Blood utilization and mortality in victims of gun violence.

BACKGROUND: Blood transfusion can be lifesaving for patients with hemorrhage; however, transfusion requirements for victims of gun violence are poorly understood. STUDY DESIGN AND METHODS: In an urban, Level 1 trauma center, 23,422 trauma patients were analyzed in a retrospective cohort study. Patients with gunshot wounds (GSWs) (n = 2,672; 11.4% of trauma patients) were compared to those with non-GSW traumatic injuries from 2005 to 2017, to assess blood utilization. RESULTS: The GSW cohort was approximately five times more likely to require transfusion (538 of 2672 [20.1%] vs. 798 of 20,750 [3.9%]; p < 0.0001), and the number of blood component units transfused per patient was approximately 10 times greater (3.3 ± 13.5 vs. 0.31 ± 3.8 units/patient; p < 0.0001), compared to the non-GSW cohort. The risk-adjusted likelihood of requiring high-dose transfusion was greater in the GSW cohort (odds ratio, 2.38; 95% confidence interval, 1.14-5.80), and requirements were increased for all four blood components (red blood cells, platelets, plasma, and cryoprecipitate). Patients with GSWs had approximately 14 times greater overall mortality (653 of 2672 [24.4%] vs. 352 of 20,750 [1.7%]; p < 0.0001]. Compared to non-GSW penetrating injuries (e.g., stab wounds), those with GSWs had approximately four times higher transfusion requirements (3.3 ± 13.5 vs. 0.80 ± 3.8 units/patient; p < 0.0001), and approximately eight times greater overall mortality (653 of 2672 [24.4%] vs. 28 of 956 [2.9%]; p < 0.0001). CONCLUSIONS: Compared to other traumatic injuries, GSW injuries are associated with substantially greater blood utilization and mortality. Trauma centers treating GSW injuries should have ready access to all blood components and ability to implement massive transfusions.

Implementing a Health System-wide Patient Blood Management Program with a Clinical Community Approach.

BACKGROUND: Patient blood management programs are gaining popularity as quality improvement and patient safety initiatives, but methods for implementing such programs across multihospital health systems are not well understood. Having recently incorporated a patient blood management program across our health system using a clinical community approach, we describe our methods and results. METHODS: We formed the Johns Hopkins Health System blood management clinical community to reduce transfusion overuse across five hospitals. This physician-led, multidisciplinary, collaborative, quality-improvement team (the clinical community) worked to implement best practices for patient blood management, which we describe in detail. Changes in blood utilization and blood acquisition costs were compared for the pre- and post-patient blood management time periods. RESULTS: Across the health system, multiunit erythrocyte transfusion orders decreased from 39.7 to 20.2% (by 49%; P < 0.0001). The percentage of patients transfused decreased for erythrocytes from 11.3 to 10.4%, for plasma from 2.9 to 2.2%, and for platelets from 3.1 to 2.7%, (P < 0.0001 for all three). The number of units transfused per 1,000 patients decreased for erythrocytes from 455 to 365 (by 19.8%; P < 0.0001), for plasma from 175 to 107 (by 38.9%; P = 0.0002), and for platelets from 167 to 141 (by 15.6%; P = 0.04). Blood acquisition cost savings were $2,120,273/yr, an approximate 400% return on investment for our patient blood management efforts. CONCLUSIONS: Implementing a health system-wide patient blood management program by using a clinical community approach substantially reduced blood utilization and blood acquisition costs.

Improving healthcare value through clinical community and supply chain collaboration.

BACKGROUND: We hypothesized that integrating supply chain with clinical communities would allow for clinician-led supply cost reduction and improved value in an academic health system. METHODS: Three clinical communities (spine, joint, blood management) and one clinical community-like physician led team of surgeon stakeholders partnered with the supply chain team on specific supply cost initiatives. The teams reviewed their specific utilization and cost data, and the physicians led consensus-building conversations over a series of team meetings to agree to standard supply utilization. RESULTS: The spine and joint clinical communities each agreed upon a vendor capping model that led to cost savings of $3 million dollars and $1.5 million dollars respectively. The blood management decreased blood product utilization and achieved $1.2 million dollars savings. $5.6 million dollars in savings was achieved by a clinical community-like group of surgeon stakeholders through standardization of sutures and endomechanicals. CONCLUSIONS: Physician led clinical teams empowered to lead change achieved substantial supply chain cost savings in an academic health system. The model of combining clinical communities with supply chain offers hope for an effective, practical, and scalable approach to improving value and engaging physicians in other academic health systems. IMPLICATIONS: This clinician led model could benefit both private and academic health systems engaging in value optimization efforts. LEVEL OF EVIDENCE: N/A.

Developing a Measure of Value in Health Care.

There is broad support to pay for value, rather than volume, for health care in the United States. Despite the support, practical approaches for measuring value remain elusive. Value is commonly defined as quality divided by costs, where quality reflects patient outcomes and costs are the total costs for providing care, whether these be costs related to an episode, a diagnosis, or per capita. Academicians have proposed a conceptual approach to measure value, in which we measure outcomes important to patients and costs using time-driven activity-based costing. This approach is conceptually sound, but has significant practical challenges. In our commentary, we describe how health care can use existing quality measures and cost accounting data to measure value. Although not perfect, we believe this approach is practical, valid, and scalable and can establish the foundation for future work in this area.