]

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[bev M.D.]

Bravo from another former blood banker! I well remember the days of arguing with an angry surgeon (or internist; the surgeons just yelled more) about when transfusions really were necessary. Keep waving the flag!