Medical and surgical patient costs reduced as well
Patients who declined transfusions but were treated with blood-conservation methods suffered fewer deaths, infections and other morbid outcomes compared with those who accepted donor blood and received standard care, a new Johns Hopkins study concluded.
Mortality rates were almost fourfold lower in patients who declined allogeneic blood transfusions (ABT) but were treated with blood-conservation methods, or 0.7%, compared with 2.7% for patients who accepted transfusions, reported the Center for Bloodless Medicine and Surgery in an upcoming paper in the journal Transfusion.
Blood-conservation measures ranged from iron supplements to autologous blood salvage, in which a patient’s blood is cleaned and cycled back into the body during surgery.
Other blood-conservation methods included the diagnosis and treatment of pre-hospital anemia, the reduction of intraoperative blood loss, and in-hospital use of IV iron and erythropoietin.
When patients who declined transfusions (so-called bloodless patients) were discharged, their hemoglobin concentrations (10.8±2.7 g/dL) were similar to patients in the control group who received transfusions (10.9±2.3 g/dL; P=0.42), according to the center’s study.
Overall, the study found that bloodless care is not an independent predictor of either death or a morbid event, said Steven M. Frank, MD, medical director of the Bloodless Medicine and Surgery Program at Johns Hopkins in Baltimore.
“Giving them a $5 bottle of iron beats $500 worth of blood, plus … you produce your own red cells and don’t require someone else’s red cells that have been stored in a blood bank for up to six weeks,” he said.
Morbid outcomes were lower, with a trend toward lower infections and thrombotic complications, with incidences of renal, respiratory and myocardial infarction also examined, but with no differences between the two groups, Dr. Frank said.
The study examined 294 patients treated at the center, mainly Jehovah’s Witnesses, who are prohibited from accepting blood from donors. The group was then compared with 1,157 patients with closely matched backgrounds who underwent surgery or received treatment at Johns Hopkins Hospital and who received blood transfusions.
The study examined billing records at Johns Hopkins and noted potential reduced costs for hospital systems now grappling with the rising cost of blood.
The combination of no ABT and blood conservation resulted in substantial savings, with a reduction in total and direct hospital costs of 12% and 18%, respectively, the study found.
The savings were particularly pronounced in patients who underwent surgery. The average total charge for bloodless patients who underwent surgery was $25,568, compared with $30,162 for their counterparts in the control group. Total costs and direct costs in the bloodless group were $18,880 and $10,347, respectively, compared with $23,752 and $12,359 in the control group, the report found.
Hospital lengths of stay were roughly the same for the bloodless patients and those in the control group.
The study is unique because it compared the outcomes of bloodless patients with those of a control group, it used risk adjustment, and it examined a wide array of surgeries and medical procedures, said to Dr. Frank, who added that most studies on patients who decline transfusions have lacked a control group, did not use risk adjustment or focused exclusively on cardiac surgery.
The study selected a “propensity, score-matched cohort” from a wider group of 60,652 patients admitted to Johns Hopkins during the study period, which ran from June 2012 to August 2013. Four control patients were matched to each bloodless patient, which both increased the sample size and made it easier to detect different outcomes between the two groups. “We matched on a four-to-one ratio,” Dr. Frank said. “That way you get more power in the analysis.”
Reviewers of the paper questioned the size of the bloodless group, suggesting it could have been larger, Dr. Frank said. The center, which is just two years old and takes in 400 patients a year, is working to increase its number of patients.
The decision to look at medical as well as surgical patients also was questioned because medical patients may not have the same requirements for transfusion. However, Dr. Frank noted the medical group included patients battling cancer and suffering from gastrointestinal bleeding. “I think it’s a strength that we included both medical and surgical patients,” Dr. Frank said.
Paul M. Ness, MD, director of the Division of Transfusion Medicine at Johns Hopkins Hospital, said advocates for bloodless medicine too often rely on anecdotal evidence to make their point. By contrast, this study offers a comprehensive, data-intensive look at the issue.
“I think this is very interesting work and I support the findings,” said Dr. Ness of the study, in which he was involved. “We had a good group of control patients and a larger sample size than some of the studies bloodless medicine advocates often quote.”
The study’s use of a control group was a significant advance on past studies on outcomes of patients who decline transfusions, agreed Sherri Ozawa, RN, clinical director of the Institute for Patient Blood Management and Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, in Englewood, N.J.
“The data get better when you have a comparative cohort so that you are comparing apples with apples,” she said.