People often associate an operation room with blood. If you get surgery, you will bleed a lot, so you need a blood transfusion, they say.
However, there is a growing voice in Korea that transfusing blood should not be taken lightly. Critics say physicians should check a patient’s hemoglobin level before an operation. During an operation, medical staffs should do their best to stop bleeding so that they can minimize blood transfusion, they say.
In this regard, experts emphasize the concept of Patient Blood Management (PBM), which they say can shift the focus of blood management from the supplier-oriented system to the patient-oriented one. PBM also gets rid of risks of transfusing such as an immune rejection, they say. The World Health Organization aggressively recommended the use of PBM in healthcare in 2010.
Chronic blood shortages
The need for a change in the blood management system has surfaced due to chronic blood shortages.
As of Monday, the Korean Red Cross reserved 21,436 units of red blood cells that could sustain the total blood transfusions at medical institutions across the nation for four days. At a proper supply level, blood banks should sustain transfusion for more than five days.
The worse news is that the blood shortage is likely to continue. As the population of teenagers and those in their 20s, who donate the blood the most, is shrinking, the blood donation rate is also going down.
According to the Red Cross data submitted to Rep. Nam In-soon of the ruling Democratic Party, the blood donation rate in Korea dropped to 7.3 percent in 2016 from 7.9 percent in 2015, after increasing from 6.9 percent in 2011. The decline in the blood donation among people aged between 16 and 29 led the fall in the overall rate. The share of blood donors aged from 16 to 19 plunged to 37.7 percent of the total in 2016 from 41.8 percent in 2015. The comparable share among those between 20 and 29 also went down to 15.8 percent in 2016 from 19.1 percent in 2015.
The number of blood donors aged between 16 and 19 also declined by 131,350 between 2015 and 2017. Those aged between 20 and 29 also fell by 151,042 during the same period. The Red Cross predicts that the number of people aged between 16 and 69 apt for blood donation will shrink by 1.88 million in 2030, compared with 2017. The number of teenagers and those in their 20s, who are major blood donors, will fall by 2.63 million during the cited period.
In Korea, the young population aged between 10 and 29 is getting smaller, and those aged more than 50 and serious patients, who take up 73 percent of the total blood transfusions, are increasing. Senior patients often need blood transfusions due to anemia and weak blood vessels.
The decline in blood donation is not the only cause for blood shortages. Critics say blood transfusions are excessive in Korea, compared with advanced countries. Korea’s use of blood transfusions is the double that of Japan, a super-aged society.
According to the Korea Centers for Disease Control and Prevention, Korea uses 41 units of red blood cells per 1,000 people, while Japan uses 26.3 units. Australia uses 27 units per 1,000 people. In Korea, the number of red blood cell transfusions rose to 1.94 million units in 2016 from 1.91 million in 2012.
|Korea’s blood transfusion per 1,000 persons is double the amount of Japan, a super-aged society, statistics show.
Lenient system for blood use
Experts said Korea’s lenient national health insurance system allows for the excessive use of blood. For example, physicians can use red blood cells without any limits in reimbursement. However, reimbursement for high-dose iron injections, an alternative treatment for blood transfusions, is extremely limited. Currently, Venoferrum Inj. is the only iron injection that can receive reimbursement only when a physician administers it to a patient in hemodialysis.
If a surgical patient gets iron shots for two or three days before a surgery, the patient’s hemoglobin levels go up. Then, the need for transfusing goes down. The anemia caused by an operation can be treated with iron injections.
Cancer patients who often suffer anemia should manage their hemoglobin levels carefully, before having a surgery. Oral iron supplements are rarely effective for cancer patients. To raise their hemoglobin levels, they need a prescription of high-dose iron injections.
However, high-dose iron injections are expensive because the national health insurance cannot cover them. Per shot, it costs about 150,000 won ($139.5) to 200,000 won, imposing heavy burdens on patients.
In contrast, blood transfusion costs about 50,000 won per unit (400cc). Since it can be reimbursed, a patient can pay only 5 percent of the cost, or 2,500 won ($2.3).
Lots of blood uses do not lead to a cut in reimbursement, either.
“We don’t limit the amount of transfusion or the number of transfusions. As long as the patient’s hemoglobin level is less than 10g/㎗ and the level declined more than 10 percent from the previous one, our system allows for a blood transfusion,” said an official at the Health Insurance Review & Assessment Service (HIRA).
Kim Young-woo, a professor at the National Cancer Center Graduate School of Cancer Science and Policy, noted that people tend to think that blood is cheap. “A patient can pay only 2,500 won because it is covered by health insurance. But if you consider facilities, equipment, and human resources, it costs nearly 1 million won to make one unit of blood,” Kim said. “Blood is a very precious resource. It should be used only for those who need it. But in reality, it is a different story,” he said.
Kim, who also serves as president of the Korean Society for Patient Blood Management, went on to say that the Korean system failed to supply the blood to those who needed the most. “The system is supposed to help physicians to use iron injections for patients who need them, but it is the opposite in reality,” he said. “Cancer patients find it difficult to absorb iron in the stomach, so oral iron supplements don’t work. They need iron shots, but iron shots are not covered by the health insurance.”
‘Limit blood transfusion to necessary cases’
Another cause of blood shortage is unnecessary blood transfusions. Under the transfusion guidelines by the KCDC and the Korean Society of Blood Transfusion (KSBT), physicians recommend blood transfusion when the patient’s hemoglobin level goes below 7g/㎗. However, they preemptively choose blood transfusion when the hemoglobin does down to 10g/㎗ (normal level is 13-14g/㎗), which was advised in the 1930s.
Trying to curb the old practice, experts in the medical community are calling for the government to adopt a PBM system as a new way of giving blood to those who need the most. PBM can help raise a patient’s hemoglobin level before a surgery and minimize the blood loss at the surgery, they say. To find a way to reduce blood transfusion, PBM promotes a multidisciplinary medical care. In Australia, most medical institutions adopted PBM and a quarter of the U.S. medical institutions also uses the PBM system.
In Korea, the KPBM is pushing the medical community to adopt PBM. In 2016, the fourth revised blood transfusion guidelines introduced the concept of PBM. The guidelines suggested a supply of blood in different types for different transfusion indications, and alternative treatments for blood transfusions. For example, the guidelines offered the “hemoglobin level at 7 g/㎗” as criteria to decide on red blood cell transfusion for chronic anemia. If there was no symptom, however, the guidelines suggested oral iron supplements or iron injections, vitamin B12, folic acid, and erythropoiesis.
KSBT’s public relations director, Um Tae-hyun, a physician at Ilsan Paik Hospital’s diagnostic department, said the transfusion guidelines aim at a safe and adequate transfusion of blood. “We aim to help physicians correctly keep the indications for transfusion, and compare the cost-effectiveness between transfusion and alternatives,” Um said. “Under PBM, physicians can shift the focus from blood products to patients and consider both transfusion and its alternative treatments. In the fourth guidelines for blood transfusion, we adopted the concept of PBM to offer different indications for transfusion in different blood products, together with alternative treatments.”
Um, who also doubles as research chief of the KPBM, made it clear that he did not intend to say “transfusion was a bad thing.”
“What I meant was that physicians should thoroughly review whether the patient needs the transfusion at a clinical level. We should enable a system to supply the blood for patients who need the transfusion,” he said.
KPBM President Kim said his gastric cancer patients receive almost zero blood transfusion. “If we apply PBM, we can reduce the amount of transfusion by at least 10 percent in cancer operations, and more than 50 percent in joint surgeries,” Kim said.
He pointed out that long-term studies have been lacking to ascertain how foreign white cells affect the patient’s immunity after a blood transfusion. “Immunity response always occurs in blood transfusion because red blood cells have their own immunity. PBM also aims to prevent unnecessary blood transfusion so that patients can have better clinical results,” Kim added.
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