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Multifacility blood transfusion management program led to $2 million in annual savings
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A 5-year effort to reduce the number of unnecessary blood transfusions across Johns Hopkins Health System led to an annual cost savings of more than $2 million.
Blood transfusions are one of the top five overused procedures and is the most common procedure performed across U.S. hospitals, according to the Joint Commission, a nonprofit organization that accredits health care organizations and programs in the United States.
Consequently, blood transfusions have been a target of initiatives such as the American Board of Internal Medicine’s Choosing Wisely campaign, designed to reduce use of treatments, tests and procedures that are often performed but may not always be necessary.
Although blood management programs have become more popular, methods for implementation across multi-institution health systems are not well understood.
Steven M. Frank, MD, professor in the department of anesthesiology and critical care medicine and director of Johns Hopkins Health System’s blood management program, and colleagues assessed the effects of a blood management clinical community program across five Johns Hopkins Health System hospitals.
The researchers compared changes in transfusion practice and blood acquisition costs for the pre- and postpatient blood management time periods. They observed an overall annual blood acquisition cost savings of more than $2.1 million — a 400% return on investment.
“At the start of the new [patient blood management] program, the five adult hospitals that comprise the Johns Hopkins Health System spent nearly $30 million annually for blood — an amount that did not include overhead costs of collection, storage and administrative expenses,” Frank said in a press release. “Those costs alone can increase the blood costs three- or fourfold. Hospitals across the country are merging into health systems in part to realize economies of scale by improving quality. Our experience with a patient blood management program shows that it is feasible to do just that.”
HemOnc Today spoke with Frank about how this effort came about, its success so far and the cost savings the institution has realized.
Question: What prompted this effort?
Answer: Patient blood management has developed during the past decade primarily based on eight landmark studies showing that we can give patients less blood and they do just as well. These landmark studies — all of which were published in The New England Journal of Medicine and JAMA — offer evidence that ‘less is more’ when it comes to transfusion.
Q: Can you describe the success you observed so far?
A: The new patient blood management program launched in January 2012 at The Johns Hopkins Hospital. Over a 5-year period, we reduced red blood cell utilization by 20%, plasma use by 39% and platelet use by 15%. The blood savings and cost savings have been substantial. In the 2017 fiscal year, we had our best results to date. We reduced our annual blood spend by about 10%, translating to an annual savings of more than $2 million. Some people do not recognize that blood is either poorly reimbursed or not reimbursed because, most often, hospitals are paid by bundled diagnosis-related group (DRG) payments rather than by line item therapy that we give to the patient.
Q: Can you speculate why so many providers were not familiar with the eight landmark studies on this topic or the recommended best practices?
A: Half of these eight landmark studies came out in the past 5 years, and it takes at least a decade for new evidence to be implemented into practice. The other issue with blood is that we are told all the time to ‘donate blood, save a life.’ This leads some to think that giving more blood is better. As it turns out, in these randomized trials, if more blood is given than needed, it is either unhelpful or harmful.
Q: How important is continued education so members of the clinical community understand the benefits of a less-is-more approach?
A: We think education is, perhaps, the most important effort. There are two ways that providers get their information. One is by education and the second is by these ‘best practice’ advisories that many of us refer to as ‘annoying pop-up alerts’ in the EHRs. If someone were to order a transfusion at Johns Hopkins today, and the patient has a hemoglobin level of 7 g/dL or higher, they will get a ‘best practice’ advisory that pops up in yellow highlight and says the patient may not need a transfusion. Then we reference two of the biggest randomized trials, both of which were published in The New England Journal of Medicine. We contend that providers are more likely to change practice by education in a grand rounds-style lecture than they are by heeding a pop-up alert when they are ordering a transfusion. Physicians do not want to be told how to practice medicine by a computer pop-up alert.
Q: Can other institutions easily implement a similar approach?
A: Nothing in quality improvement is truly easy. However, in a paper we published last fall in Anesthesiology, Table 1 lists 16 methods for implementing a program and achieving results. Some of these methods are simple, and others are harder to achieve. Most importantly, the program should be supported financially by the hospital as a quality and safety effort. You have to spend money to save money, and we showed a 400% return on investment for support of our program. If people have supported time to attend meetings and lead these efforts, the program is more likely to succeed. It also is important to harmonize transfusion guidelines across the health system based on evidence from randomized trials. Our data dashboards are critical to our program and, with the right analytics support, these can be used to do audits and reports. The dashboards allow us to create and send monthly reports on transfusion guideline compliance, and this probably was the hardest step to implement.
Q: Is there anything else that you would like to mention ?
A: Our most successful intervention — and the easiest to launch — was our ‘Why give 2 when 1 will do?’ campaign, which advocates single-unit blood transfusions. When I went to medical school, and through the 1980s and 1990s, we were taught that the dose of blood is two units. As recently as 2013, when the Choosing Wisely campaign began, we were told by experts in the field that we should give single-unit transfusions and then reassess the patient before any additional units are given. We had more success with our ‘Why give 2 when 1 will do?’ campaign than we did with any other intervention. We were able to reduce double-unit transfusions by 50% across the health system. I call this the ‘low-hanging fruit’ for any blood management program. – by Jennifer Southall
References:
Carson JL, et al. N Engl J Med. 2011;doi:10.1056/NEJMoa1012452.
Frank SM, et al. Anesthesiology. 2017;doi:10.1097/ALN.0000000000001851.
Hajjar LA, et al. JAMA. 2010;doi:10.1001/jama.2010.1446.
Hebert PC, et al. N Engl J Med. 1999;340:409-417.
Holst LB, et al. N Engl J Med. 2014;doi:10.1056/NEJMoa1406617.
Lacroix J, et al. N Engl J Med. 2007;356:1609-1619.
Murphy GJ, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1403612.
Robertson CS, et al. JAMA. 2014;doi:10.1001/jama.2014.6490.
Villanueva C, et al. N Engl J Med. 2013;doi:10.1056/NEJMoa1211801.
For more information:
Steven M. Frank, MD, can be reached at Johns Hopkins Medicine, 600 N. Wolfe St., Baltimore, MD 21287; email: sfrank3@jhmi.edu.
Disclosure: Frank reports compensation for advisory board roles with Haemonetics and Medtronic.