Anemo 2015-02-Hoffman- Considerazioni economiche nella PBM

Dr.rer. medic. Axel Hofmann, ME
Visiting Professor | Institute of Anaesthesiology
University Hospital Zurich - Switzerland
Adjunct Associate Professor | Faculty of Health Sciences
Curtin University Western Australia
Adjunct Associate Professor | School of Surgery
Faculty of Medicine Dentistry and Health Sciences
University of Western Australia
Economic Considerations on Transfusion
Medicine
and
Patient Blood Management
Axel Hofmann 03-2015 Milan

Disclaimer
In the past 5 years, Dr. Hofmann has received fees, honoraria or travel for consulting or lecturing from the following companies
and legal entities:
• Australian Red Cross Blood Service, Brisbane, Australia
• Austrian Institute of Technology, Vienna, Austria
• BBraun Melsungen AG, Melsungen, Germany
• BioMed-zet Life Science GmbH, Linz, Austria
• CSL Behring Lda, Lisbon, Portugal
• CSL Behring GmbH, Marburg, Deutschland
• Fresenius Kabi GmbH, Bad Homburg, Germany
• Hospira Ltd., Warwickshire, United Kingdom
• Janssen-Cilag, Beerse, Belgium
• Johnson & Johnson Ethicon Biosurgery, Somerville, USA
• Johnson & Johnson Medical Pty Ltd, North Ryde, NSW, Australia
• Medical Society for Blood Management, Laxenburg, Austria
• National Blood Authority, Canberra, Australia
• Physicians World GmbH, Mannheim, Germany
• Society for the Advancement of Blood Management, Richmond, VA, USA
• TEM GmbH, Munich, Germany
• The Institute for Patient Blood Management & Bloodless Medicine and Surgery, Englewood, NJ, USA
• United States Department of Health and Human Services, Washington, USA
• Vifor Pharma Ltd., Glattbrugg, Switzerland
• Vifor Pharma Österreich GmbH, Vienna, Austria
• Vifor Pharma Deutschland GmbH, Munich, Germany
• Vision Plus srl, Monza, Italy
• Western Australia Department of Health, Perth, Australia

1
Cost of Transfusion

2
Cost Drivers of
Transfusion

Transfusion Cost Driver (1): Blood Shortage
• The 70- to 80-year-olds have an eightfold
higher RBC consumption than 20- to 40-year-
olds.

Axel Hofmann 03-2015 MilanMamolo M, Scherbov S. Population Projections for Forty-Four European Countries: The Ongoing Population Ageing.
http://www.oeaw.ac.at/vid/download/edrp_2_09.pdf

Transfusion Cost Driver (2):
Newly & Re-emerging Pathogens
✘HBV variants (vl)
✘HEV (vl)
✘Herpes viruses (other than CMV, EBV, HHV-8) (t)
✘HTLV variants (t)
✘Influenza A and B viruses (other than H5N1 (t)
✘Japanese encephalitis virus (t)
✘La Crosse virus (t)
✘Lassa virus (t)
✘Lymphocytic choriomeningitis virus
✘Marburg virus (t)
✘Monkeypox virus (t)
✘Mumps virus (t)
✘Papillomaviruses (t)
✘Polyomaviruses (t)
✘Porcine endogenous retrovirus (t)
✘Porcine parovirus (t)
✘Rhabdovirus (a)
✘SARS coronavirus (t)
✘Tick-borne encephalitis virus complex (vl)
✘Torque teno (TTV/TTLV/SEN-V)
✘Vaccinia virus (t)
✘Variola virus (t)
✘Western equine encephalitis virus (t)
✘XMRV?
✘and what is next ?
✘Prions (vCJD)
✘Dengue (DENV)
✘Babesia species
✘Chikungunya (CHIKV)
✘St Louis encephalitis virus (SLEV)
✘Leishmania species
✘Trypanosoma cruzi
✘Prions (Chronic wasting disease)
✘Human herpesvirus 8 (HHV-8)
✘HIV variants
✘Human parovirus B19
✘Influenza A virus, subtype H5N1
✘Simian foamy virus (SFV)
✘Borrelia burgdorferi
✘Hepatitis A virus
✘Borna disease virus (t)
✘Classical CJD
✘Colorado tick fever virus (vl)
✘Crimean-Congo hemorrhagic fever virus (t)
✘Eastern equine encephalitis virus (t)
✘Ebola virus (t)
✘Enteroviruses (t)
✘Epstein-Barr virus (vl)
✘GB/HG viruses (a)
✘Hantavirus New World (t)
✘Hantavirus Old World (t)
Stramer, S.L., et al., Emerging infectious disease agents and their potential threat to transfusion safety. Transfusion, 2009.
49 Suppl 2: p. 1S-29S. 2009

Behaviour-based transfusion practice
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
15 12 13 16 9 3 1 7 2 11 4 6 5 8 10
Inter-Hospital Variability of Transfusion Rates in Matched THR
Patients – Study I (n=1,347)
Potential for Reduction?
Gombotz H, Rehak P, Shander A, Hofmann A. Blood use in elective surgery: the Austrian benchmark study. Transfusion 2007;47:1468-
1480
Center
Transfusionrate

Behaviour-based transfusion practice
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
15 12 13 16 9 3 1 7 2 11 4 6 5 8 10
Inter-Hospital Variability of Transfusion Rates in Matched THR
Patients - Study I & II (n=2,570)
27.7% reduction in txn rate
44.1% reduction in txn index
0.00% mortality
Center
Transfusionrate
Study I
Study II
Gombotz H, Rehak P, Shander A, Hofmann A. The second Austrian benchmark study for blood use in elective surgery:
results and practice change. Transfusion, 2014.

3
Cost Effectiveness of
Transfusion?

Cost-effectiveness: Taxi vs. Megatruck

Cost-Effectiveness Concept
∆ Outcomes
B
C
D
A$100,000
$50,000
-$50,000
∆ Costs ($)
E

Cost-Effectiveness Concept
∆ Outcomes
X ?
? 
∆ Costs ($)

Cost-Effectiveness Threshold
∆ Costs ($)
∆ QALY
1 2
$50,000
$100,000
Willingness to
pay threshold
Area of
acceptance
A
-$50,000
-1-2
X
D
C
B
Area of
rejection
E

Cost-Effectiveness: Where is Transfusion?
∆ COSTS ($)
∆ Outcomes
X

Area of
acceptance
Area of
rejection

“Does transfusion do what it is intended to do—
improve outcome or prevent adverse outcomes?”
Spiess, B.D., Risks of transfusion: outcome focus. Transfusion, 2004. 44(12 Suppl): p. 4S-14S.
Acknowledgement: Gavin Murphy
The Multi-Billion Dollar Question

Visual for the lack of efficacy:
Human microcirculation pre- and post-
transfusion after GI haemorrhage
(patient with nadir Hb 2.8 g/dL)
Acknowledgement: Dr Andreas Meier-Hellmann
Helios Klinik, Erfurt, GermanyAxel Hofmann 11-2014 Kuala Lumpur

Pre-Transfusion Microcirculation
Acknowledgement: Dr Andreas Meier-Hellmann, Helios Klinik, Erfurt, Germany
Axel Hofmann 11-2014 Kuala Lumpur

Post-Transfusion (3 Units) Microcirculation
Acknowledgement: Dr Andreas Meier-Hellmann, Helios Klinik, Erfurt, Germany
Axel Hofmann 11-2014 Kuala Lumpur

“There are few if any articles that support transfusion
actually improving patient outcomes.”
“The majority of database papers show associations between
transfusion utilization and with immunosuppression, increased
infection, increased renal failure, multisystem organ failure,
and death.”

Hofmann A, Shander A, Farmer S. Five Drivers Shifting the Paradigm from Product Focused Transfusion Practice to Patient
Blood Management. Oncologist. 2011;16. (suppl3):3-11
Thomson A, Farmer S, Hofmann A, Isbister J, Shander A. Patient blood management - a new paradigm for transfusion
medicine? ISBT Science Series. 2009;4(n2):423-35
• Infection
• Septicemia
• Delayed wound healing
• TRALI
• MOF
• SIRS
• ARDS
• Vasospasm
• Low-output heart failure
• Atrial fibrillation
• Cardiac arrest
• Renal failure
• Stroke
• Myocardial infarction
• Thromboembolism (arterial, venous)
• Diminished postop functional recovery
• Bleeding requiring re-operation
• Cancer recurrence
• Increased mortality
• Increased admission to ICU
• Prolonged mechanical ventilation
• Increased ICU length of stay
• Increased hospital length of stay
• Increased hospital readmission

• 8,500 pts
• Compared transfused vs non-transfused after
multivariable logistic regression and propensity
score analysis
2007
Murphy, G.J., et al., Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac
surgery. Circulation, 2007. 116(22): p. 2544-52.
• 30-day mortality was over 6-times higher in the txd
patients
• Increased ICU, high-dependency unit and hospital
length of stay
“RBC transfusion appears to be harmful for almost all
cardiac surgery patients”

Infectious Events
RBC units txd Adjusted OR; CI
0 AOR 1.0; 95% CI, …
1 AOR 1.46; 95% CI, 0.92–2.11
2 AOR 2.36; 95% CI, 1.42–3.30
3 or 4 AOR 3.82; 95% CI, 2.22–5.47
5-9 AOR 10.75; 95% CI, 5.83–15.9
>9 AOR 45.44; 95% CI, 22.6–73.6
Outcome Odds ratio C.I.
Composite infection 3.38 2.60 – 4.40
Ischaemic events 3.35 2.68 – 4.35
Murphy, G.J., et al., Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac
surgery. Circulation, 2007. 116(22): p. 2544-52.

Observational Studies: Dose-response Infection
Rates Associated w/ Transfusion
Author/Year Population Sample size Dose-response increased infection rate
Shorr 2005 ICU 4,892 Blood stream infection
Taylor 2006 ICU 2,085 Nosocomial infection, ICU & hospital LOS, mortality
Murphy 2007 Cardiac surgery 8,500 Infection & ischemic events
Banbury 2006 Cardiac surgery 15,592 Septicemia, bacteremia, superficial & deep sternal
wound infection
Koch 2006 Cardiac surgery 11,963 In-hospital mortality, renal failure, postoperative
ventilatory support, postoperative infection, cardiac and
neurologic morbidity, overall postoperative morbidity
Rogers 2006 Cardiac surgery 9,218 Infection
Chelemer 2002 Cardiac surgery 533 Bacterial infection
Leal-Noval 2001 Cardiac surgery 738 Infection, pneumonia
Horvath 2013 Cardiac surgery 5,158 Pneumonia, blood stream infection

• 19 RCTs with total of 6264 pts., comparing restrictive vs
liberal txn thresholds (<70/80 g/L vs <90/100 g/L)
• Population: cardiac, vascular, orthopaedic, acute blood
loss and/or trauma, ICU and leukaemia pts with chemo (1
trial).
• Restrictive reduced the risk of receiving an RBC
transfusion by 39% (RR 0.61, 95% CI 0.52 to 0.72)

• No benefit from liberal transfusion in relation to any
outcome measure, including functional recovery
• Authors: “the evidence raises the possibility of harm
associated with liberal transfusion.”
• In-hospital mortality significantly higher in liberal (23%
higher)
• Infection significantly higher in liberal (19% higher)
• In 1 trial significant increase in risk of re-bleeding (90%)

Cardiac
Critical Care
Gastrointesinal
Low Birthweight
Ortopedic
Sepsis
Overall
• Even among patients receiving RBC units with
leukocyte reduction, a restrictive RBC transfusion
strategy was associated with a lower risk of health
care–associated infection.
• This meta-analysis of randomized trials suggests that,
for every 1000 patients in which RBC transfusion is
under consideration, 26 could potentially be spared
an infection if restrictive strategies were used.
18 RCTs, n = 7593 patients
Mary A.M. Rogers, PhD, Patient Safety Enhancement Program, Department
of Internal Medicine, University of Michigan.
JAMA. 2014;311(13):1317-1326. doi:10.1001/jama.2014.2726

Stone, P.W., Economic burden of healthcare-associated infections: an American perspective. Expert Rev
Pharmacoecon Outcomes Res, 2009. 9(5): p. 417-22.
These are 2007-$.
After adjustment to 2013-$
(CPI for medical care services),
costs are increased by >24%

Pathophysiology Corroborates Causality:
Liberal Transfusion Makes the Patient Sicker
The causal link between TRIM and post-
operative infection is considered established
Refaai, M.A. and N. Blumberg, Transfusion immunomodulation from a clinical perspective: an update. Expert Rev
Hematol, 2013. 6(6): p. 653-63
Isbister, J.P., et al., Adverse blood transfusion outcomes: establishing causation. Transfusion medicine reviews,
2011. 25(2): p. 89-101
TRIM Infection
Added
LOS
Added
cost

Cost-Effectiveness: Where is Liberal Transfusion?
∆ COSTS ($)
∆ Outcomes

Area of
acceptance
Area of
rejection
Clinical and health economic
outome parameters
• Infections
• Ischemic events
• ALOS
• ICU-ALOS
• Cost of episode
• Disease free survival
• Overall survival
X

4
Reflected in
Real Life Studies?
Costs of Liberal
Transfusion Strategies:

• First study to assess clinical and health outcomes
associated with blood product transfusion across the
full spectrum of procedures and clinical conditions in
hospitalised patients

• US Nationwide Inpatient Sample (NIS) Database:
Retrospective cohort study of all hospitalizations in 2004
(n=38.66 million) to assess in-hospital outcomes associated
with blood transfusion.
• Of all admissions 5.8% (2.33 million) were transfused. After
adjustment for age, gender, comorbidities, admission type or
DRG transfusion was associated with:
– 1.7 increased odds of death (P<0.0001)
– 1.9 increased odds of infection (P<0.0001)
– 2.5 days longer LOS
– $17,194 higher charges (P<0.0001)
 $40.06 billion in extra charges for transfused
patients
Morton et al 2010 Axel Hofmann 03-2015 Milan

• US Nationwide Inpatient Sample (NIS) Database:
Retrospective cohort study of all hospitalizations in 2004
(n=38.66 million) to assess in-hospital outcomes associated
with blood transfusion.
• Of all admissions 5.8% (2.33 million) were transfused. After
adjustment for age, gender, comorbidities, admission type or
DRG transfusion was associated with:
– 1.7 increased odds of death (P<0.0001)
– 1.9 increased odds of infection (P<0.0001)
– 2.5 days longer LOS
– $17,194 higher charges (P<0.0001)
 $57 billion in extra charges for transfused
patients (2013 dollars, Medical Services CPI adjusted)
Morton et al 2010 Axel Hofmann 03-2015 Milan

Western Australia Metro Data on Transfusion and
Cost
Retrospective cohort study of all multi-day acute-care
inpatients discharged from a five hospital health service
in Western Australia between July 2011 and June 2012.
• 89,996 multi-day, acute-care inpatient separations,
• 4,805 (5.3%) were transfused at least one unit of red
blood cells
Trentino K.M., et al., Increased hospital costs associated with red blood cell transfusion.
Transfusion. In print

After adjusting for age, gender, admit type*, DRG and patient complexity
(HRT complexity), compared with non-transfused:
• mean inpatient cost 1.83 times higher in the transfused group
compared with the non-transfused group (95% confidence interval 1.78
to 1.89; p<0.001)
• total hospital associated cost of red blood cell transfusion in this
study was AUD $77 million (US $72 million), representing 7.8% of total
hospital expenditure on acute-care inpatients.
• significant dose-dependent association between the number of units
transfused and increased costs after adjusting for confounders.
*emergency or elective
Trentino K.M., et al., Increased hospital costs associated with red blood cell transfusion.
Transfusion. In print
Western Australia Metro Data on Transfusion and
Cost

How to resolve
this
multi billion
dollar
problem?

“If you find yourself in a hole, stop digging“
Will Rogers

Blood Management
Patient
Blood Management
(PBM)
Donor
Blood Management
Patient Blood is more Important Than Donor Blood
James Isbister, Clinical Hematologist, 2014

Highest prevalence of all
diseases worldwide, caused by
• absolute iron deficiency (50% of
all causes)
• functional iron deficiency
• severe hemorrhage
• chemotherapy (CIA) and/or
radiation
• medication
• congenital disorders
• other
BleedingAnaemia
and ID
Two Conditions of Clinical Significance
Very high prevalence
caused by
• local surgical or vessel interruption
• therapeutic and diagnostic
interventions
• trauma
• anticoagulant drugs
• obstetric complications
• congenital disorders
• other
related

Independent
Risk Factor
for
Adverse
Outcomes
Anemia
& Iron
Deficiency
Anaemia independently associated with increased:
• morbidity
• hospital length of stay
• Mortality
• likelihood of transfusion (2-9 fold)
Mussallam KM et al. Lancet 2011
Spahn DR. Anesthesiology 2010; 113(2) 1-14
Beattie WS, et al Anesthesiology 2009; 110(3) 574-81
Dunne JR, et al J Surg Res 2002; 102: 237-44
Shander A. Am J Med 2004; 116(7A) 58S-69S

Independent
Risk Factor
for
Adverse
Outcomes
Blood Loss
&
Bleeding
Bleeding associated with increased
• Morbidity
• ICU and hospital length of stay
• Mortality
• Elective & emergency surgery ~0.1%
• Subgroups:
• Vascular 5–8%
• Up to 20% with severe bleeding
• Major organ damage 30–40%
Causes
• On average 75 – 90% local surgical interruption or vessel
interruption
• 10–25% acquired or congenital coagulopathy
Shander A. Surgery 2007
Vivacqua et al Ann Thorac Surg 2011
Christensen et al J Thorac Cardiovasc Surg 2009
Spence et al Am J Surg 1990
Stokes, M.E., et al BMC Health Serv Res, 2011
Ye, X., et al BMC Health Serv Res, 2013
Alstrom, U., et al Br J Anaesth, 2012
Christensen M.C. et al J Thorac Cardiovasc Surg 2009.

Independent
Risk Factor
for
Adverse
Outcomes
Transfusion
Large observational studies show RBC txn is
independently associated in a dose-
dependent relationship with
•Morbidity
•ALOS
•Mortality
Shaw et al. Transfusion 2014
Parsons J et al. Crit Care 2013
Horvath K et al. Ann Thorac Surg 2013
Linder et al. BJU Int 2013
Al-Refaie et al Surgery 2012
Ferraris V et al. Arch Surg 2012
Paone G et al. J Thorac Cardiovasc Surg 2012
Bhaskar B et al. Ann Thorac Surg 2012
Stone GW et al. Am Heart J 2012
Xenos et al. Thromb Res 2012
Ferraris et al. Ann Thorac Surg 2011
Glance L et al. Anesthesiol 2011
Ranucci M et al. J Thorac Cardiovas Surg 2011
Haijar LA et al. JAMA 2010
Beattie et al. Anesthesiology 2009
Bernard et al. J Am Coll Surg 2009
Bursi et al. Eur J Vasc Endovasc Surg 2009
Chaiwat O et al. Anesthesiology 2009
Karkouti et al. Circulation 2009
Gauvin et al Transfusion 2008
Scott BH et al. Ann Card Anaesth 2008
Salim A et al. J Am Coll Surg 2008
Ho et al. Spine 2007
Kulier A, et al. Circulation 2007
Murphy GJ, et al. Circulation 2007
Bernard AC, et al J Am Coll Surg 2008
Banbury MK et al. J Am Coll Surg 2006
Jagoditsch et al. Dis Colon Rectum 2006
Koch et al. Ann Thorac Surg 2006
Koch et al. Crit Care Med 2006
Rogers et al. Am Heart J 2006
Surgenor SD, et al Circulation 2006
Taylor RW et al. Crit Care Med 2006
Leal-Noval et al. Anesthesiology 2003
Malone DL et al. J Trauma 2003
Chelemer et al. Ann Thorac Surg 2002
Dunne et al. J Surg Res 2002
Chang et al. Vox Sang 2000
Vignali et al. Vox Sang 1996
RCTs and meta-analyses therof show that liberal
transfusion strategies appear to offer no benefit but result
in increased adverse patient outcomes.
Carson et al. Cochrane Review 2012
Salpeter et al. Am J Med 2014

Triad of
Independent
Risk Factors
for
Adverse
Outcomes
Anemia
& Iron
Deficiency
Blood Loss
&
Bleeding
Transfusion
Farmer SL., et al. Best Pract Res Clin Anaesthesiol, 2013. 27(1): p. 43-58.
Restellini S, AP&T 2012
Hearnshaw SA, et al Aliment Pharmacol Ther 2010
Blair SD, et al Br J Surg 1986

The Rationale of Patient Blood Management
“PBM ... preempts and significantly reduces the resort
to transfusions by addressing modifiable risk factors
that may result in transfusion long before a transfusion
may even be considered“
Hofmann A, Shander A, Farmer S. Five Drivers Shifting the Paradigm from Product Focused Transfusion Practice to
Patient Blood Management. Oncologist. 2011;16. (suppl3):3-11
BleedingAnaemia
and ID

Triad of
Independent
Risk Factors
for
Adverse
Outcomes
Anemia
& Iron
Deficiency
Blood Loss
&
Bleeding
Transfusion
Farmer SL., Towler SC, Leahy MF, Hofmann A. Best Pract Res Clin Anaesthesiol, 2013. 27(1): p. 43-58.

Optimise
red cell
mass
Minimise
blood loss
& bleeding
Harness &
optimise
physio-
logical
reserve of
anaemia
Anemia,
Iron
Deficiency
Blood Loss
&
Bleeding
Transfusion

Optimise
red cell
mass
Minimise
blood loss
& bleeding
Harness &
optimise
physio-
logical
reserve of
anaemia
Perioperative multidisciplinary multimodal patient-specific team approach

Benefits of PBM Programs
 reduction up to 43%
 reduction of composite morbidity up to 41%,
and infection rate up to 80%
 reduction up to 68%
 reduction by 16-33%Average LOSA
AeadmissionsR
A omplicationsC
ortalityM
A ostsC  reduction by 10-24%
Gross 2015; Frank 2014; Goodnough 2014; Lapar 2013; Kotze 2012; Moskowitz 2010; Reddy 2009; Brevig 2009; Ferraris 2007; Wong 2007;
Ghiglione 2007; Freedman 2007; Martinez 2007; DeAnda 2006; Freedman 2005; Pierson 2004; Green 2004; Kourtzis 2004; Morgan 2004;
Slappendel 2003; Van der Linden 2001; Helm 1998
 reduction by 10 - 95%ransfusionT
AeoperationR  reduction up to 43%

Cost-Effectiveness: Liberal Transfusion vs. PBM
∆ COSTS ($)
∆ Outcomes

Area of
acceptance
Area of
rejection
Clinical and health economic
outome parameters
• Infections
• Ischemic events
• ALOS
• ICU-ALOS
• Cost of episode
• Disease free survival
• Overall survival
X

5
PBM:
A Win-Win-Situation
Summary

1. Too much unnecessary care
2. Avoidable harm to patients
3. Billions of dollars wasted
4. Perverse incentives in how we pay for care
5. Lack of transparency
All addressed by PBM

Transfused RBCs per Admissions in the Eight Largest Public
Austrian Hospitals (Admissions w/ >0 ALOS)
0.150
0.200
0.250
0.300
0.350
0.400
0.450
0.500
0.550
2004 2005 2006 2007 2008 2009 2010 2011
RBCsperAdmission
Year
A
B
C
D
E
F
G
Linz AKH (mit PBM
Programm)
Bekanntgabe der Ergebnisse der österreichischen Benchmark Studie zum
Verbrauch von Blutprodukten an öffentlichen Krankenhäusern
Gombotz, H. and A. Hofmann. Patient Blood Management:
three pillar strategy to improve outcome through avoidance of allogeneic blood products. Anaesthesist, 2013. 62(7): p. 519-27.
General Hospital Linz
w/ PBM Program
Publication of the results of the Austrian Benchmark Study
(blood utilization in public hospitals)

Source: National Blood Authority, 2014; Paul Ehrlich Institut, Germany
0
10
20
30
40
50
60
2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14
Unitsissuedper1.000population
Year
(Australia and WA finacial year 2013-14, Germany calender year 2013)
RBC Issuance Comparison between Germany, Australia and WA
2004-2013
WA
Australia
Germany

0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
RBCUnits
Blood collection per 1.000 population Blood transfusion per 1.000 population
What if these countries matched the WA
benchmark?
Western Australia
Benchmark
2012/13
≈ 3.5 Mio.
patients
≈ 16 Mio. RBCs
Reallocation of
≈ $24 Bn.

 Safety
 Mortality & Morbidity
 ALOS
 Health Care $$$
Problem:
Solution:
Benefit:

WHA63.12 adopted
by resolution May 21, 2010:
„Bearing in mind that patient blood management means that before surgery every
reasonable measure should be taken to optimize the patient’s own blood volume, to
minimize the patient’s blood loss and to harness and optimize the patient-specific
physiological tolerance of anaemia following WHO’s guide for optimal clinical use (three
pillars of patient blood management)“

Vi ringrazio per l’attenzione!

Anemo 2015-02-Hoffman- Considerazioni economiche nella PBM

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