In the United States, blood transfusions are the most frequently performed hospital procedure; current data suggest that approximately 12% of hospitalized patients receive transfusions.a Between 1997 and 2011, the rate of in-hospital transfusions increased 134%.a According to the American Red Cross, approximately 30 million blood components are transfused each year.b In most nontrauma situations, the decision to transfuse is a joint decision made between a clinician who offers the possibility of a transfusion to a patient and the patient who accepts the transfusion. In many situations, clinical equipoise regarding the need for the transfusion exists. Clinical equipoise is an ethical concept, defining the circumstance in which there is genuine uncertainty among the expert medical community about the preferred treatment.1 The American Society of Anesthesiologists Practice Guidelines for Perioperative Blood Transfusion reflects this equipoise, in that none of the recommendations state that patients absolutely must be transfused at certain threshold values.2 Instead, the guidelines frame the transfusion decision in terms of individual patient-level risks and benefits. Patients who are offered transfusions weigh these risks and benefits when making the decision to accept a transfusion. Patients assume risks with accepting as well as rejecting a blood transfusion, but these risks and outcomes may be valued differently by individual patients, thus making most transfusions a preference-sensitive condition.
In Crossing the Quality Chasm, the Institute of Medicine stated that high-quality health care should be patient-centered.3 Patient-centered care incorporates individual patient preferences, needs, and values into clinical decisions, thereby ensuring that patient values guide all decisions.3 The concept of patient-centered care, in which the patient partners with the physician in clinical decision-making, contrasts with “paternalistic” or physician-driven care.4 Several models conceptually describe the process of shared decision-making between patients and physicians. In the model by Charles et al.,5 which is the most frequently used model,6 there are 3 stages to decision-making: (1) information sharing between the physician and the patient, (2) consensus building on the preferred treatment, and (3) agreement on the treatment to implement. Two articles published in this issue of Anesthesia & Analgesia highlight potential problems with the delivery of patient-centered care as it relates to blood transfusion therapy in the perioperative setting.
Brown et al.7 used data from 20,930 surgical patients at a single institution to determine whether after risk adjustment, patients aged >65 years were more likely to be transfused than younger patients during their hospital stay. Twenty-seven percent of patients in the older group were transfused compared with 16% of younger patients. Using multivariable logistic regression modeling to control for medical comorbidities, type of surgery, gender, estimated blood loss, and lowest in-hospital hemoglobin concentration, older patients had a 62% greater odds of transfusion than did younger patients. Exploratory analyses demonstrated 2 interesting findings. Individual surgeons were relatively consistent in their practice of transfusing older patients more than younger patients, and specific surgical services were more likely to transfuse older patients. No currently published transfusion guidelines include patient age as a factor in the decision to transfuse. Therefore, physicians may be preferentially recommending transfusions to older patients, or alternatively, older patients are more accustomed to a paternalistic model of health care and accept transfusion therapy at a higher rate than younger patients.
Physicians may also lack knowledge about the content of transfusion guidelines, and this knowledge deficit may contribute to unnecessary transfusions. A study published in Anesthesia & Analgesia in 2010 surveyed anesthesiologists and perfusionists on the effect of the 2007 Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Clinical Practice Guidelines for Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery on their practice. Surprisingly, 25% of anesthesiologists and 33% of all of the perfusionists who completed the survey had not read all, or parts, of the guidelines.8 Other investigators have also found that physician knowledge of guideline content is low,9 and this may contribute to patients not receiving guideline-recommended care.10
In addition to physicians being unaware of guideline content, they, as well as patients, may lack knowledge of the risks and benefits of transfusions. The study by Vetter et al.11 in the current issue of the Journal provides in-depth insight into patient and physician perspectives on blood transfusions. In this single-institution study, patients who presented for a preoperative surgical consultation were asked to complete a survey that evaluated their perceptions of the risk and frequency of adverse events related to blood transfusion. A similar survey was developed for surgeons and anesthesiologists. Although transfusion safety has significantly improved in the past 20 years, 20% of patients and nearly 40% of physicians stated that transfusions were very often or always risky.11 Evaluation of specific adverse events revealed knowledge gaps for both the patients and their physicians. For example, both patients and physicians overestimated the risk of a transfusion-related fever, allergic reaction, or hemolytic transfusion reaction. While physicians correctly estimated the risk of viral transmission of human immunodeficiency virus/acquired immune deficiency syndrome and hepatitis, nearly 9% of patients believed that transmission of these diseases occurs very often or with every transfusion. Yet, despite the fact that there were significant knowledge gaps, which were worse for certain subgroups such as racial/ethnic minorities, 95% of patients were willing to undergo a transfusion if it were recommended to them by their physician.
Many clinicians perceive that the only patients who actively make transfusion decisions are Jehovah’s witnesses, who believe that allogeneic blood transfusion is prohibited by the Bible,12 but the population of patients who would refuse blood transfusion is in fact much larger. A nationally representative telephone survey found that 33% of respondents would not accept an allogeneic blood transfusion if it were recommended to them by their physician.13 In that study, as the perceived risk of transfusions increased, the likelihood of accepting a transfusion decreased.13 In another study in which participants assigned a “dread score” of 1 to 7 to various hazards, with a score of 7 indicating that the hazard was “dreaded, risky, and worrisome if exposed,” nonphysician respondents gave blood transfusions a dread score of approximately 4.5, which was similar to the dread of nuclear reactors and pesticides.14 As Vetter et al.11 demonstrated, a significant number of patients view transfusions as being “risky.” Thus, understanding patient fears and perceptions becomes important when counseling patients on the risks of blood transfusions.
There are no formal guidelines as to what information needs to be included in informed consent for blood transfusion. It is generally accepted that risks with an incidence >1% should be disclosed to patients, as well as risks that occur less frequently, but are associated with serious morbidity or mortality.15 Yet, evidence suggests that these disclosure guidelines are not routinely practiced. Friedman et al.16 evaluated consent for transfusion in the medical setting and found gaps in both the content and quality of information delivered to patients. Internal medicine residents tended to overestimate the benefits of transfusions, focus on the common, minor risks, and either not mention, or underestimate, the major risks.16 Of greater concern is that 14% of patients were not aware of the indication for their transfusion, despite having accepted the transfusion.
Shared decision-making has been associated with better patient satisfaction and health outcomes.17,18 In the era of shared decision-making and patient-centered care, it is important that physicians counsel patients with accurate information, therefore efforts should be made to increase physician knowledge of both the risks and benefits of transfusions and also of relevant transfusion guidelines. However, simply counseling with accurate information does not make the care patient-centered. Shared decision-making requires communication and joint decision-making. Studies that have attempted to quantify the degree of shared decision-making in medical encounters have found that only half of decision moments between attending physicians and patients qualified as shared decision-making,19 and using a more lenient threshold, only 40% of decision-making moments between medical students and standardized patients met criteria for shared decision-making.20 Racial disparities in shared decision-making21 and in the patient-centeredness of medical interactions have been demonstrated.22,23 Given that Vetter et al.11 found that the majority of patients were willing to accept blood transfusions despite broad misconceptions about risk and benefit and that Brown et al.7 demonstrated a disparity in transfusion practice based on age, it is quite possible that other disparities exist in transfusion decision-making. Women, minorities, and patients with a high school education or less are more likely to perceive transfusions as being nonsafe13; patients with distrust of the medical system, with low health literacy, and/or with limited English proficiency may be especially vulnerable for making misinformed decisions.c These patients may not accept an indicated transfusion because of misperceived risks, or accept a transfusion and suffer from decisional regret.
What can or should be done? One possible strategy is to develop an evidence-based decision aid for blood transfusions. Decision aids are evidence-based tools that are designed to help patients participate in decision-making when there are several health care options. Decision aids are intended to supplement patient–provider interactions by helping prepare patients to make informed, value-based decisions with their health care provider.24 An example is a decision aid for breast cancer screening. Currently, controversy exists on whether patients should initiate breast cancer screening at the age of 40 or 50 years.25 A decision aid exists to help women with this decision.d The decision aid presents the facts about breast cancer and mammography, it then asks a series of questions relating to patient’s perceived risk of cancer, attitudes toward procedures, false-positive results, and radiation exposure; this section is followed by a knowledge quiz and questions that help guide the patient through the decision. A systematic review of 115 studies found that decision aids, when compared with usual care, improved patient knowledge, reduced decisional conflict, and seemed to have a positive impact on patient–provider communication.24 At minimum, if such a decision aid was developed for blood transfusions, patients and physicians would be sharing the same knowledge, and this would hopefully result in patients making truly informed decisions about blood transfusion therapy, bringing us one step closer to high-quality, patient-centered care.
Name: Paloma Toledo, MD, MPH.
Contribution: This author wrote the manuscript.
Attestation: Paloma Toledo attests to having approved the final manuscript.
This manuscript was handled by: Franklin Dexter, MD, PhD.
a Most Frequent Procedures Performed in U.S. Hospitals, 2011. HCUP Statistical Brief #165. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb165.pdf. Accessed January 1, 2014.
b Blood Facts and Statistics. Available at: http://www.redcrossblood.org/learn-about-blood/blood-facts-and-statistics. Accessed January 1, 2014.
c 2011 National Healthcare Quality and Disparities Report. Available at: http://www.ahrq.gov/research/findings/nhqrdr/nhqrdr11/qrdr11.html. Accessed January 1, 2014.
d Breast Cancer Screening: When Should I Start Having Mammograms? Available at: https://www.healthwise.net/cochranedecisionaid/Content/StdDocument.aspx?DOCHWID=abh0460. Accessed February 14, 2014.
1. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med. 1987;317:141–5
2. American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies.. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies.
3. Institute of Medicine (IOM). Committee on Health Care in America.Crossing the Quality Chasm: A New Health System for the 21st Century. 2001 Washington, DC National Academy Press, Institute of Medicine
4. Laine C, Davidoff F. Patient-centered medicine. A professional evolution. JAMA. 1996;275:152–6
5. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44:681–92
6. Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ Couns. 2006;60:301–12
7. Brown CH 4th, Savage WJ, Masear CG, Walston JD, Tian J, Colantuoni E, Hogue CW, Frank SM. Odds of transfusion for older adults compared to younger adults undergoing surgery. Anesth Analg. 2014
8. Likosky DS, FitzGerald DC, Groom RC, Jones DK, Baker RA, Shann KG, Mazer CD, Spiess BD, Body SC. Effect of the perioperative blood transfusion and blood conservation in cardiac surgery clinical practice guidelines of the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists upon clinical practices. Anesth Analg. 2010;111:316–23
9. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ. Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med. 1989;321:1306–11
10. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635–45
11. Vetter TR, Adhami LF, Poerterfield JR, Marques MB. Perceptions about blood transfusions: a survey of surgical patients and their anesthesiologists and surgeons. Anesth Analg. 2014;118:1301–8
12. Bodnaruk ZM, Wong CJ, Thomas MJ. Meeting the clinical challenge of care for Jehovah’s Witnesses. Transfus Med Rev. 2004;18:105–16
13. Finucane ML, Slovic P, Mertz CK. Public perception of the risk of blood transfusion. Transfusion. 2000;40:1017–22
14. Lee DH, Mehta MD, James PD. Differences in the perception of blood transfusion risk between laypeople and physicians. Transfusion. 2003;43:772–8
15. Holland PV. Consent for transfusion: is it informed? Transfus Med Rev. 1997;11:274–85
16. Friedman M, Arja W, Batra R, Daniel S, Hoehn D, Paniz AM, Selegean S, Slova D, Srivastava S, Vergara N. Informed consent for blood transfusion: what do medicine residents tell? What do patients understand? Am J Clin Pathol. 2012;138:559–65
17. White DB, Braddock CH 3rd, Bereknyei S, Curtis JR. Toward shared decision making at the end of life in intensive care units: opportunities for improvement. Arch Intern Med. 2007;167:461–7
18. Wilson SR, Strub P, Buist AS, Knowles SB, Lavori PW, Lapidus J, Vollmer WMBetter Outcomes of Asthma Treatment (BOAT) Study Group. . Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med. 2010;181:566–77
19. Saba GW, Wong ST, Schillinger D, Fernandez A, Somkin CP, Wilson CC, Grumbach K. Shared decision making and the experience of partnership in primary care. Ann Fam Med. 2006;4:54–62
20. Hauer KE, Fernandez A, Teherani A, Boscardin CK, Saba GW. Assessment of medical students’ shared decision-making in standardized patient encounters. J Gen Intern Med. 2011;26:367–72
21. Peek ME, Odoms-Young A, Quinn MT, Gorawara-Bhat R, Wilson SC, Chin MH. Race and shared decision-making: perspectives of African-Americans with diabetes. Soc Sci Med. 2010;71:1–9
22. Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, Ford DE. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583–9
23. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139:907–15
24. Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson R, Trevena L, Wu JH. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;1:CD001431
25. US Preventive Services Task Force. . Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151:716–26