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The consequences of under recognition, under-diagnosis and under-treatment, regardless of clinical circumstances, can have serious health ramifications.
It’s an important topic, relevant to every hospital and health system.
A: We started a patient blood management program at our hospital back in 2006. We started where most hospitals start- looking at elective orthopedic surgical patients who were anemic- to treat that anemia prior to surgery. Our patient population initially consisted of elective total joint replacement patients: hip, and knee replacement, in an effort to reduce exposure to transfusion in the peri-operative period. We were very successful with that but soon recognized that a lot of the patients who are having elective surgery had anemia for a long period of time that hadn’t been addressed and hadn’t been managed. Some of these preexisting comorbidities showed us that there was a much broader need for anemia management than just the elective surgical patient population. That’s one of the major gaps that we see today; more and more hospitals have recognized the value of preoperative anemia management for the patients who are having elective surgery, but they’ve under-recognized, and don’t address, the background of significant anemia as a health need, as a burden in the community. These patients would benefit from anemia management in the outpatient setting. And recognizing that a significant percentage of patients who are hospitalized for nonsurgical indications develop hospital-acquired anemia, and that that may not be addressed while they’re still in the hospital adequately. Our recognition of the need to manage anemia in elective surgical patients led us to recognize that there is a gap in care for anemia in the broader patient community, and that anemia is, really, a community and population health challenge that we can address with a comprehensive anemia management initiative.
A: The gap that was easiest to recognize was the reliance on our primary care doctors to diagnose and treat patients with anemia. Secondary to that was the treatment and communication process from patient to surgeon to primary care doctor to infusion center. And the third piece was chronic disease anemia and the economic burden and quality of life impact. We discovered a lot of this in the same way (Dr. Gross described), through joint replacement cases while we were running a patient blood management program in the hospital. Since that time, my goal has been to treat anemia as a standard of care and to simplify the process for are of these patients. Closing this gap in care is good for the patients, it’s good for all of the clinical stakeholders, and good for the hospital’s bottom line by pre-habilitating these patients, treating anemia as standard of care. It’s predictable risk.
A: I have experienced all of the gaps and challenges shared. The point about having a dependence on providers, not only to diagnose and recognize anemia as a problem and treat, is a challenge. So many primary care physicians simply don’t recognize anemia as something abnormal. We would hear from patients after we identified them, “My primary care provider had said that my blood count was a little low, but that’s normal because I’m a woman,” or “This is what happens when we get older and not to be concerned.” It was concerning when you rely on the surgeon’s office to refer patients for the preoperative anemia management program evaluation and they’re not offering the standard of care that all patients deserve, especially in high blood loss procedures.
Communication gaps impact the effectiveness of the program and it starts with the patient; if they’re not well-informed of the reason they’re even being evaluated or enrolled in a program, it often can be a failure. And, if their surgeon doesn’t know they’re anemic or that there is a care plan that offers strategies to minimize bleeding and blood loss in the surgery arena, that too can impact the care for that patient. Oftentimes, it can lead to a default of transfusion. Communication with all the stakeholders can be very time consuming without a good process. We have a short time to evaluate and treat our patients, and coordinate care, so it’s important that we have the highest reliable process to make that happen. In my previous program (presurgical anemia program), we identified so many patients with chronic anemia as well that we wanted to also offer a solution to expand and help other populations (i.e. congestive heart failure and OB, non-dialysis CKD, and bariatric populations), putting a process in place to easily set up a referral and treatment process and make the anemia management program a center of care across many areas, not just the surgical population.
A: I think in multiple ways. Let’s break this out into the surgical patient population and the nonsurgical patient population. The elective surgical patient, a patient who’s enrolled in anemia management prior to their surgical procedure, is going to have a lower risk of transfusion. They’re likely to have a shorter length of stay, if it’s a surgical procedure that involves an inpatient admission, and they’re less likely to be discharged from the hospital with anemia, if anemia was managed prior to their surgical procedure. For the nonsurgical patient population, there are common comorbidities that are associated with anemia, and if the anemia is managed, the clinical outcomes from those comorbidities are improved. The example where we have the most robust evidence base for that recently is in the chronic heart failure patient population, where multiple studies have demonstrated that early recognition of anemia and treatment actually reduce both mortality and the risk of hospitalization, both cardiovascular hospitalization, and hospitalization for other reasons. Managing anemia in heart failure patients improves their overall quality of life. It’s important to develop a care plan across the full spectrum of care that includes the outpatient population prior to a hospital stay, continue that care if and when they are hospitalized, and develop a follow-up management plan after discharge.
Population health management, no question. We need an emphasis on anemia management as a chronic disease and managing the disease for all patients in and around a specific hospital’s population. We need to carefully use data-driven environments so that we know where the patients are who are at risk. We need to know the individual economics around the hospitals’ treatment and identification of patients with anemia, and how that rolls into other chronic disease states. These are all impacts for the communities that hospitals serve and to be able to identify and treat these patients reduces the overall cost of care. I truly believe this is our social and economic responsibility as leaders in healthcare. Number one, driving down the cost of healthcare for the American public. Number two, improving the lives and outcomes of patients inside and outside the hospital setting.
It is not okay to walk around anemic when it is a modifiable risk factor – we know how to identify it; we know how to treat it.
Physician leadership is also critical to the success of the coordinated care plan. Anemia is an off-the-radar disease. We are building a coalition of advocates who understand the clinical impact of anemia on the entire population and, with the help of new tele-health rules, will put anemia on the radar.
A: There was a study that was published not long ago in The Lancet that looked at anemia globally. In this study of the global, regional, and national incidence and prevalence of anemia, it was discovered that anemia affected 2.4 billion people worldwide (2015) and that this disability, compared to the disability associated with 310 other diseases, was the disability that affected the greatest number of people worldwide. I think it’s important to think about that in terms of the scope of public health. The goal of anemia management isn’t simply to reduce or eliminate transfusion. Anemia is a potent multiplier of morbidity and mortality. There was another study with over a million Medicare patients that showed if you had anemia only, you had a twofold higher risk of mortality than a group of people who didn’t have anemia, chronic kidney disease, or heart failure. But if you combine anemia with chronic kidney disease, the risk of mortality was more than threefold higher. And a combination of heart failure, chronic kidney disease, and anemia, those three conditions together multiplied your risk of two-year mortality six-fold. It’s important to treat anemia because we can actually reduce mortality, as well as improve the quality of life in patients with heart failure and patients with chronic kidney disease.
A: One of the dependencies in developing a program inside of the health system are the challenges in isolating the true costs of anemia. When you really dig in and examine aggressive anemia treatment – all of the connected pieces, the care plan, the medications, the time in the chair for the patient – you can’t ignore that by treating the patient earlier you offset significant cost by helping establish fewer admissions, shorter length of stay and reductions in other expensive services for the treatment of anemia-related outcomes. There have been a number of published studies demonstrating the economic benefit of treating anemia, and the economic burden when you fail to do so.
You’ve got our attention.