Blood transfusions are historically one of the most common—and most overused—hospital procedures in the United States. But a new study published in JAMA by Weill Cornell Medicine, NewYork-Presbyterian and Johns Hopkins Medicine investigators reveals that blood transfusions are declining nationally, underscoring the success of hospital programs aimed at reducing the procedure’s usage.
There are three types of blood transfusions: red blood cells, plasma and platelets. Red blood cell transfusions aid patients who suffer from anemia – a condition where the body does not have enough red blood cells – by increasing levels of hemoglobin, the protein in red blood cells that transports oxygen. Plasma transfusions are provided for patients with significant bleeding, liver failure or severe burns. And platelet transfusions are provided to patients with lower platelet counts or dysfunctional platelets.
The paper, published Feb. 27, is the first ever to examine blood transfusion patterns among hospitalized patients at the national level. It shows that blood transfusions for red blood cells and plasma declined from 2011 to 2014, while platelet transfusions remained stable over the same period. The authors say that this trend has important implications for healthcare costs and patient care.
“After a steady increase in blood transfusions across the nation for more than 15 years, for the first time we notice this inflection point – a significant change in pattern with a decrease in red blood cell and plasma utilization in hospitalized patients,” said first author Dr. Ruchika Goel, an assistant professor of pathology and laboratory medicine and of pediatrics at Weill Cornell Medicine, and assistant medical director of transfusion medicine and cellular therapies at NewYork-Presbyterian/Weill Cornell Medical Center. “It reflects the collective successful efforts of various patient blood management initiatives across the nation. Patient blood management has truly been a revolution in the world of transfusion medicine. This study provides evidence demonstrating the successful implementation of restrictive red blood cell transfusions, blood conservation initiatives, advocacy from medical organizations and increased adherence to transfusion practice guidelines.”
Dr. Ruchika Goel
The Joint Commission, a not-for-profit that accredits U.S. healthcare organizations, has in recent years listed blood transfusions as one of the most overused procedures. The commission has used its annual National Summit on Overuse to provide recommendations to health organizations on how to decrease the overutilization of blood transfusions.
“The liberal approach to blood transfusions is providing red blood cells when hemoglobin levels are less than 10 grams per deciliter,” said senior author Dr. Aaron Tobian, director of transfusion medicine and an associate professor of pathology at Johns Hopkins University School of Medicine. Normal hemoglobin levels depend on sex and age group, but are often within 11 to 18 grams per deciliter. “However, people can tolerate a lower hemoglobin level than we initially anticipated – around 7 to 8 grams per deciliter. So the big question is why would you transfuse if it’s not needed?”
Blood transfusions are no doubt lifesaving, but they also come with the potential risk of infection, contamination or allergic reactions. Transfusing a patient unnecessarily has no health benefit, the investigators say, while opening up the risk of adverse effects. The overuse increases the cost of healthcare delivery, and it contributes to concerns about blood product shortages.
While local surveys had indicated that hospitals were starting to restrict transfusions, investigators were until now unable to gain a snapshot of nationwide patterns. They examined National Inpatient Sample data from 1993-2014 across 47 states and 1,100 hospitals, accounting for approximately 96 percent of the U.S. population. They found that the number of blood transfusions rose steadily from 1993 to 2011. However, by 2011, transfusions of red blood cells in hospitals began to decline until 2014, the most recent data available. More specifically, the numbers revealed that red blood cell and plasma transfusions declined by 17 percent and 13 percent, respectively.
The downward trend may reflect the success of recent patient blood management programs at hospitals, which restrict the amount of blood transfusions performed.
“This study provides dramatic evidence of the success of efforts made at hospitals across the nation—including Weill Cornell Medicine and NewYork-Presbyterian Hospital—in the last several years to optimize the treatment of bleeding and anemia and avoid unnecessary transfusions through patient blood management initiatives,” said study co-author Dr. Melissa Cushing, an associate professor of clinical pathology and laboratory medicine at Weill Cornell Medicine and director of transfusion medicine and cellular therapies at Weill Cornell Medicine and NewYork-Presbyterian/Weill Cornell Medical Center.
The investigators predict that transfusions will have continued to decline past 2014. “With fewer transfusions, we are improving patient care while also lowering cost for healthcare. It’s really a win-win situation,” said Drs. Goel and Tobian.