Sifting through the opposing rulings on the legality of the subsidies on the federal health insurance exchange.
May 04--In 2008, the Community Blood Center of Greater Kansas City was riding a 14-year national boom in blood demand.
Its donors provided a record number of units of red blood cells for area hospital patients that year, and the blood center opened a gleaming new state-of-the-art laboratory about a mile from its midtown headquarters to swiftly test donor blood for infections.
But all that was about to change.
As the Great Recession took hold that year, people started worrying about their jobs and health insurance, and they canceled elective surgeries.
More important, hospitals across the country -- including St. Luke's Hospital and the University of Kansas Hospital -- had been changing policies and technology to safely minimize the need for blood transfusions, both to cut costs and to diminish risks to patients.
Research had been mounting for years that most hospital patients stayed healthier when they received little or no transfused blood. They faced less risk of infection, lung complications, even death.
From 2008 to 2011, transfusions nationwide dropped 8.2 percent, according to the most recent data from the Department of Health and Human Services. And the numbers are still trending lower, blood banking experts say, as more hospitals develop "patient blood management" programs.
Declining demand is forcing a lot of belt-tightening by blood collection organizations that less than a decade ago faced chronically short supplies.
In 2012, the Community Blood Center began losing money for the first time in a decade. It shut down its new lab, taking a $2.2 million loss, and outsourced testing to a blood center in Wisconsin. The center also cut staff and closed low-yield collection centers in Lawrence and Olathe. It still maintains six collection centers across the metro area and in St. Joseph and Topeka.
"It's a new world," said Community Blood Center executive director Jay Menitove.
Collecting all the blood needed has always been difficult, Menitove said, and the blood center still needs people to donate regularly. But, he added, "this is a paradigm change from blood shortages to an adequate supply."
Blood centers across the country have been merging, laying off staff and looking for other ways to economize. In 2010, the two blood centers serving most of Iowa merged. Two years later, three regional blood centers in Florida combined to cover an area from Key West to the Florida Panhandle. Last year, the American Red Cross announced plans to close its blood testing lab in Detroit, one of five it operated across the country.
"It's ugly. You see yourself as the good guys and you're laying people off," said Louis Katz, executive vice president of America's Blood Centers, the association of independent blood centers not affiliated with the Red Cross.
As blood centers merge, America's Blood Centers has seen its membership drop. Last year, it held a training session on mergers and acquisitions for its members.
Plummeting demand caught some blood centers off guard, Katz said, but "we had a lot of warning. The handwriting's been on the wall for a while."
To be sure, blood transfusions remain an essential part of medicine. Donated blood is usually processed into component parts that are transfused separately depending on a patient's needs -- red blood cells that carry oxygen, for example, or platelets that stop bleeding.
Transfusions can be lifesavers for people who are bleeding from traumatic injuries or who have illnesses that leave them severely depleted.
But since the early 1980s, researchers have been showing that for patients who aren't in immediate danger from blood loss, fewer transfusions are at least as good, and maybe better, for their health.
Studies linked transfusions in cancer patients to the reappearance of their disease. Other studies found death rates after heart surgery were higher in patients receiving transfusions. Report after report found associations between transfusions and pneumonia, stroke, heart attack, lung injury, delayed wound healing and organ failure.
Researchers issued warnings that transfusions temporarily depress the immune system, leaving patients vulnerable to potentially deadly infections. They called these infections "a silent epidemic."
A landmark Canadian study published in 1999 in The New England Journal of Medicine followed 838 critically ill patients who were in intensive care units at 25 hospitals. The patients who got fewer transfusions than traditionally called for did at least as well as, and maybe better than, patients who got standard treatment, the researcher concluded.
But most doctors were slow to pick up on what was becoming overwhelming evidence.
From 1994 to 2008, red blood cell transfusions climbed 40 percent in the United States, from about 10.5 million units to 14.7 million. That rapid rise was "driven by waste," Richard Benjamin, chief medical officer of the American Red Cross, told an HHS blood advisory committee in 2011.
The nation's burgeoning blood use didn't seem to follow any general standards. Transfusion rates for heart bypass surgery were up to 12 times as high at some hospitals as at other hospitals. The chances of receiving a transfusion varied significantly from one region of the country to another.
Overall, transfusions were far more common here than in other countries with advanced medical systems such as Australia and Canada.
"We're using too much blood in the United States," Benjamin said.
In 2012, the AABB, a nonprofit organization representing individuals and institutions involved in transfusion medicine, called for a "restrictive transfusion strategy" in stable, hospitalized patients.
And last summer, the American Medical Association and the Joint Commission, which accredits hospitals, listed transfusions, along with antibiotics for colds, among five commonly overused medical treatments.
Recycling blood, reducing loss
St. Luke's was an early adopter of what initially was called "bloodless medicine" and is now called patient blood management.
Often these programs were developed to serve Jehovah's Witnesses and others who declined transfusions. Eventually, hospitals began adopting the techniques for other patients as well.
"The biggest thing we've learned is just because someone's blood level is low, we don't have to give them blood," said St. Luke's heart surgeon Russell Davis, co-chair of the hospital's blood utilization committee.
"Cell saver" machines in the operating room recycle the patient's blood. As the surgeon cuts, a member of the surgical team suctions up the blood with a tube that leads to the cell saver. When enough blood is collected, the machine's centrifuge puts the blood through a spin cycle to wash and separate out the red blood cells. The blood cells are pumped into a plastic transfusion bag and go back to the patient.
"We've always used (cell savers) in heart surgery. Its use in orthopedic surgery in the past couple of years has been a big improvement," Davis said.
Surgeons use a variety of techniques to minimize bleeding. They squirt a material called BioGlue into sutures to seal repairs, for example. Something as simple as moving a heart-lung machine closer to the operating table means less blood is needed to prime the pump.
The trend toward minimally invasive surgery -- slipping catheters and laparoscopes through small incisions -- also is cutting down on blood loss.
"We will continue to become more and more minimally invasive," Davis said, "and the smaller the incision, typically, the less the blood."
Transfusions also are avoided by taking steps before surgery. Anemia from illness, poor diet or chronic bleeds in the digestive tract is common among elderly patients. Not having an adequate supply of healthy red blood cells puts them at greater risk of requiring a transfusion during or after surgery.
At St. Luke's, anemic patients go onto a treatment plan, often receiving intravenous infusions of iron, before they ever reach the operating room.
Even something as innocuous as the blood tests that hospitals run can increase the chances that patients will get a transfusion. Researchers at St. Luke's found that so much blood was being drawn from patients, they were becoming anemic. That's led to less blood being taken.
St. Luke's expanded its patient blood management program in 2011 after many meetings of physicians in various specialties and small studies that tested the benefits of treating patients' anemia before surgery.
"It sounds easy, but in medicine there's cultures and subcultures. To change a culture is very difficult," said Haseeb Ahmed, director of the blood conservation program at St. Luke's.
Transfusion expert Lowell Tilzer found that out when he came to the University of Kansas Hospital 10 years ago and tried to get other doctors interested in patient blood management.
"I was interested in patient safety. I thought, 'This is the right thing to do,' " he said.
Two units of red blood cells was the typical order doctors would give, Tilzer said, even when one unit would do.
"This was the tradition. This is what everyone would say."
Things started to change about five years ago after heart surgeons and other physicians and nurses from St. Luke's who were used to limiting transfusions moved to KU.
"It's a little difficult for other surgeons to say no when high-blood-loss cardiac surgeons do it," said Elora Thorpe, KU Hospital's transfusion safety nurse manager. "It's just part of the culture now. I don't know of any pockets of resistance."
Thorpe estimates that since 2009, blood use at KU Hospital is down 20 percent, even though it's seeing more and sicker patients. The hospital is spending an average of $2.1 million less per year buying blood. That doesn't include the money saved on nursing time and paperwork to get the blood to patients.
The St. Luke's system also has seen savings. The St. Luke's flagship hospital on the Country Club Plaza used 11,500 units of red blood cells in 1999; now it uses about 5,000 per year. The three other St. Luke's hospitals in the area also are using less blood.
When all the costs of transfusions are added in, St. Luke's estimates that its four metro hospitals saved about $30 million from 2008 through 2013.
'The right thing'
Blood demand nationwide is likely to decline another few years before bottoming out at levels 20 to 30 percent lower than in 2008, according to James AuBuchon, CEO of the Puget Sound Blood Center in Seattle.
Over time, population growth and the aging of the baby boom generation will increase the need for blood, he said in testimony last June to the Health and Human Services blood advisory committee.
But AuBuchon didn't expect demand to rise again to the level of 2008 before 2022, and maybe not until 2030.
"It's going to be some time before blood centers recover their economic footing," he said.
Menitove, the Community Blood Center's executive director, agrees that reducing transfusions is "the right thing for patients." He has made the rounds of hospitals with a talk about how "less is more."
But the nonprofit blood center lost nearly $900,000 on its business operations in 2012 and a similar amount last year. It has enough cash in reserve to stay in business for now.
Menitove, 68, is guarded about the blood center's future, and his own.
In February 2012, the blood center announced he would be retiring that year. Two years later, he's still at his desk.
He wouldn't say whether the blood center is seeking a merger partner or plans to soldier on independently.
"We'll get the job done in Kansas City, that's all I can say at the moment," Menitove said. "The blood will be collected and the patients served in an extremely high-quality way."
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