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Variability in Transfusion Practice and Effectiveness of Strategies to Improve It

2012; Elsevier BV; Volume: 26; Issue: 4 Linguagem: Inglês

10.1053/j.jvca.2012.04.003

1532-8422

Aryeh Shander, Thomas Puzio, Mazyar Javidroozi,

Blood donation and transfusion practices

MORE THAN 150 YEARS have passed since Professor William Guy delivered his Croonian Lectures on the application of the "numerical method," more commonly known as "statistics," to the "science and art of medicine" at the Royal College of Physicians.1Guy W.A. Croonian lectures on the numerical method, and its application to the science and art of medicine.BMJ. 1860; 1: 331-334Crossref PubMed Scopus (2) Google Scholar The debate over whether medicine is more a science or an art persists to this day. Although the exact definition of medicine as a science versus an art is open to wide interpretation,2Guttentag O.E. The phrase, "art and science of medicine.".Cal West Med. 1939; 50: 86-87PubMed Google Scholar the science of medicine can be defined as the "knowledge" accumulated over the years and the art of medicine as the "skill" of the practitioner in applying the knowledge and dexterity in practice. The task of synthesizing up-to-date, evidence-based knowledge and conveying it to the clinicians is in itself daunting. Hoping that clinicians adopt the knowledge and apply it effectively in caring for their patients is another challenge. Indeed, this struggle spans almost every field and aspect of medicine (eg, cardiac surgery, a marvelous and intriguingly complicated procedure requiring great skills; and the transfusion of blood, one of the most common and rapidly increasing procedures among hospitalized patients in the United States).3Wier L.M. Pfuntner A. Maeda J. et al.HCUP Facts and Figures: Statistics on Hospital-based Care in the United States, 2009. Agency for Healthcare Research and Quality, Rockville, MD2011Google Scholar It can be argued that with the advancement of science, the role of the heart has been demoted from being the center of intelligence, emotion, and sensation according to Aristotle to an organ responsible for the rather mundane task of continuously pumping blood. Nonetheless, the emergence of cardiovascular diseases as the primary cause of death for humans at the present time attests to the fact that there is nothing mundane about the heart.4National vital statistics report—Deaths: Preliminary data for 2010. Center for Disease Control, Atlanta, GA2012Google Scholar Accordingly, heart surgeries, such as coronary artery bypass graft (CABG) surgery, have become true feats of medicine in which the surgeons, anesthesiologists, perfusionists, and other members of the team use advanced science, skills, and technology to take patients to the brink of death and bring them back alive. Over the past decade, despite increases in the frequency of patient comorbidities and advanced age, the outcomes of patients undergoing CABG procedures have improved significantly. A study of the short-term outcomes of more than 1.4 million CABG surgery patients indicated that from the years 2000 to 2009, the observed mortality rates declined from 2.4% to 1.9%, and the risks of postoperative stroke, reoperation, and sternal wound infection all decreased significantly.5El Bardissi A.W. Aranki S.F. Sheng S. et al.Trends in isolated coronary artery bypass grafting: An analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database.J Thorac Cardiovasc Surg. 2012; 143: 273-281Abstract Full Text Full Text PDF PubMed Scopus (328) Google Scholar By contrast, the incidences of atrial fibrillation and renal failure in these patients continued to increase during the same study period, rising as high as 21.1% and 3.6%, respectively.5El Bardissi A.W. Aranki S.F. Sheng S. et al.Trends in isolated coronary artery bypass grafting: An analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database.J Thorac Cardiovasc Surg. 2012; 143: 273-281Abstract Full Text Full Text PDF PubMed Scopus (328) Google Scholar Cardiac surgeries are among the leading procedures using allogeneic blood transfusions. In 2008, 7.1% of all units of red blood cells (RBCs) and 12.1% of all units of platelets were used in cardiac surgery services across the United States.6Whitaker B.I. Schlumpf K. Schulman J. et al.Report of the US Department of Health and Human Services The 2009 national blood collection and utilization survey report. US Department of Health and Human Services, Office of the Assistant Secretary for Health, Washington, DC2011Google Scholar Unfortunately, allogeneic blood transfusions have been proposed as an independent risk factor contributing to negative outcomes in many patient populations, including those undergoing CABG surgery.7Scott B.H. Seifert F.C. Grimson R. Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery.Ann Card Anaesth. 2008; 11: 15-19Crossref PubMed Scopus (131) Google Scholar, 8Shander A. Javidroozi M. Ozawa S. et al.What is really dangerous: Anaemia or transfusion?.Br J Anaesth. 2011; 107: i41-i59Crossref PubMed Scopus (245) Google Scholar, 9Reeves B.C. Murphy G.J. Increased mortality, morbidity, and cost associated with red blood cell transfusion after cardiac surgery.Curr Opin Anaesthesiol. 2008; 21: 669-673Crossref PubMed Scopus (47) Google Scholar As a notable example, Murphy et al10Murphy G.J. Reeves B.C. Rogers C.A. et al.Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery.Circulation. 2007; 116: 2544-2552Crossref PubMed Scopus (978) Google Scholar reviewed the data of 98% of all adult patients undergoing cardiac surgery from 1996 to 2003 in the UK and found RBC transfusion to be associated strongly with an increased risk of infection (adjusted odds ratio = 3.38), composite ischemic outcomes (including myocardial infarction, stroke, and renal impairment/failure; odds ratio = 3.35), an increased length of stay, and an increased risk of short- and long-term mortality.10Murphy G.J. Reeves B.C. Rogers C.A. et al.Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery.Circulation. 2007; 116: 2544-2552Crossref PubMed Scopus (978) Google Scholar In another study of 5,841 patients undergoing CABG surgery with or without valve replacement, RBC transfusion was associated with an increased risk of new-onset atrial fibrillation (odds radio = 1.18). In the propensity score–matched subcohorts of this study, atrial fibrillation occurred in 46% of transfused patients versus 38% of those who were not transfused.11Koch C.G. Li L. Van Wagoner D.R. et al.Red cell transfusion is associated with an increased risk for postoperative atrial fibrillation.Ann Thorac Surg. 2006; 82: 1747-1756Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar In another study of off-pump CABG patients, allogeneic RBC transfusion had the highest predictive value for the occurrence of atrial fibrillation in the postoperative period among the studied risk factors.12Choi Y.S. Shim J.K. Hong S.W. et al.Risk factors of atrial fibrillation following off-pump coronary artery bypass graft surgery: Predictive value of C-reactive protein and transfusion requirement.Eur J Cardiothorac Surg. 2009; 36: 838-843Crossref PubMed Scopus (37) Google Scholar Similarly, Mikkola et al13Mikkola R. Gunn J. Heikkinen J. et al.Use of blood products and risk of stroke after coronary artery bypass surgery.Blood Transfus. 2012; 22: 1-12Google Scholar studied 2,226 CABG surgery patients and concluded that postoperative transfusion was a significant independent risk factor for the development of postoperative stroke (odds ratio = 1.12) in a dose-dependent manner. Finally, a reanalysis of data from 1,491 patients with acute coronary syndromes undergoing CABG surgery who participated in the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial indicates that transfusion of >4 U of RBCs is a strong and independent predictor of 1-year mortality, with >24% of post-CABG mortality being attributed to RBC transfusions; whereas hemoglobin level and major bleeding were not independent predictors.14Stone G.W. Clayton T.C. Mehran R. et al.Impact of major bleeding and blood transfusions after cardiac surgery: Analysis from the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial.Am Heart J. 2012; 163: 522-529Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar The reported risks and negative impacts of allogeneic blood become alarming when the substantial variability of transfusion practices in similar patients and/or procedures is considered. In a study of more than 80,000 patients undergoing on-pump CABG surgery at 408 U.S. hospitals performing at least 100 procedures in 2008, the rate of the transfusion of RBCs, fresh frozen plasma, and platelets showed significant interinstitutional variability, with the following respective ranges: 7.8% to 98.8%, 0% to 97.5%, and 0.4% to 90.4%. After the adjustment for patient risks, 3 hospital characteristics, location, academic status, and case volume, emerged as significant determinants of the variation in transfusion rates. However, even when combined, these hospital characteristics only accounted for 11% of the transfusion variation, with an additional 20% of the variation attributable to the case-mix difference among the hospitals, which leaves almost 70% of the variation in transfusion rates in CABG surgery patients in U.S. hospitals unaccounted for.15Bennett-Guerrero E. Zhao Y. O'Brien S.M. et al.Variation in use of blood transfusion in coronary artery bypass graft surgery.JAMA. 2010; 304: 1568-1575Crossref PubMed Scopus (349) Google Scholar In another study encompassing nearly 25,000 patients undergoing CABG surgery in the state of Michigan between 2003 and 2006, the use of allogeneic blood transfusion in women and men ranged from 72.5% to 100% and 49.7% to 100%, respectively, with 30% of the variation in transfusion rates attributed to the hospitals.16Rogers M.A. Blumberg N. Saint S. et al.Hospital variation in transfusion and infection after cardiac surgery: A cohort study.BMC Med. 2009; 7 (37-37)Crossref PubMed Scopus (99) Google Scholar These and several other reports of enormous unexplained variations in transfusion practices recently were noted in the 40th meeting of the U.S. Department of Health and Human Services Advisory Committee for Blood Safety and Availability, which stated that the wide variation is an indicator of the excessive and inappropriate use of transfusions.17US Department of Health and Human ServicesAdvisory Committee for Blood Safety and Availability: 40th meeting minutes.http://nih.granicus.com/DocumentViewer.php?file=nih_279c20e5-c8ef-4e28-b457-d86995ff40fa.pdfDate: June 8, 2011Google Scholar With the list of studies linking blood transfusion to unfavorable outcomes in patients growing8Shander A. Javidroozi M. Ozawa S. et al.What is really dangerous: Anaemia or transfusion?.Br J Anaesth. 2011; 107: i41-i59Crossref PubMed Scopus (245) Google Scholar and the uncertainty surrounding the safety and efficacy of blood transfusions,18Shander A. Fink A. Javidroozi M. et al.Appropriateness of allogeneic red blood cell transfusion: The international consensus conference on transfusion outcomes.Transfus Med Rev. 2011; 25: 232-246Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar efforts to promote appropriate transfusions, avoid unnecessary transfusions, and reduce the need for transfusion are now appreciated more than ever, making blood transfusion a potential quality indicator in cardiac surgery.19Shander A.S. Goodnough L.T. Blood transfusion as a quality indicator in cardiac surgery.JAMA. 2010; 304: 1610-1611Crossref PubMed Scopus (31) Google Scholar Not surprisingly, such efforts have been gaining favor from various stakeholders. Many clinicians, hospitals, and professional organizations have recognized this urgent need and responded with attempts to standardize care, with plans to reduce or eliminate patient exposure to unwarranted transfusions. The set of guidelines on blood conservation issued jointly by the Society of Thoracic Surgeons (STS) and the Society of Cardiovascular Anesthesiologists (SCA) is a remarkable example of such efforts.20Ferraris V.A. Brown J.R. Despotis G.J. et al.Update to the society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines.Ann Thorac Surg. 2011; 91: 944-982Abstract Full Text Full Text PDF PubMed Scopus (964) Google Scholar Other organizations, such as the Joint Commission,21The Joint CommissionPatient blood Management Performance Measures Project., June 27 2011.http://www.jointcommission.org/patient_blood_management_performance_measures_project/Google Scholar the American Medical Association, and the World Health Organization,22World Health Organization (WHO)63rd world health assembly: Availability, safety and quality of blood products.http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R12-en.pdfGoogle Scholar also have recognized the need and joined the efforts to eliminate inappropriate transfusions. These efforts point to the fact that a multimodal approach to reduce or eliminate transfusions is needed in cardiac surgery as well as other surgical and nonsurgical patients. Patient blood management (PBM) is now recognized as a persuasive strategy to achieve this goal23Spahn D.R. Moch H. Hofmann A. et al.Patient blood management: The pragmatic solution for the problems with blood transfusions.Anesthesiology. 2008; 109: 951-953Crossref PubMed Scopus (129) Google Scholar through "the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss in an effort to improve patient outcome."24Society for the Advancement of Blood ManagementWhat is patient blood management?.http://sabm.orgGoogle Scholar PBM pursues a patient-centered philosophy, as opposed to a "product-centered" one, when approaching blood transfusions by placing the emphasis on patient outcomes.25Shander A. Javidroozi M. Perelman S. et al.From bloodless surgery to patient blood management.Mt Sinai J Med. 2012; 79: 56-65Crossref PubMed Scopus (64) Google Scholar The core strategies or "pillars" of PBM consist of proactive diagnosis and treatment of anemia (particularly in the preoperative setting), minimization of blood loss, and management of anemia and the physiologic response to anemia without allogeneic blood transfusion.25Shander A. Javidroozi M. Perelman S. et al.From bloodless surgery to patient blood management.Mt Sinai J Med. 2012; 79: 56-65Crossref PubMed Scopus (64) Google Scholar, 26Goodnough L.T. Shander A. Patient blood management.Anesthesiology. 2012 Apr 6; ([Epub ahead of print])PubMed Google Scholar Despite all the efforts to promote PBM in the perioperative arena (eg, the original 2007 and the updated 2011 guidelines by the STS/SCA on blood conservation in cardiac surgery)20Ferraris V.A. Brown J.R. Despotis G.J. et al.Update to the society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines.Ann Thorac Surg. 2011; 91: 944-982Abstract Full Text Full Text PDF PubMed Scopus (964) Google Scholar, 27Ferraris V.A. Ferraris S.P. Saha S.P. et al.Perioperative blood transfusion and blood conservation in cardiac surgery: The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists clinical practice guideline.Ann Thorac Surg. 2007; 83: S27-S86Abstract Full Text Full Text PDF PubMed Scopus (747) Google Scholar and the increasing publicity of such efforts among clinicians, reports of the adoption of these strategies have been somewhat disappointing. In a survey of cardiac anesthesiologists and perfusionists in the United States and Canada,28Likosky D.S. FitzGerald D.C. Groom R.C. et al.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: 316-323Crossref PubMed Scopus (54) Google Scholar more than two thirds of the respondents indicated that they had been exposed to the 2007 STS/SCA guidelines,27Ferraris V.A. Ferraris S.P. Saha S.P. et al.Perioperative blood transfusion and blood conservation in cardiac surgery: The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists clinical practice guideline.Ann Thorac Surg. 2007; 83: S27-S86Abstract Full Text Full Text PDF PubMed Scopus (747) Google Scholar yet only 20% indicated having an institutional discussion of the guidelines. Fourteen percent reported the formation of an institutional monitoring group, and just about one fourth indicated at least 1 practice change because of the guidelines. Finally, the reported transfusion practices remained widely variable.28Likosky D.S. FitzGerald D.C. Groom R.C. et al.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: 316-323Crossref PubMed Scopus (54) Google Scholar It is clear that the issuance of practice guidelines, although essential, is by no means adequate to bring about the widespread changes in transfusion practices. Transfusion decisions are complex and are affected by many factors, ranging from a sincere but often unsubstantiated desire to accelerate patient's recovery, to a fear of legal consequences. They often are complicated by a lack of high-quality evidence.18Shander A. Fink A. Javidroozi M. et al.Appropriateness of allogeneic red blood cell transfusion: The international consensus conference on transfusion outcomes.Transfus Med Rev. 2011; 25: 232-246Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar In addition, even if the guidelines could offer the best evidence-based information available, their scope is still limited to the realm of the "knowledge" of medicine and does not effectively address the "art" element of medicine (ie, the skills of the surgeon and the rest of the team). In their article in this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Biancari et al29Biancari F. Mikkola R. Heikkinen J. et al.Individual surgeon's impact on the risk of reexploration for excessive bleeding after coronary artery bypass surgery.J Thorac Cardiovasc Surg. 2012; ([Epub ahead of print])Google Scholar report on the impact of individual surgeons on the risk of bleeding in patients undergoing CABG surgery. Looking at 2,001 patients undergoing CABG surgery (of whom 113 subsequently underwent re-exploration for bleeding), the rate of re-exploration for bleeding ranged from 1.4% to 11.7% among the 12 studied surgeons. In multivariate analysis, the authors identified the individual surgeon, a low body mass index, and a low estimated glomerular filtration rate as independent predictors of re-exploration. Additionally, they indicated that the individual surgeon was an independent predictor of substantial postoperative blood loss.29Biancari F. Mikkola R. Heikkinen J. et al.Individual surgeon's impact on the risk of reexploration for excessive bleeding after coronary artery bypass surgery.J Thorac Cardiovasc Surg. 2012; ([Epub ahead of print])Google Scholar This study provided an interesting and unique insight into the effect of individual surgeons on surgical bleeding and the associated re-exploration, both of which are among the major predictors of transfusion and an unfavorable outcome.30van Straten A.H. Kats S. Bekker M.W. et al.Risk factors for red blood cell transfusion after coronary artery bypass graft surgery.J Cardiothorac Vasc Anesth. 2010; 24: 413-417Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar It should be noted that a number of issues undermine the robustness of the findings, particularly those based on regression analysis. It often is stated that, in logistic regression, keeping the number of outcome events per variable analyzed reasonably high is important for avoiding bias, variability, too wide or unreliable confidence intervals, and other issues.31Peduzzi P. Concato J. Kemper E. et al.A simulation study of the number of events per variable in logistic regression analysis.J Clin Epidemiol. 1996; 49: 1373-1379Abstract Full Text PDF PubMed Scopus (4763) Google Scholar Although the rule of thumb of having at least 10 events per variable has been challenged as being too conservative in certain situations,32Vittinghoff E. McCulloch C.E. Relaxing the rule of ten events per variable in logistic and cox regression.Am J Epidemiol. 2007; 165: 710-718Crossref PubMed Scopus (2140) Google Scholar the number of events (113 re-explorations) still may be too small when the long list of the variables considered (and not just the variables meeting the preset entry criterion of regression analysis) in the study by Biancari et al29Biancari F. Mikkola R. Heikkinen J. et al.Individual surgeon's impact on the risk of reexploration for excessive bleeding after coronary artery bypass surgery.J Thorac Cardiovasc Surg. 2012; ([Epub ahead of print])Google Scholar (listed in Table 1 of the article) is viewed. Additionally, the way the variable "surgeon" (a categoric variable usually in need of "dummy coding") was treated and entered into the regression analysis is not adequately explained and may preclude a clear interpretation of some of the reported parameters. Nonetheless and beyond these possible limitations, the conclusions of the report by Biancari et al regarding the variations among surgeons appear to be reasonable and in line with findings of other reports. In a previous study of 18,891 CABG, valve, or combined CABG and valve replacement surgeries (of which 566 patients underwent reoperation for bleeding), the surgeon as well as an older patient age, higher acuity, greater comborbidities, valve surgery, longer myocardial ischemia, and longer duration of cardiopulmonary bypass time were all identified as significant risk factors for reoperation.33Vivacqua A. Koch C.G. Yousuf A.M. et al.Morbidity of bleeding after cardiac surgery: Is it blood transfusion, reoperation for bleeding, or both?.Ann Thorac Surg. 2011; 91: 1780-1790Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar The impact of individual surgeons on other outcomes in other procedures also has long been recognized.34Hermanek P. Hermanek P.J. Role of the surgeon as a variable in the treatment of rectal cancer.Semin Surg Oncol. 2000; 19: 329-335Crossref PubMed Scopus (63) Google Scholar, 35Penninckx F. Surgeon-related aspects of the treatment and outcome after radical resection for rectal cancer.Acta Gastroenterol Belg. 2001; 64: 258-262PubMed Google Scholar Overall, these findings leave readers with a challenging situation in which a relatively complex, hard-to-quantify, and hard-to-modify factor—the skill of surgeons—plays a critical role in the outcome of patients, their risk of bleeding, and the associated complications. Additionally, and as previously discussed, such tools as guidelines cannot be relied upon to bring about the desired changes in practices.28Likosky D.S. FitzGerald D.C. Groom R.C. et al.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: 316-323Crossref PubMed Scopus (54) Google Scholar What can be done then to make the changes and improve the practices and the outcomes of patients? In another article in this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Andreasen et al36Andreasen J.J. Sindby J.E. Brocki B.C. et al.Efforts to change transfusion practice behaviour and reduce transfusion rates are effective in coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2012; 26: 545-549Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar reported their success in changing transfusion practices and reducing transfusion rates in CABG surgeries through a multimodal approach. The authors evaluated 450 patients undergoing elective CABG surgery before and after implementing a number of strategies to reduce blood transfusion at their institution in a period spanning the years 2004 to 2010. Despite the fact that patient populations remained relatively comparable during this time period with respect to the evaluated parameters, the authors noticed significant reductions in allogeneic transfusion rates from 64% to 47% and frequency of overtransfusions from 36% to 16%, as well as a significant reduction in the amount of chest tube drainage.36Andreasen J.J. Sindby J.E. Brocki B.C. et al.Efforts to change transfusion practice behaviour and reduce transfusion rates are effective in coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2012; 26: 545-549Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar The reduction in allogeneic transfusion rates was most prominent for the RBC transfusions (ie, rates decreased from about 60% to 37%), followed by fresh frozen plasma (ie, rates decreased from about 28% to 16%), whereas platelet transfusion rates increased from about 20% to 24%, which was an unexpected finding that the authors attributed to a possible increased awareness of the clinicians of the risks of bleeding.36Andreasen J.J. Sindby J.E. Brocki B.C. et al.Efforts to change transfusion practice behaviour and reduce transfusion rates are effective in coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2012; 26: 545-549Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar The strengths of the "transfusion-sparing" program reported in this study include the implementation of various strategies and the inclusion of different team members (physicians and nurses). The study could have benefited from the inclusion of more patients. The sample size was calculated based on the expected reduction in chest tube drainage, whereas the focus of the study was on transfusion. The evaluation of additional comorbidities and possibly risk/fitness scores (eg, American Society of Anesthesiologists physical status classification) could have ascertained the comparability of the patients at various stages of the study. Additionally, with years placing the studied patients apart and without control groups, it is difficult to rule out the possible impact of changes other than the implemented program (eg, changes in operative characteristics listed in Table 2 of the article36Andreasen J.J. Sindby J.E. Brocki B.C. et al.Efforts to change transfusion practice behaviour and reduce transfusion rates are effective in coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2012; 26: 545-549Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar or the potential increased awareness of the clinicians of the risks of transfusion acquired from other sources). Although the results reported by Andreasen et al36Andreasen J.J. Sindby J.E. Brocki B.C. et al.Efforts to change transfusion practice behaviour and reduce transfusion rates are effective in coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2012; 26: 545-549Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar are certainly impressive, there is still some room for improvement because their approach did not make use of the full potentials of PBM. Namely, PBM places substantial emphasis on preventive measures best exemplified by proactive screening for and the management of anemia before surgery. Another measure not used in this study is the role of acute normovolemic hemodilution although the evidence supporting this technique (or the specific patients who benefit most from it) may not have been well established yet.25Shander A. Javidroozi M. Perelman S. et al.From bloodless surgery to patient blood management.Mt Sinai J Med. 2012; 79: 56-65Crossref PubMed Scopus (64) Google Scholar, 26Goodnough L.T. Shander A. Patient blood management.Anesthesiology. 2012 Apr 6; ([Epub ahead of print])PubMed Google Scholar Finally, this study did not provide any data on the clinical outcomes to evaluate the impact of the program on the outcomes of the patients, which is the ultimate goal of PBM. Nonetheless, the authors should be commended for implementing their blood management program successfully and reporting the results. The study supports the effectiveness of multimodal programs in changing and improving transfusion practices36Andreasen J.J. Sindby J.E. Brocki B.C. et al.Efforts to change transfusion practice behaviour and reduce transfusion rates are effective in coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2012; 26: 545-549Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar and adds to an accumulating body of evidence on similar initiatives.37Brevig J. McDonald J. Zelinka E.S. et al.Blood transfusion reduction in cardiac surgery: Multidisciplinary approach at a community hospital.Ann Thorac Surg. 2009; 87: 532-539Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 38Freedman J. Luke K. Escobar M. et al.Experience of a network of transfusion coordinators for blood conservation (Ontario transfusion coordinators [ONTraC]).Transfusion. 2008; 48: 237-250PubMed Google Scholar, 39Green J.A. Blood conservation in cardiac surgery: The Virginia Commonwealth University (VCU) experience.J Cardiothorac Vasc Anesth. 2004; 18: 18S-23SAbstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Brevig et al37Brevig J. McDonald J. Zelinka E.S. et al.Blood transfusion reduction in cardiac surgery: Multidisciplinary approach at a community hospital.Ann Thorac Surg. 2009; 87: 532-539Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar reported the results of implementing a multidisciplinary blood conservation program based on the data from 2,531 consecutive cardiac surgeries performed from 2003 to 2007 at a single center. In the studied period, allogeneic RBC transfusion incidence decreased from 43% to 18%, whereas patient outcomes remained unchanged. These studies showed that despite challenges, clinical practices, even as complex as the management of patients undergoing cardiac surgery, still can be effectively and substantially improved. The key may lie in drawing on multimodal programs using a wide range of strategies targeted by team members at various aspects of care. Such an approach is a central principle of PBM.26Goodnough L.T. Shander A. Patient blood management.Anesthesiology. 2012 Apr 6; ([Epub ahead of print])PubMed Google Scholar Thus, PBM offers enormous potential in improving clinical practices (including but not limited to transfusion practices) and improving the clinical outcomes of the patients. Systematic strategies to collect and analyze data are required to evaluate the safety and efficacy of PBM as a standard of practice; yet, the endorsement of PBM by a growing number of clinicians, hospitals, professional societies, and national and international agencies is a positive sign. Although the dilemma of medicine as an art versus a science may not be resolved any time soon; hopefully, wider implementation of PBM strategies will make clinicians more knowledgeable and better skilled in caring for their patients with the added benefit of improved clinical outcomes.