Lab Soft News: Lower Blood Transfusion Rates as a Metric for High Quality Care

Generally speaking, I think that the amount of blood transfused to a patient can and should be used as a metric for the quality of care delivered by physicians, particularly surgeons. I have long been aware of differences in transfusion rates by hospitals or by regions of the country. Much of this can be explained by local customs and norms rather than well defined standards of care. When I was a blood banker back in the 1970's, one of the hospital cardiac surgeons would frequently transfuse six units of blood for a CABG when type-and-screen was the common blood order for the same procedure at the Cleveland Clinic. Once again, or perhaps still, the amount of blood being transfused is in the news. (see: Too many blood transfusions? New standards urged). Below is an excerpt from a recent article. Not much new, at least for me, but worth emphasizing:

There's a lot of variation around the country in how quick doctors are to order up a few pints — not in cases of trauma or hemorrhage where infusing blood fast can be life-saving, but for a range of other reasons....Now a government advisory committee is calling for national standards on when a transfusion is needed — and how to conserve this precious resource. All the variability shows "there is both excessive and inappropriate use of blood transfusions in the U.S.," advisers to Health and Human Services Secretary Kathleen Sebelius concluded earlier this month. "Improvements in rational use of blood have lagged."....The U.S. uses a lot of blood, more than 14 million units of red blood cells a year. Between 1994 and 2008, blood use climbed 40 percent, [an expert] told the HHS Advisory Committee on Blood Safety and Availability. In many years, parts of the country experienced spot shortages as blood banks struggled to bring in enough donors to keep up....One study published last fall tracked more than 100,000 people who underwent open-heart surgery, a transfusion-heavy operation. Just 8 percent of those patients received transfusions at some hospitals, while a startling 93 percent did at other hospitals. But survival wasn't significantly different at hospitals that used more blood than at hospitals that used less....Overall, the U.S. uses about 49 units of blood for every 1,000 patients, substantially more than Canada or Britain where those transfusion rates are in the 30s....Consider Eastern Maine Medical Center. Transfusion chief Dr. Irwin Gross described how doctors now order blood via a computerized form that warns if they're about to deviate from the guidelines and tracks who uses the most.

I was instrumental in developing the maximum surgical blood order schedule (MSBOS) in 1976 (see: Hospitals Seek to Limit Blood Transfusions as a Cost-Saving Measure; Reducing Wastage of Blood and Blood Products in Hospitals) Here's a quote from the first of these two notes:

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.

If you are scheduled for an elective surgical procedure, ask the surgeon whether he or she agrees with the premise that better surgeons use less blood intra- and post-operatively. A follow-on question is to ask about his or her average blood use for the procedure and how it compares to peers. Regardless of the response, you will have made a key point.