Despite growing evidence about the dangers of unnecessary transfusions, there continues to be a wide variation in practices across the country, suggesting blood is often used inappropriately, says Lawrence Goodnough.
Though the nation’s blood supply has never been safer, blood transfusion has always been recognized as carrying risks, including possible outcomes related to longer hospital stays, immune system changes leading to cancer recurrence, multi-system organ failure and exposure to unknown, emerging pathogens, said Lawrence Goodnough, MD, professor of pathology and of hematology at the School of Medicine.
“We think blood saves lives, though that has never been proven,” said Goodnough, who is also director of the transfusion service at Stanford Hospital & Clinics. “So it’s a matter of less is more. There is such a thing as over-transfusion, and I think people are increasingly recognizing that.”
He has written a commentary and co-authored two papers in a clinical series on transfusion medicine published in the May 25 issue of the Lancet. The series focuses on trends in blood inventory, blood transfusion and alternatives to blood.
Stanford medical center is among the institutions that have made a concerted effort in recent years to decrease the use of blood supplies. In 2009, a multidisciplinary task force at the center spearheaded an effort to capitalize on the electronic medical records system at Stanford Hospital & Clinics to encourage doctors to think twice before ordering transfusions. Now, if a physician tries to order blood for a patient with levels of hemoglobin — the quantity of red blood cells carrying oxygen in the body — above a certain level, a pop-up on the screen alerts the doctor to guidelines on when to transfuse blood and asks the clinician to explain the reason for the request. This appears to cause some physicians to reconsider or cancel the order for blood transfusion, Goodnough said.
The result is that use of red blood cells at the hospital fell from 30,443 units in 2009 to 23,118 in 2012 — a 24 percent decrease. Transfusions of all blood products at the hospital declined from 60,204 to 48,678 during that same period.
“Here, we are leveraging electronic medical records to reverse this national trend toward overutilization and motivating people to follow a more restrictive blood practice,” Goodnough said. “We’re very proud of what we’re doing here at Stanford.”
Goodnough, who has devoted much of his career to blood conservation, notes that the use of blood briefly declined in the early 1980s in response to the AIDS epidemic, as well as to the widespread problem of hepatitis C infection among transfused patients undergoing heart surgery. However, with the advent of intensive screening and other safety measures, the number of transfusions began steadily rising, largely because of the demands of specialized care and an aging population, he said.
Today, some 24 million blood components, including red blood cells, plasma and platelets, are transfused annually in the United States. Among the 39 million patients discharged annually from U.S. hospitals, 2.3 million — or 5.8 percent — received transfusions, according to the report.
The downward trend in blood usage began in 2009, largely in response to the rising costs of blood, which can run between $500 and $1,000 for each transfused unit, Goodnough said. For the first time, transfusions of blood components provided by the American Red Cross, which collects about half of the nation’s supply, fell by 3 percent in both 2009 and 2010, he said.
That trend has continued, with subsequent decreases of 3 percent in 2011 and 5 percent in 2012, Red Cross officials recently reported at a meeting of the International Society of Blood Transfusion.
He said physicians’ experiences treating Jehovah’s Witnesses, who object to transfusion for religious reasons, and the publication of findings from four key clinical trials have contributed to the growing recognition that patients can do just as well with less blood during treatment. But there is no standard guideline, and some controversy, regarding what level of hemoglobin should trigger a transfusion, he said. He said he believes every patient needs to be evaluated individually.
“I don’t think there is one laboratory value that should be used. Older patients may be different than younger patients, for instance,” he said. “So the message is that there is not one number. We should use a restrictive transfusion philosophy — when the treating team is convinced that the benefits of transfusion would outweigh the risks.”
Despite growing evidence about the dangers of unnecessary transfusions, he said there continues to be a wide variation in practices across the country, suggesting blood is often used inappropriately.
“If you look, for instance, at patients undergoing coronary artery bypass surgery, there is widespread variability throughout the United States for a routine bypass or valve replacement on transfusion outcomes, with regional differences and differences among academic and community medical centers,” he said.
He said the American Medical Association has highlighted the danger of unnecessary transfusion and included blood transfusion among a list of five overused treatments. (The others were heart stents, ear tubes, antibiotics and the induction of birth in pregnant women.)
Yet changing clinical practice to ensure that every transfusion is necessary and appropriate remains a challenge, Goodnough said.
“The big question is how to best translate these findings into clinical practice … and overcome clinicians’ resistance to change,” he said.