Mechanism of Transfusion Overuse

1. Mechanism of Transfusion Overuse Aryeh Shander, MD, FCCM, FCCP Chief, Department of Anesthesiology, Critical Care and Hyperbaric Medicine. Englewood Hospital and Medical Center, Englewood, New Jersey Clinical Professor of Anesthesiology, Medicine and Surgery Mount Sinai School of Medicine, New York

2. Current Status • Although perceived as “life saving”, now many concerns • Blood use in the US and western world is cultural not scientific • Poor understanding of the blood components • Guidelines produced by industry • Recognition of overuse and inappropriate use • Efforts to correct these issue but: • Product centered • Not patient centered

3. TRANSFUSION OVERUSE • Is there OVERUSE? • How much OVERUSE is there? • Does BLOOD OVERUSE fit into the OVERUSE model? • What can be done about it? Are we asking the right questions?

4. Do harm to patients • Excess costs to society • Defy patients’ preference • Affects healthcare quality IOM – National Round Table on Health Care Quality 1980 coined the term “overuse” JAMA Intern Med. 2013

5. TJC - National Patient Safety Goal (NPSG) overuse of treatments, procedures and tests for the hospital • Consequences of overuse: tests, treatments and procedures • Overuse may be defined as: “The use of a health service in circumstances where the likelihood of benefit is negligible and, therefore, the patient faces only the risk of harm.” • The focus is to identify and eliminate overuse • NPSG provides for incremental implementation and an evaluation of the effectiveness http://www.jointcommission.org/assets/1/6/HAP_NPSG_Overuse_Rpt_2011-11-14

7. Transfusion OVERUSE • Reports of 40 – 60% inappropriate RBC transfusions • Implementation of any restriction (Inverse evidence) • Reduction of 12 to 83% • Reduction of 9 to 77% • Reduction of 85% FFP Wilson k. et. al. TRANSFUSION 2002 Tinmouth A. et.al. Arch Int Med 2005 Sweeney J. et. Al.Transfusion 2011

8. High Frequency of Transfusions May Be Inappropriate 494 RBC transfusion studies analyzed – 450 clinical scenarios 15 experts used RAND/UCLA Appropriateness Method “Appropriateness” based on improving health outcomes Shander et al. TransMed Rev. 2011. 232-246.

9. Variation of blood transfusion in patients undergoing major non-cardiac surgery Qian F. Et al. Ann Surg. 2013 Feb;257(2):266-78

10. Transfusion Confusion • Articles demonstrating significant variability in practice • Goal is to reduce variability practice Aronson S. AMA PCPI – TJC 2012

11. Addressing the concept of Overuse • BENEFIT-HARM TRADEOFF - potential harms exceed the potential benefits, and therefore the services should not be delivered • BENEFIT-COST TRADEOFF - services where the magnitude of potential benefits is small relative to the costs • CONSIDERATION OF PATIENT PREFERENCE -tradeoffs between outcomes such as survival and quality of life - The ‘shared-decision making’ principle Initiating measure to curb overuse require definitions and clear strategies How should a culture that encourages overuse or fails to discourage it be mended? Lipitz-SnydermanABach B P.JAMA INTERN MED 2013

12. BENEFIT-HARM TRADEOFF potential harms exceed the potential benefits, and therefore the services should not be delivered

13. Infectious Risks of Transfusion Mintz PD, ed. Transfusion therapy: Clinical principles and practice. 3rd ed. Bethesda, MD: AABB Press, 2011.

14. Noninfectious Risks of Transfusion *Data from multiple sources; for references, see Petrides M, AuBuchon JP. To transfuse or not to transfuse: An assessment of risks and benefits. In: Mintz PD, ed. Transfusion therapy: Clinical principles and practice. 3rd ed. Bethesda, MD: AABB Press, 2011

16. FOR BLOOD IT IS NOT THE PATIENT

17. BENEFIT-COST TRADEOFF services where the magnitude of potential benefits is small relative to the costs

18. Acquisition costs have more than doubled in the past few years, and are expected to rise 5% to 10% annually Source: America‘s Blood Centers, 2004

20. Retrospective cohort study of all hospitalisations in the US in 2004 (n=38.66 million) to assess in-hospital outcomes associated with blood transfusion. • 5.8% (2.33 million) transfused • After adjustment for age, gender, comorbidities, admission type or DRG transfusion associated with: • 1.7 increased odds of death (P<0.0001) • 1.9 increased odds of infection (P<0.0001) • 2.5 days longer LOS • $17,194 higher charges (P<0.0001)  $40.1 billionmorechargesfortxedpts! Morton J et al. American Journal of Medical Quality 2010, 25(4) 289-296

21. ActivityBasedCost of Transfusion from a Provider‘sPerspective Shander A, Hofmann A, Ozawa S, Theusinger O, Gombotz H, Spahn D. Transfusion 2010

22. TOTAL cost of TRANSFUSION Howmuchisthe total costofbloodtransfusionfrom a societalperspective? • Costincurredtodonors? • Costofproducingbloodcomponentsfortransfusion? • Costoftransfusionlogisticsandpreparationwithinhospitals? • Costofadministeringandmonitoringactualtransfusion? • Costoftreatingadversetransfusionoutcomes? • Costoftreatingtransfusiontransmitteddisease? • Costoflitigation (claimsofcontaminatedvictims)? • Costof lost productivity? • Costoforganizingandmaintainingnationwide/continentalhemovigiliancesystems? Transfusion 2010

23. CONSIDERATION OF PATIENT PREFERENCE tradeoffs between outcomes such as survival and quality of life - The ‘shared-decision making’ principle

24. BLOOD TRANSFUSION • NBCUS: In 2011, total of 13M + units of RBC • RBC and plasma transfused (50/1000) • AHRQ: Blood transfusions occurred in 1/10 of all hospital stays that had a procedure One of the fastest growing top-five procedures Consumption of safety?

25. Transfusion Practice • Influence of knowledge and attitudes on the quality of physicians' transfusion practice • Amount of transfused products was inversely • proportional to physician knowledge of • transfusion medicine • Attending MD - lower knowledge scores, • greater confidence than residents • >60% of residents inappropriate transfusion due • attending pressure (once a month) • Salem-Schatz SR, Avorn J, Soumerai S B. JAMA 1990

26. Transfusion Medicine In American Undergraduate Medical Education Transfusion is the most common procedure in hospitals N = 86 American medical schools surveyed (AAMC) 83% administrators reported - didactic lectures 48% of medical schools providing 1 or 2 hours of lectures Handful reported small group sessions on transfusion medicine (6%) 92% administrators were unfamiliar with the 1989 or the 1995 TMAA curricula. Karp JK. et al. Transfusion. 2011 Nov;51(11):2470-9

27. Addressing the concept of Overuse • BENEFIT-HARM TRADEOFF - potential harms exceed the potential benefits, and therefore the services should not be delivered • BENEFIT-COST TRADEOFF - services where the magnitude of potential benefits is small relative to the costs • CONSIDERATION OF PATIENT PREFERENCE -tradeoffs between outcomes such as survival and quality of life - The ‘shared-decision making’ principle Initiating measure to curb overuse require definitions and clear strategies How should a culture that encourages overuse or fails to discourage it be mended?

28. Mending the Problem • Are we asking the right question? • Liberal vs. Restrictive transfusion practice • Asking the same question over and over and expecting different answers? • More guidelines FOR TRANSFUSION • Who follow and why should they? • Changing culture • Can be done but resources are needed

29. Blood Transfusion 2013

30. N = 603 patients [26.4% patients in the restrictive group and 39.1% in the liberal group were transfused (P =0.001)] • Rate lower in restrictive group for: • Post-operative infections - 5.4% vs. 10.2% • Respiratory complications - 1.7% vs. 4.9% • Hospital stay, cardiovascular complications and mortality rate were not different in the two groups • A restrictive transfusion protocol was not associated with worse outcome and resulted in a lower transfusion rate compared to the liberal policy Blood Transfus. 2013

31. N = 921 patients – 2 groups [Restrictive strategy (n = 461) vs. Liberal strategy (n = 460)] • 51% Restrictive strategy vs. 15% Liberal strategy, did not receive transfusions (P<0.001) • The probability of survival at 6 weeks was higher in the restrictive-strategy vs. liberal-strategy group (95% vs. 91%) • Further bleeding - 10% restrictive group vs. 16% liberal group (P=0.01) • Adverse events - restrictive-strategy 40% vs. liberal-strategy 48% (P=0.02) • Restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding N Engl J Med. 2013

32. Ongoing clinical trials on liberal vs. restrictive transfusion strategy in Europe TRIGGER TRIAL TRISS TRIAL

33. NO difference but a trend favor liberal transfusion REALY TRYING HARD! Am Heart J 2013

34. Mending the Problem • Are we asking the right question? • Liberal vs. Restrictive transfusion practice • Asking the same question over and over and expecting different answers? • More guidelines FOR TRANSFUSION • Who follow and why should they? • Changing culture • Can be done but resources and urgency are needed

35. Goodnough LT et.al. Lancet 2013

37. UK and CANADA – • Recognition of variability in transfusion practice • Variability denotes OVERUSE • Potential for reduction

38. Patient Blood Management GuidelinesThe National Blood Authority (NBA) is funding and managing the development of the following six modules as part of a comprehensive, evidence-based, Patient Blood Management (PBM) Guidelines.

39. Significant % of All Transfusions Are Not Preceded by a Lab Hb Measurement “the decision to transfuse is made without any Hb measurement because of the long turnaround time for laboratory testing.” 2,981 surgical patients Frank S et al. Anesthesiology 2012

40. WHAT ARE THE MECHANISMS OF TRANSFUSION OVER USE? • Poor education • Poor culture • Concentration on product not the patient • Lack of regulation and payment • Money for product safety not prevention • Missing objective decision making aids • Too many measures and few aids

41. THANK YOU