Recently, experts in Patient Blood Management (PBM) gathered in Seoul to share their latest knowledge and opinions at an international conference. The Korean Society for Patient Blood Management (KPMB) hosted the “International Symposium on Patient Blood Management 2017 Seoul” on Dec. 1-2, under the main topic “PBM! The Standard Patient Care.” The event was the first international academic conference in Korea where PBM experts from around the world gathered to discuss PBM issues.

KPBM hosted the event to push for a fundamental shift in the Korean policy of blood management. The organization claims that the blood management policy should focus on patient care, rather than the blood supply, through PBM.

KPBM President Kim Young-woo, who also serves as a professor at the National Cancer Center, said Korea should adopt PBM as standard medical care to minimize blood transfusion. PBM offers abundant medical evidence that it improves patient outcomes, according to Kim. Korea Biomedical Review met Kim to listen to why KPBM claims PBM is a new way of blood management.

Question: Why do we need PMB?

Answer: Korea’s blood shortage is in a serious situation. The population of teens and those in their 20s is shrinking. With the population aging, the blood supply will go down further. But first of all, we have much medical evidence that minimizing transfusion leads to better patient outcomes.

We’re not saying we should reduce the use of blood through PBM. We are saying we should approach the issue with more focus on patients. PBM is one of the many ideas how to improve patient outcomes and their quality of life. Blood is a precious resource readied by people’s donation and expensive treatment. Therefore, blood should go to the one who needs it the most.

There are three stages in PBM. First, it corrects anemia of a surgical patient before surgery. Second, PBM minimizes hemorrhage during operation to reduce the need for blood transfusion. Third, it effectively treats anemia after the surgery.

Q: Do you think doctors use blood transfusions too much?

A: Hypothetically, Japan would use more blood than Korea because the population of the elderly is much larger in Japan. But in reality, Korea uses blood twice as much than Japan. As of 2015, Korea used 41 units of blood per 1,000 people, and Japan, 26.3 units.

In Korea, doctors opt for transfusing even when a patient does not need an urgent care and the hemoglobin level is around 9-10g/㎗ (while blood transfusion guidelines recommend transfusing when the level goes down to 7 g/㎗ and below). Doctors take transfusion too lightly.

In gastric cancer surgery, the National Cancer Center rarely uses blood transfusion, with less than 1 percent of gastric cancer surgical patients receiving a transfusion. At Seoul National University Hospital, Seoul Medical Center, and Samsung Medical Center, there is almost no hemorrhage in gastric cancer surgeries. However, in all gastric cancer surgeries in Korea, 20 percent of surgical patients get a blood transfusion. This means blood use varies depending on hospitals and doctors. That is why we should use PBM as a universal system.

Q: People are more aware of the term “transfusion-free” than PBM. Are you saying we should go transfusion-free?

A: Some people feel uncomfortable with the word, transfusion-free. Patients who need blood should get a transfusion. I’m not arguing that all surgeries should go transfusion-free. The KPBM does not seek transfusion-free. I think the KPBM shares the same stance with the Korean Society of Blood Transfusion and the Korean Red Cross. (KSBT’s public relations director Um Tae-hyun also serves as KPBM’s research committee chief). Korea should reduce unnecessary transfusion and redirect saved costs to supply the quality blood. In Japan, hospitals provide 100 percent white cells-filtered blood. But in Korea, that’s not the case.

Q: KPBM also argues that the national health insurance system allows excessive blood use, right?

A: Iron injections, which can treat anemia before surgery, are not covered by health insurance. For cancer patients, oral iron supplements are not effective. As non-reimbursed, iron shots are expensive. So, doctors raise patients’ hemoglobin levels by transfusing. Not being covered by health insurance means iron injections are not recognized as a standard treatment. But we have plenty of evidence that iron injections are effective to correct anemia.

A self-transfusion device, “Cell Saver,” started to be reimbursed several years ago, but doctors don’t use them much. The government’s blood management policy is excessively focused on the blood supply. One of the most important tasks for every transfusion committee at every hospital is to monitor the blood waste and reduce it.

In May last year, Kim published his study on JAMA which showed that high-dose iron injections were effective to treat acute anemia occurring after gastric cancer surgery. The seven-year study involved 454 patients who had anemia after gastric cancer surgery and their surgeons at seven hospitals, including the National Cancer Center, Kyungpook National University Hospital, Samsung Seoul Hospital, Seoul National University Hospital, Asan Medical Center, Hwasun Chonnam National University Hospital.

The patients, whose hemoglobin levels were low at around 7-10g/dl within five to seven days after surgery, were divided into two groups. In one group, doctors intravenously administered high-dose iron injection “Ferrinject” (ingredient: ferric carboxymaltose). The other received placebo.

Results showed that 92.2 percent of the patients with iron injections saw their hemoglobin levels going up to 12.3g/㎗ on average, near the normal level of 13-14g/㎗. In contrast, the placebo group’s hemoglobin levels remained low at 10.8g/㎗ on average, still showing symptoms of anemia.

Q: Do we need law revisions to adopt PBM?

A: Because Korea is experiencing serious blood shortages, we need to adopt PBM as soon as possible. We should revise the Blood Management Act, change Transfusion Committee into Patient Blood Management Committee, and allow hospitals to adopt PBM universally. In the Blood Information Management System (BIMS) which mostly contains supply data, we need to save patients’ clinical data to monitor blood is appropriately used. We also need to help patients get easier access to iron injections by making them reimbursed. The concept of blood management fees should be changed to incentives that are given for minimizing blood transfusion. Going forward, we should also think about how to reflect PBM in the criteria of the Medical Institution Certification and Evaluation.

Q: If we forcefully push for an adoption of a PBM system, the medical community might develop antipathy against it. What would you say to those who oppose the idea?

A: PBM is patient-oriented medicine. To reduce blood transfusion is part of PBM’s aim, not the ultimate goal. In the past 10 years, clinical studies and medical evidence have supported PBM. If doctors learn about the medical evidence, they will change themselves. If there is a new treatment that helps patients get better quicker, doctors should accept it and apply it to patient care.