Article: Patient Blood Management Could Bring Life and Savings

Global patient blood management pioneer and longstanding WAPBM Committee Member, Clinical Professor James Isbister, was recently interviewed for a feature article discussing the cost saving potential of PBM, its history and its capacity to improve patient outcomes. 

Patient Blood Management Could Bring Life and Savings

Health initiative focused on patients’ blood greatly improves patient outcomes and lowers costs by millions.

In 1976, Doctor James Isbister joined German surgeon Konrad Messmer on a tour of Australia, as a ‘supporting act’ to the Professor’s lectures on managing blood in surgical patients. A consultant haematologist at Sydney University Medical School, Dr Isbister had long been an advocate for prioritising the blood of the patient over donor blood.

At the time, transfusion of blood was often seen as a prophylactic treatment – intended to prevent diseases – rather than just an after-the-fact measure. Dr Isbister’s lectures were an opportunity to communicate his ideas, based on years of observing poorer ICU outcomes for patients receiving blood.

The lectures saw little attendance, with many of those that did belong to Australian branches of the Jehovah’s Witnesses. It soon became apparent that these groups – one of the most famous groups to refuse blood and tissue donations – were attempting to use Isbister’s ideas to drum up support for religious exemptions. Whilst this could be argued in retrospect as co-opting the lectures, there was merit to it.

According to a 2016 review, Jehovah’s Witnesses lose half as much blood as normal patients do during cardiac surgery. They were a third less likely to suffer a stroke, and a third as likely to suffer a heart attack. He may have disagreed with their reasoning, but it was clear to Isbister that something deeper was at play.

 

“Bloodless surgery” had been related to Jehovah’s Witnesses for some time. It referred to the different treatment style surgeons adopted when they took on a Witness as a patient. The principle was to minimise blood loss the patient may experience during surgery. Where this could be corrected with a transfusion in other patients, a Witness would refuse any such measure. The focus had to be on the blood already in the patient, and this difference had to be accounting for improvement in postoperative outcomes.

Dr Isbister continued his interest in reducing the clinical use of transfusions into the early 2000s and expanded the idea to other conditions, such as anaemia. A condition where the blood has decreased levels of haemoglobin (the protein that carries oxygen), anaemia affects approximately two billion people worldwide according to a 2018 study published in the Lancet. It is one of several dangerous conditions relating to blood loss, as patients with anaemia are threatened with critically low oxygen levels before they can naturally replenish their blood.

A 2005 meeting of the Medical Society for Blood Management saw these ideas come together, with Isbister coining the term ‘Patient Blood Management’ (PBM). “It came off the top of my head,” says Isbister, now a Professor Emeritus of Clinical Medicine. With his colleagues, Prof Isbister developed the term into three main ‘pillars’, with the patient’s understanding of all three being vital to proper treatment. “Your blood is important to you, whatever is going on,” Isbister elaborates. He believes that keeping a patient involved in the processes allows them to better advocate for themselves. 

Pillar 1: Optimise the levels of blood before procedures

“You explain… to any patient when you find they’ve got a problem,” says Prof Isbister. He stresses that problems with blood are no different. Indeed, given that blood interfaces with almost every system in the body, blood is a vital part of the body.

Any problems that are found or were pre-existing need to be addressed; anaemia, iron deficiency, hypo/hypertension. The list goes on, and any of them can increase the risk of complications in other procedures. There may well be nothing wrong with the patient’s blood; it is crucial to know what is going on in the body before any procedure.

Pillar 2: Minimise the loss of blood during procedures

Prof Isbister explains that the loss of blood during procedures must be reduced as much as possible. “Unless it’s absolutely essential,” he concludes, adding a caveat to the pillar. He continues that it is dependent on the nature of the procedure what ‘minimise’ and ‘essential’ specifically mean. A blood draw – taking small blood volumes for testing – is logically impossible to cause zero blood loss, whilst in some surgeries, blood loss can deteriorate into a life-threatening situation.

A vital component of this is how much understanding the patient has of the procedure and its associated risk of blood loss. Clinicians must communicate this risk and the risks of blood transfusion, if the patient is to give properly informed consent. “It’s always important you get an idea of what they always understand,” says Isbister. He says this ought to apply not just to PBM, but “in all of medicine.”

Pillar 3: Promote the reproduction of the patient’s blood

Prof Isbister describes this as “the interesting one”. He explains that the body has a large reserve of blood already; the average human has around four to six litres of blood at any given time. Of that, you can comfortably lose around half a litre or so, hence why the average blood donation is 470 mL.

“The body can respond to losses,” he notes. The traditional treatment for major blood loss was a straightforward blood transfusion. Prof Isbister argues that it’s in the patient’s best interests for clinicians to promote blood reproduction and manage any nutrient/mineral deficiencies.

On paper, PBM was a simple and effective innovation. Reducing requirements and costs for blood donation and storage, whilst improving patient outcomes for non-surgical and surgical hospital visits alike. However, medicine is full of ideas that sound good on paper but do not stand up to the stresses of real conditions.

 

In 2008, the Western Australian Department of Health set out to test just that; the efficacy of PBM in an active public system. Having previously had success with PBM in one of its private hospitals in Fremantle, the Department overhauled the clinical procedures in its four major public teaching hospitals – Fiona Stanley, King Edward Memorial, Royal Perth, and Sir Charles Gairdner Hospitals – to focus on PBM.

Over six years, more than 600,000 admitted patients were tracked at the four sites. It was a resounding success. Mortality, length of stay, risk of stroke, and risk of infection, all decreased by noticeable margins. These stemmed from a drop in blood transfusions of over two-fifths, corresponding to savings on the order of tens of millions of dollars.

Prof Isbister says he had “no doubt from the beginning” that the study would demonstrate the merits of PBM. “It was addressing what we call the Three E’s,” he explains, as a summary of the landmark study’s conclusions. “The evidence, the ethics, and the economics,” continues Isbister. All three need to be demonstrated as improved under PBM, and if the study weren’t aimed at all three, it simply wouldn’t have had the same impact.

“Not only was it a research case, it was a good business protocol,” concludes Prof Isbister.

The wider research community – Australian and international – had mixed reactions to the substantial shift in clinical practice PBM represented. Although the amount of blood donated is growing with the world’s population, demand for blood without the implementation of PBM is projected to greatly exceed its supply. The core idea of PBM contradicts this; a large portion of this demand is unnecessary.

Speaking to the ABC in March of this year, Perth ICU specialist Simon Towler reiterated the unnecessary nature of many blood transfusions. “If you transfuse somebody where they don’t really need it, it’s all risk and no benefit,” he commented. He recalls studies as far back as 1999 that show mortality improves if blood is transfused more sparingly. “The evidence base around the adverse effects of transfusion has continued to grow,” he summarised.

This is not intended to scare people away from donating, especially in the wake of the COVID-19 pandemic. With the surge of cases in January and February, Dr Anastazia Keegan – a Perth-based haematologist – estimates that 100,000 blood donors were in some way impacted by COVID. “Around half a million blood donors every year in Australia,” she says, “do a pretty good job of meeting supply and demand.” The loss of up to one-fifth of donated blood represents a challenge to supply levels that PBM could present a solution for.

Despite its resounding success, PBM’s implementation in WA and proposed implementation elsewhere are controversial. In an interview with PerthNow, Bebe Loff pointed out that Dr Shannon Farmer and Dr Axel Hofmann – lead authors on the WA study and major proponents of PBM – were Jehovah’s Witnesses. An associate professor of ethics at Monash University, Loff said that “the raising of doubt about the safety of blood… can have an impact on people’s willingness to accept blood products… and donate.” Whilst Professor Loff doesn’t question the efficacy of the program as demonstrated by the study, she argues their personal refusal to accept blood transfusions presents a unique question as to the motivations of the program.

 

Medical systems in other Australian states and countries like Belgium, Turkey, and South Africa, have begun to implement PBM over the last decade. A major factor in this was the WHA63.12 resolution in May 2010. This was the World Health Assembly’s recommendation to its member states that the three pillars of PBM be adopted en masse. However, uptake of the programs put together by national governments is slower than expected for a potentially lifesaving change in procedures.

Prof Isbister believes this has a simple explanation; PBM is a paradigm shift. He describes this as a careful process, saying that at the right time you need to “[blow] the whole system up.” Moving too quickly leaves it vulnerable to flaws that could have been addressed ahead of time. Conversely, moving slower leaves little apparent progress until the actual paradigm shift occurs, and the system radically changes.

Isbister calls that the “tipping point” of the shift. “I think at the moment [medical systems] are getting to a tipping point,” he says. Everything has come together; changes to clinical training, implementation of PBM guidelines, and doctors becoming favourable to the change. Despite the pushback from the perspective of blood being the “safest pharmaceutical”, Prof Isbister within the next few years PBM will predominate in the clinical treatment of patients with healthy or unhealthy blood.

Although he retired from clinical work some years ago, Prof Isbister maintains an advisory role on Western Australia’s PBM Executive Committee. He focuses on mentoring younger clinicians around Australia, likening himself to the “vagabond scholars” of Italy during the Black Death. “My ‘progeny’ have ended up doing [PBM],” he says, remarking that ironically, the clinical shift he had such a large role in came into practice only after the end of his clinical career.

“It’s basically a no-brainer for any patient you talk to,” he says, joking that if a patient hears about PBM and its success, it’s only natural to think that “this should have been going on for years!”

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