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New Strategies Needed to Monitor Blood Usage

New Strategies Needed to Monitor Blood Usage

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%.[1] Many of the regional blood centers are operated by the American Red Cross, which collects approximately 45% of the blood in the United States.[2]

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.[3] 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.[4]

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 medical resources.

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 hospitals.[5-8]

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).[9]

Validity Questioned

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 care settings.

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.[10]

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.[11]

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 outlier.

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.[11]

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, or monitor physician compliance with them, is especially applicable to the blood banking industry, since blood usage rates can vary widely among physicians.

Hospital administrators, faced with the task of improving cost-effectiveness, have traditionally taken a reactive, report card type approach to standardizing treatment protocols among their physicians, rather than a proactive approach.

By singling out and reprimanding physicians with questionable blood usage patterns, the hospital is sending a message: That physicians need to be constantly looking over their shoulder, and if and when their practices are questioned, they may find themselves in an uncomfortable, defensive situation that is not conducive to education or change.

Performance improvement efforts using instrument panels would likely have a positive impact in blood banking by making better, timelier information readily available to physicians and their patients.

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.[12]

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 here.

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.[12]

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 six month.

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 Corporation.

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.

Recommendations

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.[13]

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.

References

1. Wallace EL, Churchill WH, Surgenor DM, et al: Collection and transfusion of blood and blood components in the United States, 1992. Transfusion 35:802-812, 1995.

2. Leveton LB, Sox HC, Stoto MA: HIV and the Blood Supply: An Analysis of Crisis Decisionmaking. Washington, DC, National Academy Press, p. 6, 1995.

3. Wallace EL, Surgenor DM, Hao HS, et al: Collection and transfusion of blood and blood components in the United States, 1989. Transfusion 33:139-144, 1993.

4. Woolhandler S, Himmelstein DU, Lewontin JP: Administrative costs in U.S. hospitals. N Engl J Med 329:400-403, 1993.

5. Pennsylvania Health Care Cost Containment Council: A Consumer Guide to Coronary Artery Bypass Graft Surgery. Harrisburg, PA, 1995.

6. Welch HG, Miller ME, Welch WP: Physician profiling: An analysis of inpatient practice patterns in Florida and Oregon. N Engl J Med 330:607-612, 1994.

7. NY State Department of Health: Coronary Artery Bypass Graft Surgery in New York State. Albany, NY, New York State Department of Health, 1992.

8. Sawyer D, Donaldson S: Surgical Scorecards. Prime Time Live Transcript #248, 1992.

9. Corrigan JM, Nielson DM: Toward the development of uniform reporting standards for managed care organizations: The Health Plan Employer Data and Information Set (Version 2.0). Jt Comm J Qual Improv 19:566-575, 1993.

10. Berwick DM, Wald DL: Hospital leaders' opinions of the HCFA mortality data. JAMA 263:247-249, 1990.

11. Bader B: Rediscovering Quality. Rockville, Md, Bader and Associates, 1992.

12. Ullman M, Metzger CK, Kuzel T, et al: Performance measurement in prostate cancer care: Beyond report cards. Urology 47:356-365, 1996.

13. Gottlieb LK, Margolis CZ, Schoenbaum SC: Clinical practice guidelines at an HMO: Development and implementation in a quality improvement model. Qual Rev Bull 16:80-86, 1990.

 
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