Background: In 2013, the American Society of Hematology released the Choosing Wisely initiative, which includes 10 recommendations for better healthcare stewardship. The first recommendation advises against transfusing more than the minimal number of red blood cell (RBC) units to relieve symptoms of anemia or to keep hemoglobin (Hgb) in a safe range (7 to 8 gm/dL in stable, non-cardiac patients). Transfusions beyond this suggested range may be unnecessary and increase healthcare costs, particularly for patients with hematologic malignancies, who often suffer from prolonged anemia during treatment with intensive chemotherapy.
Methods: In July of 2014, new blood administration guidelines were implemented in the outpatient hematology/oncology clinic at Froedtert & the Medical College of Wisconsin. These guidelines recommended administration of 1 unit packed RBCs (PRBCs) for Hgb 7.0-8.0 gm/dL and 2 units for Hgb less than 7.0 gm/dL in stable hematology/oncology patients. Guidelines were reinforced by removing buttons from the electronic health record which had previously expedited a default order for 2-unit transfusions, and by requiring the indication for transfusion when an order for blood is placed. After successful implementation of these guidelines, the guidelines were expanded in September of 2014 to the inpatient hematology/oncology service. The inpatient guidelines recommended administration of 1 unit PRBCs for Hgb <7.0 gm/dL. Data was collected on the pre-transfusion hemoglobin, number of units transfused and average number of units transfused per episode for the year before implementation of the guidelines (Y1) and annually thereafter (Y2, Y3).
Results: Following the implementation of blood management program guidelines in August 2014, the average pre-transfusion hemoglobin levels decreased in this patient population. Average pre-transfusion hemoglobin was 7.73 gm/dL, 7.18 gm/dL, and 7.17 gm/dL for Y1, Y2, and Y3 respectively. The average number of units transfused per episode also decreased from 1.73 in Y1 to 1.23 and 1.17 in Y2 and Y3. The total number of units transfused annually in this patient population was 5488, 4787, and 4987 for Y1, Y2, and Y3 respectively. With the guidelines, total consumption of blood products decreased by 9-12% annually despite an increase in patient volumes. Inpatient days increased by 32%, inpatient discharges increased by 11% and outpatient visits increased by 16% for patients with hematological malignancies since the intervention. Overall, this resulted in an average decrease in blood utilization by 601 units per year, with an associated annual average cost savings of $120,801 (direct cost for units of blood).
Discussion: The results of this study demonstrate that using a lower standardized transfusion threshold is feasible in both inpatient and outpatient hematology/oncology settings and efficacious at reducing overall blood utilization. Given the increased number of patients seen in clinic and increase inpatient days during the intervention, the improvement in blood utilization cannot be explained simply by decreased patient demand. The improvement in blood utilization resulted in significant cost savings and potential time savings for our patients. Furthermore, when administration costs are accounted for, cost savings would be even greater. However, the overall impact of this intervention on patient outcomes and quality of life was not assessed and will need to be addressed in future studies.
Conclusions: Implementation of a blood management program with more restrictive guidelines on PRBC administration resulted in decreased blood utilization and improved cost savings for inpatient and outpatient hematology/oncology settings.
Michaelis: Celgene: Speakers Bureau; Novartis: Other: Consultation for New Product; Incyte: Other: consultation for product. Atallah: ADC Therapeutics: Research Funding.
Asterisk with author names denotes non-ASH members.