The ongoing challenges and future directions for patient blood management

For those with mature PBM programs, priorities may include ongoing education of patients and physicians as well as improvement of systems to enable PBM activities. Anecdotally, patient awareness of PBM is low. Increasing awareness may empower patients to advocate for themselves and seek out PBM options (Arya et al 2023). This will allow patients to effectively participate in shared decision-making and select interventions that are right for them. Physician education is paramount and may seem like an insurmountable task. Introducing PBM concepts into the curriculum early in medical training will set the stage for future learning. We should also prioritize the education of primary care providers (PCPs).

Our experience has consistently shown that lead time for perioperative anemia optimization matters (Pavenski et al 2022); however, we frequently receive referrals too close to the surgery date, leaving no time for PBM interventions to be administered or to have any effect. Ideally, PCPs will screen and refer patients at the same time as placing a referral to a surgeon. Moreover, screening should be for all patients at risk of iron deficiency and anemia, allowing for treatment before anemia negatively impacts their health.

Women and girls are more likely to be iron-deficient and anemic, and women have a higher probability of receiving perioperative transfusions (Arya et al 2024). Hence, women and girls should be prioritized for anemia screening and PBM. Recently, the American Society of Hematology (ASH) released resources on the diagnosis and management of iron deficiency, with a podcast specifically dedicated to tackling iron deficiency in women (https://www.hematology.org/iron-deficiency-initiative#educational). Furthermore, anemia should be re-framed as a priority for treatment.

Few physicians will accept anemia as a normal state; however, a surprisingly large number will deprioritize its treatment. Wider dissemination of studies that demonstrate improvement in health outcomes and quality of life following anemia treatment across a range of medical conditions is necessary. For example, outcomes in congestive heart failure have been shown to improve with treatment of iron deficiency anemia (Kalra et asl 2022). To achieve better outcomes for our patients, treatment of anemia should be prioritized. Lastly, reliance on transfusions to fix anemia also stems from the established hospital information systems, where transfusions are easier to order than intravenous iron. To improve uptake of PBM, systems, perhaps aided by algorithms and AI, should enable easy identification of anemic patients and convenient ordering of PBM interventions. In the wake of the publications of MINT and new AABB guidelines on RBC transfusions in acute myocardial infarction (Pagano et al 2025), there was a renewed debate on the benefit and safety of restrictive versus liberal transfusion triggers and need for more trials. However, in the words of one PBM physician, the more important question is not how much to transfuse, but how to most effectively treat anemia. This leads to another important priority, personalized PBM, where investigations and treatments are tailored to an individual patient’s needs. In PBM, as in other parts of medicine, one size rarely fits all.