December 2011
Feature Story

Karen Titus

Irwin Gross, MD, cuts an ordinary figure at Eastern Maine Medical Center, Bangor. As the medical director of EMMC’s patient blood management program, Dr. Gross passes his days predictably enough: meeting with patients, consulting with fellow physicians, attending hematology section meetings, and affixing his John Hancock to prescriptions for medications such as intravenous iron or erythropoiesis-stimulating agents, including darbepoetin.

Did we mention Dr. Gross is a pathologist?

As it turns out, he also enjoys turning the traditional role of the pathologist on its head, then kicking it down the hospital hallway for good measure. In doing so, he’s also managed to transform patient blood management at his institution.

Dr. Gross’ patient blood management program is not unique in the United States, but it’s hardly common, he says. Most, he suspects, have been launched by clinicians—typically an anesthesiologist or a surgeon, or occasionally by a hematologist or hospitalist.

If there are reasons pathologists can’t do the same, the logic is lost on Dr. Gross, who’s also medical director of transfusion services at EMMC. Compared to other physicians, he says, pathologists have an advantage: laboratory expertise in anemia, coagulopathy, and hematopathology. After that, it’s merely a matter of becoming comfortable with clinical adventures.

He’s clearly made himself at home on that side of town. “I’m actually the physician of record for anemia treatments in our clinic,” he says. “There’s no reason why pathologists can’t get comfortable with the use of medications.”

Dr. Gross spoke about pathologist-directed preoperative anemia management at the CAP ’11 meeting in Dallas-Fort Worth in September. While this is only one part of EMMC’s broader patient blood management program—“It just touches our presurgical, elective surgery patient population,” Dr. Gross says—it’s a vital one. Patients who are diagnosed with anemia and treated before elective surgical procedure, Dr. Gross says, are less likely to be transfused. And published data suggest that treating anemia—independent of the transfusion issue—improves patient outcomes, he says.

A retrospective review of nearly 8,000 non-cardiac surgical patients (Beattie WS, et al. Anesthesiology. 2009;110:574–581) found prevalence of anemia (defined as Hgb less than 12 g/dL for women, and less than 13 g/dL for men) to be nearly 40 percent. Anemia was associated with increased mortality (odds ratio, 2.29), after adjustment for major confounders and elimination of patients who had severe anemia or who were transfused, Dr. Gross says.

In another retrospective study (Wu W-C, et al. JAMA. 2007;297:2481–2488), researchers using the VA National Surgical Quality Improvement Program database looked at 310,311 veterans 65 or older who underwent major non-cardiac surgery. The 30-day mortality and cardiac event rates increased by 1.6 percent with every one percent increase or decrease in hematocrit value from the normal range.

When Dr. Gross started the preoperative anemia management program at EMMC nearly five years ago, he was quick to recognize there were some patients with preexisting conditions who were having elective surgical procedures. “But when we looked back at their medical records, we saw that they’d been anemic for some period of time, sometimes years,” Dr. Gross recalls. Clinicians weren’t necessarily identifying or fixing the problem.

Dr. Gross soon turned the preoperative anemia management program into a more broadly based clinic. In addition to seeing the elective surgical patient population, Dr. Gross and his program coordinator, an RN, also see patients with chronic heart failure who have anemia, iron deficiency, or both; patients with inflammatory bowel disease (Crohn’s or ulcerative colitis) who have long-standing anemia; and patients with rheumatoid arthritis and related diseases. They also help manage patients who develop surgically induced malabsorption syndrome (usually as a result of bariatric surgery).

The rewards at EMMC have been considerable, Dr. Gross reports, with reductions in transfusions, length of stay, and perioperative infections. Since patient blood management got underway in 2007 and with no change in the MS-DRG Case Mix Index or admissions, the number of patients receiving a blood transfusion has declined from 2,843 patients in 2006 to 1,534 patients in 2010. Overall length of stay at EMMC has dropped from 5.19 days in 2006 to 4.77 days in 2010. Surgical site infections in cardiac surgery have fallen in the same period from 1.5 percent to less than 0.4 percent, far below the National Health Safety Network benchmark in 2009 of 2.96 percent.

Like a pickpocket, anemia hides in plain sight in the general population, says Dr. Gross, a board member of the Society for the Advancement of Blood Management. “In a busy, primary care physician’s practice, it has almost become what I refer to as a normalized deviation —when deviation from the normal value becomes the norm. It’s so common they don’t see it as abnormal anymore.”

That invisibility may have helped Dr. Gross in an unexpected way. When he broached the idea of starting an anemia management program, he wasn’t trying to wrest patient care away from anyone. By finding a void and offering to fill it, he neatly sidestepped potential turf issues with other physicians.

“That’s a very fair assessment,” Dr. Gross says. No one’s pushed back—not primary care providers, not surgeons, not hematologists. “In fact, they’ve embraced this,” Dr. Gross says.

The primary care physicians now refer patients to the anemia management clinic, which provides initial treatment and creates followup treatment plans.

The orthopedic surgeons are equally enthralled. Thanks to the clinic, Dr. Gross says, “They’re being given a patient on the day of surgery whose hemoglobin has been optimized for the surgical procedure. It requires no real effort on their part other than to identify the patient population that they want to have managed.” And as an extra pair of eyes reviewing lab studies—in the context of diagnosing and treating anemia—Dr. Gross has identified patients with serious, unrecognized comorbidities. In one case, it was an undiagnosed colon cancer in a patient with unexpected iron deficiency. “We were able to say, ‘Gee, the priority here is really not the elective [joint] replacement.’”

Dr. Gross already enjoyed solid relationships with his clinical colleagues, thanks to heading up transfusion services. And when he started the anemia management program, he and the medical staff leadership at EMMC decided he would be part of the hematology section of the medical service, not just pathology. “If other pathologists are interested in doing something like this, it would be important for them to lay the groundwork with clinical colleagues, probably hematology,” he says. Upfront, he also spent time in the operating room with anesthesiologists, orthopedic surgeons, and cardiothoracic surgeons.

He hatched his plans in 2006, leaving a private group practice in October that year. For the next three months he studied the structure and services of patient blood management programs at other hospitals; the EMMC program launched in January 2007. He was the sole staff member until June 2008, when Tiffany Nelson, RN, joined him as program coordinator.

The leap for Dr. Gross was not a big one—but it shouldn’t be for most pathologists, he contends. Anyone who practices surgical pathology already has a rapport with surgeons, he notes. The same might also be true—if to a slightly lesser extent—with anesthesiologists, based on conversations pathologists have with them regarding component therapy in a bleeding patient. And, he continues, pathologists are already involved with emergency department physicians and hospitalists, when they discuss patients who are bleeding, or talk about toxicology results for a patient who may have overdosed.

“We already engage on both the AP and CP side in direct patient care and discussion with our clinical colleagues,” Dr. Gross says. His blood management program is merely a logical extension of those interactions, he says.

“I reject the notion that pathologists are a bunch of hermits who don’t want to see people,” he says. “Most of the pathologists I’ve known and worked with over the years are very personable, and given the opportunity and the right tools, they don’t shy away from patient contact.”

Even if this is not a leap for pathologists, creating a patient blood management program might require a series of small hops. “I think pathologists need to get out of their comfort zone a little bit,” Dr. Gross concedes. “Put scrubs on and get into the operating room to establish some credibility in terms of their clinical credentials.”

Clinicians may have embraced the program, but in the laboratory, more than a few eyebrows have been raised. “Pathologists are often not comfortable with this,” he says.

Why does this make some pathologists squirm? “The last time most pathologists were involved with bedside care and writing orders was probably their last year of medical school,” Dr. Gross says. And few if any pathology residency programs are designed to bring pathologists to the bedside. “As you get further and further out from training, it becomes more and more of an experience you’re no longer familiar with. I think that’s where the discomfort comes from.”

Pathologists may worry about the liability issues of writing prescriptions, he adds. Dr. Gross isn’t buying it. “I think pathologists need to wrap their minds around the fact that the medical-legal risk is actually very, very low,” he says. “It’s probably no higher than what they currently experience when they’re signing out biopsies.”

Dr. Gross had been part of a large private practice pathology group for 22 years when he decided to approach the EMMC administrators with his ideas for a patient blood management program as a hospital-sponsored initiative. He’s now a hospital employee. Since his pathologist colleagues remain in a private group practice with a separate revenue stream, they don’t provide cross coverage for patient blood management when he’s on vacation (though they do provide call coverage for the blood bank); instead, he’s covered by an EMMC anesthesiologist and a vascular internist.

Because Dr. Gross is a hospital employee, reimbursement is not an issue. But payment shouldn’t be an issue for private practice pathologists, either, he says, since they can bill under the pathology consultation code series. If patients are seen in clinic, E/M codes can be used. And, he notes, intravenous iron given at an infusion center generates revenue for a hospital. Conceivably a private pathology practice could provide medical direction for an infusion clinic for anemia management, with a medical director billing under Part A, rather than billing direct patient care under Part B. “There are reasons to believe there are sources of new revenue for a pathology group by doing this,” he says.

Dr. Gross faced one other group with understandable worries: those who feared job loss. Early on, he knew that if he reduced transfusion rates, he’d also be reducing workload, and thus employees, in the blood bank.

It’s a common source of resistance to any new program. “If someone waltzes in and says, ‘We’re going to do patient blood management and cut our transfusion volume by 50 percent,’ the first thing they’ll think is, ‘Two or three of us are going to lose our jobs.’” EMMC has, in fact, dropped its red blood transfusions by 55 percent since 2006. The staff has been reduced by 2.5 FTEs, but by attrition.

Dr. Gross says he struck a bargain with the blood bank staff, telling them that as transfusion rates dropped, they would become more involved with patient clinical care. They do first-pass transfusion review and decide whether to involve me in a physician’s order for transfusion. They collate laboratory results and have access to patients’ electronic medical records. “I’ve taught them to navigate through the clinical information, to abstract, if you will, those things I want to know before I call a clinician and consult about a transfusion decision,” Dr. Gross says.

The blood management setup has left Dr. Gross essentially in the position of running a sole proprietorship, though the service continues to evolve. This fall he was interviewing candidates to fill a new provider position at the clinic—either a physician assistant or a nurse practitioner. This will let the clinic expand its anemia management services to include additional outpatients, while freeing time for Nelson, the program coordinator, to expand her role as transfusion safety officer. The added employee will also provide consults on the inpatient side to identify patients who would benefit from anemia management post-discharge.

Like most sole proprietors, Dr. Gross has given thought to what will happen to his practice and the patient blood management program if he departs. Ideally, he says, the hospital will continue to see the value of the service and fill his position. Or maybe his pathologist colleagues will set any reservations aside and decide to oversee the program themselves.

For now, however, Dr. Gross sounds satisfied with his role, not the least because he enjoys direct patient contact. That’s one of the reasons he was drawn to coagulation and transfusion medicine originally, he says, though it didn’t fully satisfy that need.

The patient blood management clinic does. Treating previously undiagnosed anemia can make “patients feel better than they’ve felt in, sometimes, years,” he says. “They’re grateful, and it’s satisfying, all this time after medical school, to once again be involved face to face with patients and get that kind of positive feedback.”

Related Links

• Flow diagram A (PDF, 508 KB)
• Flow diagram B (PDF, 493 KB)