In December 2016, the U.S. Agency for Healthcare Research and Quality posted a new statistical brief on inpatient red blood cell (RBC) transfusion. The AHRQ reported that the number of adult inpatient stays featuring the procedure had continued to rise, growing 85.8 percent from 2000 through 2013. And the rate of increase was climbing substantially faster than that of inpatient stays.
Thanks to a collaborative approach that builds on its strengths, Geisinger Health System in Pennsylvania is ahead of the game. In 2013, a paper on blood product utilization published by the health care performance consortium Premier, Inc., gave pathologist Amanda E. Haynes, D.O., FCAP, what she needed to put Geisinger’s own performance in context, create a sense of urgency, and enable a pivotal shift in attitudes. The resulting system-wide effort saved more than $1 million in blood acquisition costs in 2015.
Premier had looked at lower blood product utilization coupled with better-than-expected patient outcomes to benchmark one in four (7.4 million) patient discharges at 464 member hospitals. They’d also used the percentage of annual discharges reflecting inpatient transfusion as a quality measure. Geisinger had shown up in the bottom decile for blood utilization management, Dr. Haynes says, adding, “That one piece of data and peer comparison was enough to get the attention of the administration and the other physicians.”
Dr. Haynes had already been thinking about a paper in the journal Transfusion describing an activity-based costing model for RBC transfusion that accounted for process steps, staff and consumables. Incorporating indirect expenses yielded RBC unit costs that were 3.2- to 4.8-fold higher than blood product acquisition costs alone. That nailed it.
Data-driven goals drive efforts
Dr. Haynes had three goals at the outset: (1) Look at transfusion rates by service line or individual physician so that improvement goals could be focused and tailored; (2) Begin using evidence-based transfusion guidelines reflecting recent research showing that using a lower hemoglobin threshold for transfusion did not compromise patient safety; and (3) Embed those guidelines in the electronic health record as part of the computerized physician order entry system to encourage compliance and track system-wide progress in that direction. In the end, they were three for three.
Dr. Haynes data-driven arguments generated support from clinicians, health information management specialists, and administrators alike. By July 2013, Geisinger had a diverse, well-integrated team and a patient blood management project that used evidence-based transfusion guidelines. Geisinger’s pre-surgical planning began to integrate principles designed to prevent anemia. Blood management tools (for example, use of tranexamic acid in orthopedic hip and knee surgery, laboratory-guided transfusion algorithms for cardiac surgical bleeding, and anemia management interventions before elective surgery could be scheduled) were embedded into bundled episodes of care.
In July of 2015, Dr. Haynes' team was able to report 23 percent and 27 percent drops in packed red blood cell utilization at Geisinger's two largest campuses. That translated to a $1.2 million drop in blood acquisition costs across the health system in 2015 compared to the year before.
Metrics will drive movement in population health, Dr. Haynes says, by providing the foundation that makes the most difference for the most patients. The goal is to reach a point where only hemorrhaging patients will receive an RBC transfusion. Until then, she will do monthly reports to the service line leaders that track physician performance against the transfusion guidelines. And her team will continue to recruit medical staff champions at each location and encourage nurses to advocate within their clinical teams for the patient safety benefits that accrue with adherence.
Other blood use rates show improvement
The Geisinger group did not target platelet and plasma use during the project period, yet utilization rates for both improved. It seems there’s more than one way to build on success.
“We’ve really just scratched the surface," Dr. Haynes says. “What can we do to further impact the utilization of plasma or of platelets? Platelets are almost three times the cost of red cells. We haven’t even really started.”
She’s still studying the data from Geisinger’s third campus. Post-project data mining had suggested a problem with the benchmarking. That could be all it was, but still, she wonders why the outliers didn’t prompt immediate questions about how the model had been applied at that campus.
“If you’re going to do change management, you can’t just apply one standard process across the health system,” Dr. Haynes says. “You have to understand the culture of each and every campus, what the differences are, and what different approaches can be used to impact change in those different cultures.”
And to do that — she’s mining the data.
Dr. Haynes, who joined the medical staff at Pennsylvania’s Geisinger Health System in 2010, is currently director of transfusion medicine, medical director of stem cell processing, the vice chair of the Geisinger Health System Patient Blood Management Committee, a physician leader for their strategic plan, and a member of the College of American Pathologists’ Council on Scientific Affairs and Nominating Committee.