The US blood system is a vast network comprised of approximately 190
regional blood centers, which collect 90% of the nation's blood, and 621
hospital blood centers, which collect the remaining 10%. Many of the
regional blood centers are operated by the American Red Cross, which collects
approximately 45% of the blood in the United States.
The United States is almost completely self-sufficient in its blood
supply, with only 2% of the supply being imported from Western Europe each
year. Safety protocols for the collection, processing, and distribution
of blood and blood products are regulated by the FDA through the Center
for Biologics Evaluation and Research.
Whole blood, packed red blood cells, platelets, and frozen plasma products
account for 0.29% of total hospital expenditures in the United States,
including blood storage, processing, and transportation.
Hospital administrators, looking to improve their bottom line and remain
competitive in a managed care environment, are holding physicians more
accountable for blood and blood product usage. However, most of the efforts
to assess physician performance have focused on utilization review techniques.
Recently, "report cards" have been developed to more formally
assess physician performance in the use of blood products and other important
These efforts at accountability have inherent cultural and operational
obstacles, as described below, and are not generally well accepted by many
physicians. Newer approaches have recently been developed and implemented,
based on prospective evaluations that include assessments of quality of
care, patterns of care, and costs of care.
The Report Card Approach
At the policy level, report cards were developed in response to demands
from health care regulators, contractors, purchasers, and consumers for
an effective means by which to evaluate and compare health care providers.
Many large managed care organizations have developed report cards on providers'
quality of care, while policy makers and researchers at the state and federal
level have generated surgical procedure report cards for physicians and
Report card implementation has resulted in the definition of sets of
health plan performance measures, the most prominent of which is the Health
Plan Employer Data and Information Set (HEDIS), developed by the National
Committee for Quality Assurance (NCQA).
The use of report cards in comparing providers has caused much scientific
controversy. Questions of validity have been raised by physicians who doubt
the fairness and consistency of the measures applied in different health
Physicians argue that report cards fail to control adequately for condition-
specific factors such as severity of illness, comorbidity, and coincident
conditions, as well as for patient acceptance of effective care, all of
which play major roles in determining patient outcomes.
At hospitals throughout the country, report cards have been implemented
to monitor the use of transfused blood products. For example, at one hospital,
software programs have been developed that identify all transfusions to
patients with hemoglobin concentrations above a certain level. Each case
so identified is reviewed by a pathologist for assessment of clinical need,
based on documentation in the medical record.
For those cases in which documentation is insufficient, the attending
physician is asked to provide support for the decision to use transfusion.
If upon further review, the transfusion is still felt to be clinically
unnecessary, an additional assessment by the utilization review committee
is carried out. If this committee agrees with the determination, formal
documentation about the incident is attached to the physician's file.
The entire review process is based on retrospective assessments and
requires multiple levels of communication and documentation. The inadequacy
of this process has been substantially documented. Furthermore, the report
card process runs counter to today's advanced management thinking concerning
motivation and performance.
In addition to concerns over the validity of report cards, many feel
that their widespread use may have significant adverse health care implications.
Feedback from report cards based on evaluation of overuse may cause physicians
to alter their practice patterns to err on the side of underuse of important
blood products so as to minimize their chances of being identified as an
Another problem with report cards is that they are inherently static
tools, and although they may be able to determine certain performance deficits,
they do not clarify which of many underlying processes contribute to those
deficits. It has also been documented that poor outcomes are due largely
to failures in the processes of care rather than to individual error.
Instrument Panel Approach
The numerous concerns surrounding report cards have caused many in the
health care industry to explore other potentially more valid and more acceptable
performance measures. The trend toward the use of real-time performance
improvement tools in many business settings has prompted the use of similar
measures, namely the "instrument panel," in the health care arena.
Potential Impact of Instrument Panel Approach on Physician Performance
The use of instrument panels to help develop clinical practice guidelines,
Hospital administrators, faced with the task of improving cost-effectiveness,
By singling out and reprimanding physicians with questionable blood
Performance improvement efforts using instrument panels would likely
In this system, selected indicators are measured at frequent intervals
to generate statistical process control charts. These charts provide quality
assurance personnel access to essential, current information that can be
used to facilitate decision making and needed change. When using an instrument
panel in blood banking, potential indicators might include quality of care,
patient satisfaction, quality of life, length of stay, functional status,
return to work, and cost of care.
One advantage of the provider-initiated, continuous quality improvement
approach relative to static report cards is that it is broader in its organizational
reach, thereby reducing certain systematic and potentially confounding
sources of variation. Providers are also capable of capturing data pertinent
to selectively chosen measurement indicators, a large advantage over the
more rigid, externally based report cards.
The practical benefit of the instrument panel in the clinical setting
comes when it is integrated with clinical practice guidelines. This performance
measurement methodology is extremely beneficial in the effort to standardize
clinical practice through guidelines, thereby contributing greatly to quality
and efficiency of care.
A Real-Life Example
Citrus Valley Health Partners (CVHP), comprised of the Queen of the
Valley and Inter-Community campuses of Citrus Valley Medical Center, as
well as Foothill Presbyterian Hospital and Citrus Valley Hospice, serves
a suburb of approximately 720,000 northeast of Los Angeles.
It is an example of a large health-care provider that has recently initiated
a capitated approach to blood product usage. As a part of this capitation
program, CVHP is ideally suited to develop prospective performance measures
in its blood banks using a model similar to the instrument panel described
This provider has adopted a universal computer system for its three
hospital networks that facilitates its ability to collect the necessary
clinical data required to monitor prospective performance improvement measures.
A program to establish a comprehensive database to track and monitor
blood and blood product overusage and underusage throughout CVHP is currently
underway. The information systems are designed to identify clinical episodes
that are associated with overuse, under-use, or misuse of blood products
in a prospective fashion.
One of CVHP's goals is the development of a total blood management system
that will determine appropriate blood and blood product usage based on
successful treatment regimens within the CVHP system. Target ranges are
calculated according to previous yearly usage rates and projected rates
as determined by revised clinical practice guidelines.
CVHP takes a proactive approach to ensure physician compliance with
its guidelines, namely educating physicians beforehand rather than reprimanding
them after the fact. The company openly communicates its expectations for
its physicians and explains its position that standard treatment protocols
are beneficial not only for CVHP but also for the patients it serves.
When variant usage patterns are determined through computer monitoring,
the company can assess whether the patterns are consistently variant or
represent isolated incidents.
If usage patterns are variant throughout the system, then target ranges
and clinical practice guidelines will be reevaluated. If usage patterns
are isolated as coming from a single physician, then that physician will
be reoriented as to the established clinical practice guidelines.
An important aspect of this approach is the cultural fit of instrument
panels. Physicians at CVHP have been involved in other capitated payment
programs with successful implementation in the past few years.
In one of the early examples of instrument panel benefits, three physician
outliers were identified based on adverse outcome rates. After reorientation
of the physicians, adverse outcome rates decreased from 30% to 4% within
In addition to instrument panels, CVHP has devised other strategies
to succeed in a capitated payment environment. For example, they have entered
into a blood usage risk-share agreement with their main blood service provider,
HemaCare works with CVHP to develop target ranges for each individual
blood product, and if CVHP usage falls below those ranges, the cost savings
from lowered utilization are split between CVHP and HemaCare, creating
another incentive for CVHP's proactive approach to its blood usage.
CVHP is also attempting to implement widespread use of newer technologies
such as leuko-reduced platelet products using the COBE LRS system, which
HemaCare provides at no additional charge. The use of leuko-reduced products
eliminates the need for bedside filtration units and cytomegalovirus testing,
as well as lowering required nursing administration time, a cost benefit
that would be maintained even if health care providers were charged more
for leuko-reduced products.
The shift from externally based report card programs to provider-initiated
integration of guidelines and instrument panels could be very beneficial
to the blood banking industry as a whole, especially as medical payment
strategies move toward capitation.
The teamwork and analysis that are required to implement such a performance
improvement strategy are likely to enable providers to thrive in a rapidly
changing health care environment, a secondary effect of performance improvement
programs that has been previously documented.
Health care providers who use performance measures to focus on individual
components within the health care system, such as blood banking, while
considering their use as part of a larger integrated delivery system are
in a better position to determine and implement effective performance measures.
Use of effective performance measures brings health care providers one
step closer to improving patient treatment outcomes while at the same time
achieving a better cost profile. These goals are even more attainable when
advanced performance measures integrating instrument panels with clinical
practice guidelines are implemented.
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