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Table 4 Summary of measures to consider for implementing PBM, sorted by level of intervention: Government (national and/or regional), funding, research, healthcare provision, training/education, and patients

From: Making patient blood management the new norm(al) as experienced by implementors in diverse countries

Measures Rational / Expectations Examples Points to consider
GOVERNMENT LEVEL (national or regional)
 National Policy • National initiatives and guidance push the hospitals towards PBM implementation • AUS: National policy for PBM and national measures to support implementation
• TUR, KOR: Close collaboration of PBM leaders with MoH
• TUR: qualification for a 3-yr EU grant dedicated to a systematic country-wide implementation of PBM [55]
• CHN: officially addressed the importance of PBM to improve clinical practice [56]
CHALLENGES
• Changing of policy priorities; political instability (LBN)
• Policy priority of shifting from tertiary hospitals to primary care level antagonizes the pre-operative PBM interventions (CHN)
• National policy not a game changer in countries with decentralized healthcare (CHE)
 Blood Shortage • Actual and anticipated blood shortage is recognized on a policy level and requires action; donation volume is shrinking, the demand for blood is increasing (aging population)
• Donor deferrals due to new or re-emerging pathogens; cancelled blood collections due to lockdown during epidemics
• Family replacement schemes: mandatory donations may increase risk and limit access
• ZAF, CHN, MEX: Frequent supply issues
• HRV, GRE: Seasonal shortages
• KOR, ZAF: Shortage and COVID-19 virus riska
• BRA: Zika-Virus [57]; supply issues in public system
• AUS, TUR: Shortage predicted
• LBN, GRE, MEX: Replacement modus
• CHN: 30% Reciprocal blood donation
REMARK
• Impact of COVID-19 pandemic on blood supply [58]
 Strong PBM Thought Leadership • Fosters a broader country-wide acceptance and change
• Liaise on policy level, engage with payers, engage specialist societies, and introduce medical curricula
• KOR: Korean PBM Society with multi-disciplinary leadership function
• TUR: EU-funded project for PBM implementation across Turkey
REMARK
• May be difficult for few individuals to cover that scope and thus, formation of a high-level work or interest group may be advisable
 PBM Incentives • Attract clinicians to become part of the change
• Increase level of experience and familiarity with PBM
• CRO: participation in international clinical study
• TUR, KOR, MEX, ZAF: National pilots & research opportunities
REMARKS
• Involve practitioners actively in research
• Recognition of individual initiative through active engagement and authorship
 National Guidelines • Adapting international guidelines to local healthcare context can be essential for acceptance
• National guidance will facilitate coordinated and homogeneous activities across the country
• ZAF, TUR, KOR, MEX, BRA, HRV, CHN: ongoing projects to locally adapt international guidelines RISK
• Scattered / fragmented approaches will make it difficult to consolidate in best practice
FUNDING LEVEL
 Alignment of policy and funding • Consensus for a reimbursement and funding solution • KOR: Center for Disease Control in the MoH and the Health Insurance and Reimbursement Agency (HIRA) committed to PBM related projects (1) auditing the current level of transfusion appropriateness in each hospital, and (2) funding dedicated projects on PBM implementation in the country CHALLENGE
• Heterogeneity in access to healthcare and its funding requires different approaches for funding and reimbursement of PBM (MEX, LBN)
 Reimbursement • Increase the willingness to invest in establishing PBM
• Adjust reimbursement systems to incentivize improved health outcomes and efficiency and disincentivize transfusion volume [59, 60].
• KOR, MEX, AUS, TUR: Funding national pilot or full implementation projects
• BRA: volume-dependent reimbursement to hospitals (fee for service) incentivizes a high use of transfusions; but first examples of capitation-based hospital reimbursement emerge (supportive for PBM)
CHALLENGES
• Potential other sources of funding (NGOs, special international projects)
• Funding always compromised during (economic) crises
 Cost transparency for blood; Cost ‘fairness’ • Mandate full cost transparency of transfusion and PBM to allow for cost-effective allocation of (public) funds • GRE, HRV: Not knowing the cost of blood products or artificially low cost impedes adoption of PBM REMARK
• Even if at zero cost to the hospital, blood products are not for free from a societal perspective
 Funding and resources in hospital • Secure funding necessary for setting up the infrastructure (including point-of-care testing devices, cell salvage equipment, pre-operative anemia clinic, continuous medical education (CME) and training
• Identify and remove dis-incentives
• HRV, GRE, LBN, MEX: Difficulties in securing funding despite principal support for the concept
• BRA, LBN: Fee for service dis-incentivizes PBM (imbalance between profitability and patient health)
• Alignment across budgets: e.g. pharmacy budget vs other cost
REMARK
• Use measures / local data to demonstrate the realistic budget needs, ROI, time frame required [61].
RESEARCH LEVEL
 Quality measurement/assurance • Use of quality measures, to track blood use (i.e., units ordered, used, and discarded per hospital, ward, type of intervention and individual specialists) to shift focus to patient needs and outcomes • KOR, MEX, CHE, AUS: pursuing quality and performance measurement initiatives REMARK
• Performance measures empowers local transfusion committees and PBM implementation task forces
 Collecting and publishing local data • Demonstrating impact of PBM with local data on clinical outcomes, adverse events or complications,
• Capturing and reporting local epidemiology data (prevalence)
• Quantify opportunities, risks, and cost for PBM in the local setting; ideally as multi-disciplinary intra- or inter-hospital collaboration
• AUS, CHE, KOR: local data collection systems initiated or established to enable reporting, benchmarking, or performance analysis
• TUR: publication of local data [62]
REMARKS
• Local evidence helps to refute that the international experience may not be transferrable to the local context
• Local research motivates participants to gain expertise and to become part of the change
 Health-economic analyses • To convince stakeholders of the cost-effectiveness of PBM, analyses must be based on local data (cost / outcomes) • Health-economic evidence from AUS, CHE, GER, and the USA [63, 64] CHALLENGE
• Current H/E evidence from countries with specific economic and health-economic settings and may not be generalizable
 International support and collaboration • Cross-fertilize and share the learnings transnationally • International collaboration is frequent, e.g. strong engagement of IFPBM & SABM, ZAF w. National Blood Authority in AUS, KOR w. AUS, BRA w. SABM. REMARK
• Includes international teaching, web-based services, advisory exchange, or involvement of experts in another country’s task forces.
HEALTHCARE PROVIDER LEVEL
 Communication • Strengthen belief and commitment of clinical staff
• Re-align all stakeholders around the transfusion process
• GRE: Generation of an intra-hospital consensus and protocol with reporting system for restrictive blood use
• MEX, ZAF, AUS: continuous communication, involvement, and feedback by coordinator / initiator in hospital,
• ZAF, MEX: Chat-group in a social media platform to report local experiences, announce events, and post relevant publications, questions. and suggestions
A common vision and buy-in by those who need to change their practice is essential to achieve change [65]
 Identify allies, build teams • To increase clout and trust across specialties
• Foster multi-disciplinary collaboration, mutual endorsement and support
• LBN: Expanding across specialties already in initial phase added great impetus MEX, TUR: Multidisciplinary PBM Academies; LEB, KOR, ZAF: Multidisciplinary Iron Academies REMARKS
• PBM is a team effort [15, 21, 61]
• Supports forming a guiding coalition [65]
 Prior experience with PBM • Expand the knowledge and openness for PBM by involving care personnel from different disciplines in implementation projects • Pilot projects in several hospitals/wards to involve and expose them to PBM methods REMARK
• Overcome the stickiness of the old practice [66] and resistance to change
 Ensure support from hospital administration • Design/align the organization to enable optimal and sustainable PBM across specialties
• Secure funding for staff, systems support (IT), other resources
• Get approval to establish a multi-disciplinary PBM committee
• Most initiatives reported that alignment with hospital administration / CEO was improving chances for success
• HRV, GRE: Activities under departmental responsibility may not need agreement by hospital management.
• LBN, SAU, HRV, LBN: To get funding for establishing PBM was difficult and therefore done within the existing resources (overtime)
• BRA, MEX: dedicated project management ensures planning and roll out across specialties / departments
REMARKS
• While small changes could be introduced individually or within one specialty the full potential can only be achieved with multi-disciplinary change
• Understand the economic and system incentives and to be in close communication to collaboratively identify the path to implementation (milestones, tasks, and responsibilities)
 Local champion (Medical Director or project coordinator for PBM) • Responsible for planning, organizing and directing PBM, supporting specialists, and ensuring continuous data collection, reporting and benchmarking, • HRV, GRE, MEX: general role in training, education, information, protocol development
• BRA: Change management
• AUS, CHE: organize PBM at patient level (case management)
REMARK
• PBM coordinator can be a success factor for sustainability (AUS, CHE)
 Hospital protocols (SOPs) • Tailor PBM protocols to the specific hospital context and routines
• Increase local ownership across the disciplines, interdisciplinary commitment
• HRV, GRE, TUR, MEX, BRA: Several interviewees reported the development of local protocols before the availability of National Guidelines  
 Data collection, reporting & benchmarking system • Shows impact, measures gaps, and helps to improve quality of care • ZAF, KOR: currently developing a monitoring system in hospital(s)  
 Nudging clinicians & stimulating competition • Using IT or quality reporting systems to motivate and remind physicians to practice PBM
• Using the competitive nature of people to motivate them to excel in PBM
• AUS, CHF, MEX, ZAF reported use or plan to use competitive forces or ‘nudging instruments’ to remind practitioners to improve their PBM practices (reminders, league tables) REMARKS
• Include IT and/or quality specialists in developing the local procedures for mapping into data collection and analytical support tools
• Nudging = nonregulatory and nonmonetary interventions that steer people in a particular direction while preserving their freedom of choice” [67, 68]
 Involving the entire care team • Alignment, participatory processes • ZAF: Importance of involving nurses who have high influence on the patient care
• GRE: Importance of aligning the ordering of blood products.
REMARK
• Includes nursing, hospital pharmacy, blood ordering process to ensure common goals
 Seizing local opportunities for improvement • Create momentum: Use opportunities in own environment for starting with specific aspects of PBM
• Move forward faster and prove success
• HRV, LBN: Start within ward/ department
• ZAF: start with communication & education of hospital specialists
• MEX, BRA: pilots
REMARK
• Even small ‘wins’ will motivate people
TRAINING & EDUCATION LEVEL
 Education and Training for PBM • Identify and address knowledge gaps among specialists
• Update under-and postgraduate curricula
• AUS: Integration in medical school (University of Western Australia) curriculum & exams
• MEX, ZAF, TUR: PBM academies and/or continued medical education (CME) for practitioners
• AUS, ZAF: online training material [69]
REMARKS
• Training of all specialists concerned (incl. anesthesiologist, intensive care specialists, surgeons, hematologists, oncologists, gastroenterologists, obstetricians & gynecologists) and nursing staff in relation to benefits of PBM,
• Avoid asymmetry in information to prevent that ‘eminence wins over evidence’ in the choice of therapy
 Increase Awareness Transfusion Risks • Overcome eminence-based practice (“transfusion is always beneficial”) and increase the knowledge about the associated risks • Global: Many of the specialists who administer transfusions during surgery (surgeons, anesthesiologists) often don’t see the mid- or long-term complications (infections, immune reactions, thrombosis). REMARKS
• Necessitates re-education of all participants in the transfusion decision
• Requires information, education, and reminders across specialties (publications and newsletters, conferences, social media-channels)
 Medico-legal aspects and protective measures as part of PBM training • Strengthen the assertiveness of physicians relating to PBM • BRA: Litigation is commonly used by patients to get access to procedures which they perceive to be beneficial  
PATIENT & PUBLIC LEVEL
 National information campaigns • Develop awareness for PBM
• Encourage patients to discuss PBM at their doctor’s appointment
• Prevent litigation against physicians following guideline-compliant restrictive transfusion strategies
• Decrease patient demand blood transfusion
• KOR, LBN, ZAF: Initiated or conducted national awareness campaigns through important media channels
• BRA: Litigation is commonly used by patients to get access to procedures which they perceive to be beneficial
RISKS
• If done too early, doctors might be overwhelmed by patient demand
• Too much information on transfusion risks may negatively impact the willingness of the public to donate blood
REMARK
• Involving patients, collaborating with patients, and informing the public may improve understanding and reduce the risk for litigation
 PAG initiatives • Co-create national information campaigns (PBM thought leaders, politicians, PAGs)
• Explore patient experiences and preferences
• Engagement / advocating for PBM insurance coverage
• Achieve comprehensive patient education on risks and benefits of all treatment options (including transfusion) for anaemia, blood loss and coagulopathy
• Ensure fully informed consent and/or shared decision making
• PAGs to request PBM certification and/or hospitals accreditation
• HRV, KOR: Initial contacts
• TUR: In contact with 5 NGO’s, who receive regular information
• GRE, LBN, HRV, KOR, BRA: increasing demand for participatory medicine and shared decision making by PAGs and/or healthcare policy
REMARKS
• PAG-patient interaction relating to transfusion and/or PBM not yet common
• Co-creation / co-production: researchers, practitioners and the public join efforts and share responsibilities to develop, implement, monitor, evaluate and re-develop interventions [70]
  1. Abbreviations: MoH Ministry of Health, SABM, https://sabm.org Society for the Advancement of Blood Management, ROI Return on Investment. Country Abbreviations: AUS Australia, BRA Brazil, CHN Peoples Republic of China, HRV Croatia, GRC Greece, KOR Republic of Korea, LBN Lebanon, MEX Mexico, ZAF South Africa, CHE Switzerland, TUR Turkey, PAG Patient Advocacy Group, IFPBM International Foundation Patient Blood Management, SABM Society for the Advancement of Blood Management
  2. aThe risk of COVID-19 viral infection only became apparent starting in January 2020. Hence, this threat was only mentioned in the last interviews (KOR, ZAF, SAU)