Health Service Focus

01.10.15

Enabling more efficient anaemia management

Source: NHE Sep/Oct 15

Toby Richards, professor of surgery at University College London, discusses how improving the management of anaemia in surgical patients could reduce the need for routine blood transfusions and save the NHS millions of pounds.

The current standard procedure for patients with anaemia who are to undergo surgery in the UK is blood transfusion – but could this be about to change? 

A major piece of research by University College London and NHS Blood & Transplant is evaluating whether a single dose of intravenous iron administered to patients with anaemia prior to major surgery reduces the need for perioperative blood transfusion. 

Conducted across 35 health sites, the five-year PREVENTT trial – preoperative intravenous iron to treat anaemia in major surgery – is due to conclude next year. The Health Technology Assessment funded study is a double blind phase 3 randomised controlled trial, with all patients followed for six months from the date of their operation. 

NHE caught up with the programme’s chief investigator to get a picture of how the work is progressing. “My trial is taking those people who have anaemia prior to major surgery and we are randomising them between intravenous iron or placebo,” said Toby Richards, professor of surgery at University College London. 

“But I have to say blood transfusion is a highly successful practice, and it is a hugely successful service. However, in the last five to 10 years, there has been increasing awareness on two things: one is the appropriateness of blood transfusion and second is the problem of anaemia and anaemia management in the hospital setting.” 

Anaemia is a definite risk factor for surgery. “If you’re anaemic before you undergo an operation this is associated with  a higher risk of complications, a higher need for blood transfusion, increased length of stay in hospital and worse outcomes following surgery,” said Prof Richards. His work, initially a Health Foundation Shine 2010 project, has identified that anaemia is actually very common in people undergoing surgery. 

“We found that a third of all people coming in for major surgery were anaemic,” he said. “Also, that group of patients are 2.5 times more likely to need a blood transfusion. They are also more likely to need more blood.” 

An audit carried out by the Shine team also revealed that the group with anaemia spent an average of nine days in hospital, compared to six days for non-anaemic patients. 

A secondary objective of the study is to evaluate the effect of intravenous ferric iron Ferinject solution compared with placebo on health-related quality of life, post-operative morbidity, safety and length of hospital stay.

“Many people take oral iron tablets to manage anaemia, and most women have been on oral iron at some point during their lifetime,” said Prof Richards. “But I can give you a year’s supply of iron in an injection with Ferinject in 15 minutes. You will also feel better within five days. So the question has evolved: it is not ‘should we be transfusing people?’; it is really whether transfusion is now a second-line drug, and whether iron should be a first-line drug.” 

NHE was told that a single unit of blood costs about £130, but once the cumulative NHS costs such as nursing time, administration and treatment costs are added together it is more than £600. The cost of an iron transfusion, says Prof Richards, is £150-200 and it is given over 15-30 minutes. 

If the PREVENTT trial is successful it will be assessed by NICE and the approach could be rolled out into full clinical practice, potentially savings millions of pounds. 

“If I show that I’ve reduced blood transfusion and reduced complications in 5% of patients, I will save the NHS £35m. That would be direct savings,” said Prof Richards. “As part of an enhanced recovery plan the potential savings could be far greater in terms of bed days. But bed days are quite difficult costs to qualify.” 

He added that results of the study could also change the care pathway, as it would lead to a more “reflective process” on looking at the quality of operations and whether the patient is as fit as they can be for the operation so they can recover faster. 

“In cancer, for instance, if you operate quickly and have a complication, then people will recover more slowly, which means they get their chemotherapy later. This does have an effect on outcomes – we know this,” said Prof Richards. “The way I describe it is, if you are going to run the marathon you are going to get fit and ready for it. If you are fit and ready then you’ll do well and recover faster. It is the same for an operation.” 

NHE was told that at its heart the initiative is a ‘quality improvement programme’ and the fact that NHS Blood & Transplant, the provider of blood, is leading on the initiative to potentially reduce blood transfusions is truly groundbreaking. 

Dr Kate Pendry, consultant haematologist and NHS Blood and Transplant’s clinical director for Patient Blood Management, said: “PREVENTT is a very significant study. Around 30 to 40% of patients going in for major surgery have anaemia, and while blood components are used to save and improve thousands of lives each year, there is evidence of inappropriate use of transfusion to manage anaemia rather than the use of iron. NHS Blood and Transplant is, with others, working to support safe and appropriate use of blood in hospitals and promote the use of transfusion alternatives. 

“Consultants in our Patient Blood Management Team have been recruiting patients into PREVENTT study in their hospital roles and our Patient Blood Management Teams are ideally placed to put the study findings into practice. They will train and educate clinical staff, based on evidence that emerges, on the best treatment for these patients, and will also develop resources for patients such as information leaflets.”

For more information about the PREVENTT study, click here.

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