Update on the Concept of "Overuse"

2014 - 2 April – Patient- and Family-Centered Care
Aryeh Shander, MD, FCCM, FCCP
An expert delves into the intricacies and nuances of patient blood management.
Patient blood management (PBM) is becoming a household term in the field of medicine. Case in point: the most recent National Blood Collection and Utilization Survey Report has dedicated a full chapter to PBM.(1) Critical care practitioners should be familiar with the concept of PBM and one of its strongest drivers for implementation.

In July 2011, recognizing the significant risks of transfusions, wide variability and deficiencies in transfusion practices, changing patterns of demand for blood, and documented success of PBM programs, the U.S. Department of Health and Human Services Advisory Committee on Blood and Tissue Safety and Availability made the following recommendations to Assistant Secretary of Health Howard Koh(2):
•  Identify mechanisms to obtain data on PBM, utilization of transfusion and clinical outcomes.
•  Support development and promulgation of national standards for blood use, recognizing the value of patient management, blood conservation and conservative blood use.
•  Take steps to establish transfusion expertise as integral to transfusion practices in hospitals and other patient-care settings.
•  Establish metrics for good practices in blood use and PBM.
•  Advise the Office of the National Coordinator for Health Information Technology on the need to integrate PBM and blood utilization into electronic health records.
•  Promote education of medical students and practitioners on optimizing PBM and the use of transfusion, and elevate awareness of the essential role of PBM in the quality and cost efficiency of clinical care.
•  Promote patient education about transfusion risks, benefits and alternatives to promote empowerment in decision making.
•  Support PBM demonstration projects.
•  Support research on noninvasive clinical measures to define indications for transfusion (e.g., ischemia, hemostasis, platelet function, and patient’s functional status).
This followed the adoption of declaration 63.12 by the World Health Organization, which addressed the global importance of incorporating PBM into clinical practice as a patient safety measure. In conjunction with these activities, the American Medical Association-convened Physician Consortium for Performance Improvement and The Joint Commission, under its president Mark R. Chassin, MD, have been playing a pivotal role in promoting PBM as a means to improve quality of care.

In 2002, The Joint Commission established the National Patient Safety Goals (NPSGs) to help healthcare organizations prevent or completely eliminate the occurrence of specific medical errors, the most common being patient misidentification and surgical site infection. During a recent evaluation of the need for new NPSG issues, Joint Commission staff identified the overuse of treatments, procedures, and tests in hospitals and critical access hospitals as a potential topic for a future goal. Research shows that overuse occurs with significant frequency in the United States. Based on a 1980 Institute of Medicine definition, overuse was described as “the use of a health care service in circumstances where the likelihood of benefit is negligible and, therefore, the patient faces only the risk of harm.” The proposed NPSG was designed to focus on the safety and quality issues associated with overuse, although The Joint Commission recognizes that cost is also a concern.
In late 2011, a proposed NPSG on reducing the overuse of treatments, tests and procedures was circulated to the field for comment. Analysis of the results indicated that many believed overuse to be an important patient safety issue. The field review also provided a significant amount of information on the complexity of identifying and managing overuse issues.
Based on feedback from their proposal, The Joint Commission conducted two focus groups composed of field review respondents who had indicated their willingness to be contacted. Focus group participants represented several disciplines with varying opinions about whether overuse should be considered as an NPSG. Issues identified in the field review and in the focus groups include the following:

•  Lack of a widely accepted definition of overuse

•  Lack of benchmarks or criteria for making care decisions in these areas

•  Limited resources available for measurement

•  Insufficient guidance on how to address the issue in the NPSG

•  Patients’ requests to receive services they do not need
•  Involvement of other organizations, such as payers, in overuse
The insights gained from these activities were used to convene the National Summit on Overuse.  The event was co-hosted by The Joint Commission and the Physician Consortium for Performance Improvement in September 2012. Its purpose was to validate evidence and data that certain interventions are overused, review related guidelines and quality measures, and develop strategies for reducing overuse.  Proceedings from this meeting, including the resulting recommendations, can be downloaded from The Joint Commission website.(3) Late in 2013, the American Hospital Association issued its white paper, which advanced similar recommendations based on comparable data.

The list of “overused” interventions is overwhelming and, as such, the summit limited itself to five areas:
•  Antibiotics for viral upper-respiratory infections
•  Clinical transfusion practices
•  Therapeutic approaches toward acute otitis media with effusion
•  Early-term elective delivery
•  Elective percutaneous coronary intervention procedures
Accordingly, each of the five multidisciplinary work groups convened for the summit focused on one of these areas to validate the appropriate data, review guidelines and quality measures, and develop strategies to reduce overuse. The blood management work group contained representatives from surgery, critical care, internal medicine, transfusion medicine, hematology, and anesthesiology, and was led by a member of the Society of Critical Care Medicine.
Transfusion is one of the top five procedures in hospitalized patients, with approximately 15 million units of red cells transfused annually. The critically ill are prone to overuse as defined above. Hospital Alliance for Resuscitation Quality (HARQ) data report that one of every 10 patients admitted to an acute care hospital will be transfused. Blood component use in the critically ill is common;(4,5) this population is estimated to have transfusion rates above 40%, with more than 90% of transfusions given to patients with stable anemia and demonstrating no benefit. Studies performed in this population suggest that the use of red cells is associated with an approximately 50% chance of receiving plasma and 25% chance of platelets.(6) In one-fourth to one-half of those patients transfused, the components were not indicated. In addition, up to 90% of blood transfusions may represent “overuse” or be unnecessary. Moreover, data on the extensive variability of transfusions not only corroborate the “overuse” data but suggest that best practices can be achieved by benchmarking low transfusion centers and making them examples of “best practice.” Injury may or may not be a direct result of overuse, but it is estimated to affect 60,000 patients each year. These numbers might be significantly low as a result of underreporting. Clearly, this is a patient safety issue.

The Society for the Advancement of Blood Management and the American Association of Blood Banks have been promoting PBM. Not only will PBM help improve patient outcomes, it will also promote patient safety, which is an important aspect of the culture at the Society of Critical Care Medicine. As we progress toward value-based healthcare, defining and addressing the modifiable risk of transfusion and poor outcomes will help in identifying anemia and coagulopathy. Preventative measures will follow, including reduced phlebotomy and early initiation of appropriate long-term treatments. In light of this, it is vital to further the concept of PBM in intensive care units, moving from a product-based approach (i.e., “blood products”) to a patient-based approach (i.e., identifying the medical condition and enacting measures for prevention and treatment with the intent of better clinical outcomes). It is also important to adopt the current definition and matrix of PBM as developed by the Society for the Advancement of Blood Management and the American Association of Blood Banks.(7)

1. The 2011 National Blood Collection and Utilization Survey Report. American Association of Blood Banks Web site. http://www.aabb.org/programs/biovigilance/nbcus/Documents/11-nbcus-report.pdf. Accessed August 15, 2013.
2. Advisory Committee on Blood Safety and Availability recommendations [letter]. U.S. Department of Health & Human Services Web site. https://wayback.archive-it.org/3919/20140402193348/http://www.hhs.gov/ash/bloodsafety/advisorycommittee/recommendations/reommendations_201106.pdf Published June 2011. Accessed August 15, 2013.
3. Proceedings from the National Summit on Overuse. September 24, 2012. The Joint Commission Web site. http://www.jointcommission.org/assets/1/6/National_Summit_Overuse.pdf. Accessed August 15, 2013.
4. Corwin HL, Gettinger A, Pearl RG, et al. The CRIT Study: anemia and blood transfusion in the critically ill--current clinical practice in the United States. Crit Care Med. 2004;32:39-52.
5. Walsh TS, Garrioch M, Maciver C, et al. Red cell requirements for intensive care units adhering to evidence-based transfusion guidelines. Transfusion. 2004;44:1405-1411.
6. Makroo RN, Mani RK, Vimarsh R, Kansal S, Pushkar K, Tyagi S. Use of blood components in critically ill patients in the medical intensive care unit of a tertiary care hospital. Asian J Transfus Sci. 2009;3:82-85.
7. Patient blood management [definition]. Society for the Advancement of Blood Management Web site. http://www.sabm.org/glossary/patient-blood-management. Accessed August 16, 2013.