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article imageDoctors do 180 on America's most common medical procedure

By Business Insider     Apr 8, 2015 in Health
The most common medical procedure performed for patients hospitalized in the US in 2011 was a blood transfusion.
Specifically, 12 percent of hospital patients who underwent some procedure had a blood transfusion.
That's more than needed breathing machines and echocardiograms, according to the Agency for Healthcare Research and Quality.
But evidence is mounting that a substantial portion of blood transfusions are not necessary. That means some patients are taking on risks and costs for a procedure that isn't really helping them.
In fact, The Joint Commission, a nonprofit that accredits hospitals, included blood transfusions in a 2012 report as one of five overused hospital procedures. Studies of thousands of hospital patients have shown that stricter guidelines for ordering transfusions do not have a negative effect on patient health overall, and even have a positive one.
As Emily Anthes reports in Nature News, a movement is underway to curb the use of blood transfusions in hospitals.
"We've gone 180 degrees, and now we think less is more," Steven Frank, an anesthesiologist and director of the blood-management program at the Johns Hopkins Health System, told Nature News.
Between 2009 and 2012, Stanford reduced the amount of blood transfused in its hospital and clinics by 24 percent. The hospital saved $6.4 million and saw patient mortality and length of hospitalization fall throughout the system. Giving blood transfusions less often yielded a win-win result: patient did better, and the hospital saved money.
It may seem a simple matter to do less of something, but reducing the frequency of blood transfusions flies in the face of doctors' habits formed over years of practice. Changing those habits — cemented over decades — will be uphill work, but the evidence suggests it will be worthwhile.
Transfusions aren't a no-brainer
It's important to realize that blood transfusions do not simply involve replacing something the body has lost, as with drinking water after a sweaty workout. Blood transfusions instead take live cells from a healthy person and put them into another person's body, more like a skin graft.
"Blood is analogous to a liquid organ transplant," Frank told Nature News.
Thus, transfusions can trigger immune and allergic reactions if the patient's body and transfused blood cells do not get along. Complications can also include damage to the heart, lungs, and liver, but these effects are rare. The FDA monitors deaths potentially related to blood transfusions and recorded only 59 (out of millions of transfusions) in 2013.
Because deaths and serious damage are rare and potentially more common negative reactions are subtle, we see only the risks of transfusions in recent studies that look at thousands of people who have received another person's blood, Anthes explains in Nature News.
In one such study, published in PLoS Medicine in 2014, researchers looked at data on more than 20,000 patients in 40 countries and found that the effect of blood transfusions on mortality rates was dramatically different for patients with severe injuries than those with milder injuries.
For worse-off patients, those whose risk of death was predicted as above 50 percent, blood transfusions were associated with a decrease in mortality rates. But in the group of patients whose risk of death was predicted as less than 20 percent, more of those who received transfusions died than those who didn't.
According to this, blood transfusions may be worth it only for patients who really need them.
Less is more
The task is, then, to determine which patients really need blood transfusions and which ones will be better off without them.
One piece of information doctors use to gauge a patient's need for a blood transfusion is the concentration of hemoglobin in the patient's blood. Hemoglobin is the molecule that carries oxygen through the body. Doctors had thought that a below-average hemoglobin concentration meant a patient needed a blood transfusion — until a study published in the New England Journal of Medicine in 1999 challenged standards that had been in place since the 1940s.
The study randomly sorted patients into two groups, those who received transfusions when the hemoglobin concentration in their blood dipped down to the level at which doctors would traditionally order transfusions, and those whose doctors allowed their hemoglobin concentrations to drop even lower before ordering transfusions.
The scientists were surprised to find that being stingier with blood transfusions did not change mortality rates.
"We proceeded to check all of our results because, frankly, we didn't believe it," study leader Paul Hébert told Anthes.
But it was true: Stricter guidelines for giving transfusions did not increase death rates and were even associated with decreased mortality in patients who were not as sick or were under age 55.
Doctors from Stanford adopted the stricter guidelines in 2010, and the percentage of patients in the university's hospital system receiving blood transfusions dropped from 22% in 2009 to 17% in 2013. (This is still greater than the national average — the Joint Report notes that blood transfusion practices vary widely nationwide.) While transfusion rates declined, mortality decreased and patients were discharged from the hospital sooner, on average.
The Stanford results show that changing doctors' practice on blood transfusions is possible and can be good for patients, though it took automated notifications every time a doctor ordered a transfusion through the hospital's electronic records system.
But the better outcomes regarding patient health, not to mention the money saved, indicate the change is not only worth the effort, but necessary.
This article was originally published on Business Insider. Copyright 2015.
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