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Dec 13, 2010 - Email: david.roxby@health.sa.gov.au; [email protected]. 3Australian Red Cross Blood Service, 301 Pirie Street, Adelaide, SA ...
Health Service Research Feature

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Australian Health Review, 2011, 35, 327–333

Red alert – a new perspective on patterns of blood use in the South Australian public sector Rachel L. W. Allden1,5 BCom, MBA, Principal Consultant (Blood Organ and Tissue Programs) Romi Sinha1 MBBS, Senior Information Analyst (Blood Organ and Tissue Programs) David J. Roxby2 BAppSc, MAppSc, ARCPA, Head of Unit (SA Pathology Transfusion Service) Susan Ireland1 BAppSc (Med Lab Science), GradDip (Health Service Mgmnt), Manager (Blood Organ and Tissue Programs)

Paul Hakendorf2 BSc, MPH, Deputy Director (Clinical Epidemiology Unit) Kathryn L. Robinson3,4 MBBS, FRACP, FRCPA, Transfusion Medicine Specialist and Haematologist 1

Department of Health (SA), Level 8, 11 Hindmarsh Square, Adelaide, SA 5000, Australia. Email: [email protected]; [email protected] 2 Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia. Email: [email protected]; [email protected] 3 Australian Red Cross Blood Service, 301 Pirie Street, Adelaide, SA 5000, Australia. Email: [email protected] 4 The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA 5011, Australia. Email: [email protected] 5 Corresponding author. Email: [email protected]

Abstract Objectives. In 2006 South Australia had a red cell issue rate, measured as product issues per 1000 population, 22.4% higher than the national average. A pilot study was undertaken to investigate the disparity in issue rates between SA and the national average with a secondary aim of establishing information on SA red cell use. Methods. A linked electronic database was developed using clinical, epidemiological and red cell transfusion data within hospitals in the SA public sector. Aggregated red cell use across the SA public health sector was analysed by clinical variables such as Diagnosis Related Group (DRG), including speciality related groups (SRGs) and major diagnostic categories (MDCs). The DRGs that were associated with blood use were identified and applied to national hospital separations data in order to derive comparative blood utilisation rates for SA and Australia. Results. Although blood issue and usage by population measure showed a significant difference of 22.4 and 22.0% respectively between SA and Australia, when measured against weighted separations the differences reduced to 7.4 and 7.1% respectively. Conclusion. This study showed the importance of analysing blood issues and utilisation on an activity adjusted basis rather than a raw per capita basis. What is known about the topic? Transfusion practice can be monitored by various methods such as retrospective review of medical records and blood orders, prospective audits and analysis of blood usage by DRG classification. Blood utilisation studies have been used to describe the use of blood for a whole population or hospitals in order to understand the clinical reasons for transfusion. These studies also help to describe current practice, assess variability in practice and suggest areas where improvements in transfusion practice could be achieved. What does this paper add? This study enabled an analysis of red cell usage in South Australia and the factors that can influence blood utilisation rates. This study also emphasised the fact that blood usage is better represented on a hospital activity basis rather than by raw population. What are the implications for practitioners? The major implications for health practitioners would be the key findings related to red cell usage patterns. Firstly, older patients (>65 years) represented 36.5% of admissions and received 56.9% of the total red cells transfused. This has huge implications for future red cell use as an ageing population will both drive up demand and also result in a decreasing red cell donor pool. Secondly, high use of red cells in medical diagnoses such as haematology, medical oncology and gastroenterology confirms the current trend towards increasing use of red cells in  AHHA 2011

10.1071/AH10957

0156-5788/11/030327

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medical diagnoses. This implies the need to focus on reducing reliance on blood use for medical patients and improve transfusion practice by regular audits, dissemination of guidelines and education.

Introduction

Box 1. Key terms Issue, Issues – refers to red cells that have been collected and distributed by the Australian Red Cross Blood Service to pathology services in Australia or South Australia. Data on both SA and national issue rates are presented in this study. Use, Usage, Utilisation – refers to red cells that have been transfused in the hospital setting. Data on SA public hospital transfusion rates (calculated from patient level data) are presented in this study as well as derived aggregated data on SA and national utilisation rates. Product loss – red cells that were issued but not transfused due to product outdating, storage, transport or damage. Product loss represents the difference between issue and utilisation figures. Data on both SA and national product loss rates are presented in this study.

Blood products have a central therapeutic role in clinical medicine. Demand for blood products continues to increase, despite greater attention to the appropriateness of transfusion. This is driven by a greater burden of chronic disease due to aging of the population, increasing severity of illness with better life support technology and newer blood-intensive surgical procedures. In addition, changing population dynamics present significant challenges for the blood supply with up to 60% of transfusions given to patients older than 65 years old.1 A shrinking donor pool, increasing clinical demand and the unique nature of altruistically donated blood puts pressure on the blood supply and increases the risk of shortages. With reduced capacity for a parallel increase in supply as well as changes in blood donor eligibility, the need to better understand the drivers of red cell utilisation becomes even more imperative. Continuous monitoring of blood product usage by auditing and feedback is critical for improvements in transfusion practice.2 Transfusion practice can be monitored by various methods, such as the retrospective review of medical records and blood orders,3,4 prospective audits5,6 and analysis of blood usage by DRG classification.7 Patient classification systems using DRG groupings have been also used for healthcare reimbursements, transfusion costs and predicting the use of blood products.8–10 The DRG casemix classification, based on the concept that treatment episodes for similar patients will consume similar resources, has been used as an appropriate way of funding hospitals in Australia.11 SA currently has in place a leading safety and quality program, namely; BloodSafe.12 Despite the successes that the BloodSafe program has had in improving rates of clinically appropriate transfusions, the unweighted issue rate of red cells to SA per capita was 22.4% higher than the national average in 2005–06. Raw issue rates do not provide an accurate measure of product utilisation as they do not take into account product loss. As well, other factors such as the underlying population age structure, cross-jurisdictional flow of patients, differences in hospital throughput rates and differences in clinical practice have an effect on product demand and therefore utilisation. The principal aim of this study was to investigate the disparity in issue rates between SA and the national average with a secondary aim of establishing information on SA red cell use that could be used to drive transfusion clinical practice improvement projects.

transfusion related pathology details in order to have a complete record of the transfusion service episode for further analysis. Ethics approval from the Department of Health’s Human Research Ethics Committee was sought and granted before study commencement. The key unit of measurement for the data linkage was the number of red cells or whole blood units transfused during a single stay in hospital during calendar year 2006. Only homologous units collected via the Australian Red Cross Blood ServiceA were included. Autologous units were excluded on the basis that these units are generally collected as part of patient specific private arrangements. Paediatric packs are split into a set of 4 and each unit is usually counted as being equivalent to 0.25 adult units. However for the purposes of this study the volume effect of paediatric units was small and all blood units were counted as one.

Methods Study scope and datasets The period chosen was calendar year 2006 as this was the latest complete year available at the time of study commencement for both hospital and pathology based data. The project enabled linking of patient hospital morbidity records and blood

Stage 1 The linked electronic database enabled data analysis on aggregated red cell use across the SA public health sector by clinical variables such as DRGs, surgical and medical procedures (International Classification of Disease (ICD) codes) including speciality related groups (SRGs) and major diagnostic categories

A

Data linking Pathology and hospital morbidity datasets from 25 SA public sector hospitals were linked on the basis of matching patient and hospital identifiers along with the transfusion date(s) (from the pathology dataset) being on or between the hospital admission and separation dates (from the hospital morbidity dataset). The end result was a complete set of electronic hospital morbidity records with appended pathology fields indicating whether a transfusion had occurred during the hospital stay and the total number of units. Data analysis Two primary types of analysis were performed:

Australian governments fully fund the Australian Red Cross Blood Service for the provision of blood products and services to the Australian community.

Patterns of blood use in the SA Public Sector

(MDCs);13 as well as demographic variables such as age and gender. Key statistics produced from this analysis included average red cells transfused across clinical or demographic groups, as well as the range of units and the proportion of single unit transfusions. Stage 2 Data and results from the first stage then enabled the key issue of the differing red cell issue rates between SA and the Australian average to be more fully explored. The comparative analysis in this stage would ideally be between the public sectors of SA and Australia involving application of the DRG average transfusion rates under stage 1 to Australian public sector DRG activity. The resulting expected aggregated Australian public sector blood use could then be compared against actual use to determine any real differences in usage rates. However, blood data split between the public and private sector are not readily available, due in part to disparate systems but also to regular inter-sector product transfers. As a consequence a proxy methodology was adopted. Australian Institute of Health and Welfare published activity (hospital separations) data for all Australian Hospitals combined and for all SA hospitals combined (2005–06)14 were then used in this analysis along with public and private sector cost weights (2005–06) published on the Commonwealth Department of Health and Ageing’s National Hospital Cost Data Collection (NHCDC).15 Cost weight data are used for outcomes measurement, performance information and policy development and provide the healthcare industry with a nationally consistent method of classifying all types of patients, their treatment and associated costs. Using data obtained from stage 1, the DRGs that were associated with blood use in the SA public sector were identified and this analysis was limited to this more comparable activity dataset. Weighted separations for this data subset were calculated by weighting the raw separations for each included DRG by the relevant cost weight (with public cost weights applied to public separations and private weights to private data) with summation of the results. Weighted separations per 1000 population for SA and Australia were calculated and compared to assess differences in hospital throughput rates. Comparisons were then made between SA and Australia regarding weighted activity adjusted blood issue rates. Finally, the addition of data on combined public and private sector product loss rates was applied to the issue data in order to derive comparative blood utilisation rates. Results In the study period, 49 041 units were issued by the Australian Red Cross Blood Service to SA public sector hospitals. After allowing for product loss, as reported to the Australian Red Cross Blood Service (Electronic Returns Information Capture, ERIC, see http://www.transfusion.com.au/eric, accessed July 2010), a total of 47 098 units were presumed to have been transfused in the public sector. A further 2734 units were known to have been transferred to the private sector and 954 units related to small hospitals. These were not within scope because of the low number of transfusions that occurred or the profile not being that of a hospital where repeated transfusion activity was to be expected.

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This resulted in a total of 43 324 units available for matching in this study of which 92.6% (40 124) were matched. Of the 327 995 admissions to the hospitals in scope in 2006, 3.9% (12 803) received a total of 40 124 red cells or whole blood at an overall average per patient transfused of 3.1 units. Females had a higher representation in hospital admissions than males (1.04 : 1), but males received more transfused units (1.13 : 1). Older (65 years) patients represented 36.5% of admissions, but received 56.9% (22 843) of the total units transfused including 43.5 % (9937) for medical reasons and 49.2% (11 250) for surgical reasons. Surgical admissions represented 22.0% of admissions and used 46.1% of transfused red cells. By contrast, medical admissions represented 69.7% of admissions and used 47.6% of transfused red cells. Obstetrics patients represented 7.1% of admissions and received 3.4% of total units transfused. SRGs related to the treatment of haematological malignancies, orthopaedics, GIT endoscopy, cardiothoracic surgery, medical oncology, colorectal, vascular and general surgery formed the largest clinical entities, accounting for over half (57.9%) of all red cells transfused. Figure 1 shows the red cell distribution among the SRG groups. The total number of DRGs associated with blood transfusion in 2006 was 513. Twenty-three percent (151) of DRGs with recorded admissions in 2006 did not use any red cell units. Table 1 shows the top 20 DRGs associated with transfusion accounting for 47% of total red cells transfused. When national and SA activity levels for DRGs associated with blood use (as per this study) are compared, SA’s total health sector weighted activity per capita is 14% higher compared to national activity. Table 2 summarises the national and SA issue and utilisation rates based on population and weighted activity. In 2005–06 SA had a per capita issue rate 22.4% above the national average and 22.0% above for the per capita utilisation rate. However, when issues and utilisation are measured on a weighted activity basis the rates drop by approximately two-thirds to 7.4 and 7.1% respectively.

Discussion This study presents an analysis of red cell usage in public sector hospitals within SA. There was some fallout of record matching due to several reasons, including patients being treated in emergency departments without a recorded unit record number (required for matching), retrievals in the field, coroner’s case files not yet released, patient transfers between hospitals and campuses, and incomplete data capture. The overall match rate of 92.6% for the public sector hospitals in scope compares well with other similar studies, such as the Canadian survey of red cell use in 45 hospitals in central Ontario, which achieved a match rate of 85%.16 Older patients (65 years old) utilised 56.9% of the total units transfused, comparable with the study of Vamvakas et al.17 which documented use of 53% of all transfused red cells by patients over 65 years of age. Given an older population demographic for SA, with associated needs for higher levels and greater complexity of hospital services, this will have implications for future blood requirements in this group for both surgical and medical reasons.

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Endocrinology 1% Neurology 1%

Renal medicine 1% Renal dialysis

Chemotherapy and radiotherapy 1%

Plastic and reconstructive surgery 1%

Transplantation 1% Non-acute 1%

1%

Interventional cardiology 1%

Cardiology 2% Respiratory medicine 2% Neurosurgery 2%

Haematology 27%

Upper GIT surgery 2% Urology 2% Gynaecology 2% Gastroenterology 3% Colorectal surgery 3% Vascular surgery 3%

Tracheostomy 10%

General medicine 3% General surgery 3% Obstetrics 3% Medical oncology 4%

Orthopaedics 8% GIT endodoscopy 6%

Cardiothoracic surgery 5%

Fig. 1. Summary of red cell units transfused by Speciality Related Groups in South Australia – 2006.

Our study also showed that medical admissions represented 47.6% of total red cell usage, consistent with the trend towards increasing use of red cells in medical diagnoses reported in the Wallis et al. UK study.18 Generally audits of red cell use have focussed on surgical specialities, such as orthopaedics and cardiothoracic surgery, which represented 8 and 5% of total use of red cells respectively in this study. This study highlights significant red cell use outside these surgical specialities with haematology patients and complex, high acuity patients, as indicated by the need for tracheostomy, accounting for 27 and 10% respectively of total red cells transfused. High transfusion requirements for haematology and tracheostomy DRG groups were also comparable with other studies.8,11 Whyte and Brook,11 in their study on suitability of DRGs to quantify blood use, had a similar representation of DRGs with a high association of transfusion. The mean red cell units transfused per separation (for patients who received blood) for red blood cell disorders, tracheostomy, and lymphoma and non-acute leukaemia was 3.0, 8.8 and 3.2 in their study compared to 2.4, 8.1 and 2.2 respectively in our study.

However, there are limitations in using DRGs to understand red cell utilisation. For instance the tracheostomy grouping (DRG A06Z) generally includes patients with a multitude of diagnoses in the ICU setting. Diagnoses related to aortic aneurysm, acute myocardial infarction, and sepsis were some of the more common underlying conditions in patients transfused within this DRG in our study. The increased transfusion rate for these patients relates to both the severity and nature of the underlying condition as well as the length of stay in intensive care where almost all of the transfusions took place. As another example, DRGs associated with gastrointestinal endoscopy capture patients requiring endoscopic intervention for gastrointestinal haemorrhage or the underlying disease and not necessarily the procedure or intervention undertaken per se. It is therefore important that the data generated from studies such as these be shared with the relevant clinical community in order to establish meaningful approaches to presenting the data at SRG, DRG, diagnosis or procedure levels. This approach has been taken in SA where data are presented in such a way as to answer key clinical questions about local and State-wide blood use. Transfusion data

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Table 1. Summary of admissions and transfusion details by top 20 Diagnosis Related Groups in South Australia, 2006 CPB, Cardiopulmonary Bypass Speciality related diagnosis

Diagnosis related group

Tracheostomy Haematology

A06Z – tracheostomy or ventilation >95 h Q61A – red blood cell disorders with catastrophic comorbidities Q61B – red blood cell disorders with severe comorbidities Q61C – red blood cell disorders without catastrophic or severe comorbidities R61C – lymphoma and non-acute leukaemia, same day R61A – lymphoma and non-acute leukaemia with catastrophic comorbidities R61B – lymphoma and non-acute leukaemia without catastrophic comorbidities R60A – acute leukaemia with catastrophic comorbidities R60B – acute leukaemia with severe comorbidities Q60A – reticuloendothelial and immunity disorders with catastrophic or severe comorbidities I08A – other hip and femur procedures with catastrophic or severe comorbidities I03B – hip replacement with catastrophic or severe comorbidities or hip revision without catastrophic or severe comorbidities G02A – major small and large bowel procedures with catastrophic comorbidities G61A – GI haemorrhage age >64 or with (catastrophic or severe comorbidities) G42A – other gastroscopy for major digestive disease G46A – complex gastroscopy with catastrophic or severe comorbidities F04A – cardiac valve procedure with CPB pump without invasive cardiac investigation with catastrophic comorbidities F06A – coronary bypass without invasive cardiac investigation with catastrophic or severe comorbidities F08A – major reconstruct vascular procedures without CPB pump with catastrophic comorbidities W01Z – ventilation or craniotomy procedures for multiple significant trauma

Orthopaedics

Colorectal surgery Gastroenterology Gastrointestinal endoscopy

Cardiothoracic surgery

Neurosurgery

linkage is not readily available within individual hospitals so that the central provision of such data helps to inform clinical practice improvement initiatives and provide measures that can be readily followed over time. This study also enabled the key matter of the differing red cell issue rates between SA and the Australian average to be more fully explored. It showed that SA hospital throughput levels were markedly higher, which may be due to our older population demographic with its associated needs for higher levels and

Admissions

Admissions with transfusion

Percentage of admits with transfusion (%)

Units transfused

Average units transfused for admissions with transfusion

734 184

466 142

63.5 77.2

3795 434

8.1 3.1

307

201

65.5

571

2.8

3536

1289

36.5

3123

2.4

2112

922

43.7

2029

2.2

176

117

66.5

424

3.6

732

244

33.3

655

2.7

125

109

87.2

566

5.2

382

265

69.4

621

2.3

339

182

53.7

574

3.2

528

313

59.3

854

2.7

520

230

44.2

631

2.7

377

191

50.7

681

3.6

463

147

31.7

434

3.0

515

204

39.6

647

3.2

349

191

54.7

749

3.9

121

87

71.9

380

4.4

316

199

63.0

594

3.0

150

98

65.3

477

4.9

85

63

74.1

491

7.8

possibly greater complexity of hospital services, and SA’s role as a referral centre for Northern Territory patients. Taking into account just the different weighted activity levels, the difference between national and SA issue rates dropped from 22.4% on a raw population basis to 7.4% on an adjusted activity basis. A similar drop was seen when issues data were adjusted for product loss to explore comparative rates of blood utilisation (22.0 to 7.1%). Although weighted hospital activity is not by itself the only driver of blood use, it is a more comprehensive indicator than raw

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Table 2. Blood issues to and therapeutic blood usage within the Australian and South Australian public and private health sectors 2005–06 – comparisons against population and weighted activity measures Sources: monthly supply reports from the National Blood Authority20; population data from ABS population estimates as at December 200521; AIHW Australian hospital statistics 2005–0622; National Hospital Cost Data Collection Round 10 (2005–06) cost weights15; Australian Red Cross Blood Service Electronic Returns Information Capture (ERIC) System (http://www.transfusion.com.au/eric) Australia Whole blood issues 2005–06 Red cell issues 2005–06 Total Product lossA Total therapeutic use Population at 31 December 2005 Issues per 1000 population Usage per 1000 population Total weighted separationsB 2005–06 Total weighted separations per 1000 population 2005–06 Issues per 1000 weighted separations Usage per 1000 weighted separations

1509 757 034 758 543 5.6% 716 065 20 452 334 37.1 35.0 5 745 401 280.92 132.0 124.6

SA 121 70 090 70 211 5.9% 66 069 1 546 274 45.4 42.7 495 034 320.15 141.8 133.5

Difference (%) –

22.4 22.0 – 14.0 7.4 7.1

A

Product loss is equivalent to non-therapeutic use resulting from product expiry, breakage, storage and transport issues. The percentages for SA and Australia are based on the average monthly levels reported for 2007–08, 2008–09 and 2009–10 as complete and comparable public and private sector data for 2005–06 were not available. B Weighted separations are based on raw separations data from the Australian Institute of Health and Welfare ‘Australian Hospital Statistics 2005–06’, Supplementary Detailed Tables S12.3, S12.4, S12.11 and S12.12 multiplied by the relevant AR-DRG v5.0 Round 10 (2005–06) National Cost Weights for the Public and Private Sectors. Data have been extracted for both South Australia and Australia (inclusive of South Australia) for this comparison, using only those DRGs that utilised blood in South Australian public hospitals in 2006 (as ascertained by this study).

population figures. Therefore, blood issues and usage data are better represented on an activity basis rather than by raw population. The authors acknowledge the data limitations of the methodology applied for the comparative analysis. The key aim of this analysis was to illustrate the effect on the Australian and SA ratios by assessing blood issues and usage against hospital activity levels instead of against population measures, rather than to determine precise rates. This study has led to several recommendations related to red cell use in SA. As each unit costs approximately $35019 to collect and process with additional costs to the health system being incurred in terms of storage, testing, transport, product administration time and adverse event management, a better understanding of transfusion practice and appropriateness is important to assess the potential future effect on already stretched health budgets. It is intended to continue this study on a regular basis in order to build trends in changing indications for red cell transfusion, as well as other blood products, monitor links between hospital activity levels and blood use and provide input into transfusion related continuous practice improvement initiatives. The results of this study provide a good baseline on which to compare utilisation rates both within SA over time and with other Australian jurisdictions. Future studies are being expanded to include haemoglobin and other laboratory results such as red cell indices, ferritin and EGFR (estimated glomerular filtration rate) to better understand the threshold for transfusion and also to determine the incidence of pre-operative anaemia in some of the surgical specialties and associated transfusion requirements. The results of future studies

will provide support for such initiatives within individual hospitals and clinical areas. Conclusion Although there are many factors that can influence blood issue and utilisation rates, at a broad level the data indicate that the apparent higher issue rate of red cells can be mostly explained by the comparatively higher hospital throughput rates in SA. Nevertheless there may still be opportunities for improvement within hospitals and specialities and benchmarking with other jurisdictions would be an advantageous next step. Competing interests The authors declare that no conflicts of interest exist. Acknowledgements The authors gratefully acknowledge Ken Davis and Rosemary Velardo from SA Pathology for data provision; Professor John Turnidge, Chair and all members of the Red Cell Utilisation Study Steering Committee for their input and guidance; and Barbara Parker, BloodSafe Nurse, for the literature search.

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Manuscript received 23 August 2010, accepted 13 December 2010

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