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Estimating the cost of blood: past, present, and future directions

https://doi.org/10.1016/j.bpa.2007.01.002Get rights and content

Understanding the costs associated with blood products requires sophisticated knowledge about transfusion medicine and is attracting the attention of clinical and administrative health-care sectors worldwide. To improve outcomes, blood usage must be optimized and expenditures controlled so that resources may be channeled toward other diagnostic, therapeutic, and technological initiatives. Estimating blood costs, however, is a complex undertaking, surpassing simple supply versus demand economics. Shrinking donor availability and application of a precautionary principle to minimize transfusion risks are factors that continue to drive the cost of blood products upward. Recognizing that historical accounting attempts to determine blood costs have varied in scope, perspective, and methodology, new approaches have been initiated to identify all potential cost elements related to blood and blood product administration. Activities are also under way to tie these elements together in a comprehensive and practical model that will be applicable to all single-donor blood products without regard to practice type (e.g., academic, private, multi- or single-center clinic). These initiatives, their rationale, importance, and future directions are described.

Introduction

Delivering health care at a reduced cost while maintaining or improving the quality of care is a challenging global quest. From societal and payer perspectives, collecting and maintaining a blood supply free of potentially infectious viruses, bacteria, and prions is enormously costly.1 For example, detecting HIV and HCV with nucleic-acid testing (NAT) exceeds the acceptable limit to gauge cost-effectiveness benchmark ($80,000 per-quality of life-year [QALY] gained) by 72- to 105-fold.2 With blood donor pools shrinking owing to population aging, restrictions on blood donor eligibility3, *4, and operative procedures rising to increase demand, recruitment efforts need to be reinforced to replace deferred donors, resulting in increasing incremental cost for each additional unit donated.5 Implementing appropriate checks to ensure that transfusions are administered safely without laboratory, clerical, managerial, screening, or administration errors6 is associated with costs still to be estimated.7

Transfusion-related adverse events, both short- and long-term, are among the costliest contributors to health care expenditures.8 Costs associated with long-term consequences are among the hardest to quantify.*4, 9, *10, 11, 12, 13, *14 Pharmacoeconomic analyses are complex because of uncertainties with calculating the probabilities of illness, projecting future outcomes, and discounting.1 Lost wages and adverse events that have an impact on quality of life add to indirect costs of blood product transfusions, but these factors have rarely been incorporated into quantitative cost-analyses.15, 16 Adding increased liability and regulatory (i.e., haemovigilance) issues to the list, blood product costs will continue to trend upward.

Despite the increasing cost of blood, transfusion practices remain quite liberal17, 18, variable from institution to institution19, and are often inappropriate.20, 21 The percentage of costs attributable to inappropriate blood transfusion ranges between 9% and 44%.21 Frequent transfusions are also linked to poorer outcomes, including increased patient mortality22, 23, a higher incidence of nosocomial infections24, multi-organ failure25, 26, and increased length of hospital and ICU stays.23, 27, 28

How is the cost of blood to individuals, health-care providers, and society determined? Unless all contributing cost elements are accounted for, beginning with blood collection, continuing through pretransfusion preparation and transfusion administration, and lasting throughout follow-up, the cost of blood is very likely to be underappreciated. That premise forms the rationale and basis of this manuscript. Past attempts to ascertain the cost of blood and the shortcomings of studies will be reviewed, as well as the progress made by the Society for the Advancement of Blood Management (SABM) toward estimating what blood really costs from a societal perspective. We also examine our expectations about how these estimates and descriptions of cost elements can serve as benchmarks and roadmaps that institutions worldwide can use to examine their processes, optimize blood usage, and save valuable resources.

Section snippets

Past: evaluations of blood and transfusion costs

Studies on the economics of blood have been conducted in oncology patients29, 30, *31, *32, in the perioperative and ICU setting21, 33, in neonates34, and in patients who require chronic transfusions (e.g., sickle cell anaemia, thalassaemia, chronic renal disease).35, 36, 37 Cost analyses have been used to compare red blood cell (RBC) administration to transfusion alternatives.15, 36, 38, 39 Although these studies provide useful information, several shortcomings exist. First,

Present: Elements contributing to blood cost

Blood costs will generally depend on the number of steps it takes to deliver the transfused unit; simply stated, more steps translate into higher costs. Process flow diagrams (e.g., Figure 1) can help illustrate the complexities involved in administering blood transfusions after the decision to transfuse is made.*31, *32 Although it generates valuable information, this approach does not include cost elements incurred before a unit is ready to be transfused, i.e, beginning at donor recruitment

Cost-effectiveness evaluations of blood transfusions

Strategies to improve blood safety are resource-intensive. In some cases, pharmacoeconomic principles have been applied and cost-effectiveness studies performed to help determine whether society can afford to pay for the added safety benefit. Value is assigned to variables measured in health units, i.e., years of survival gained, number of infections avoided, or hospital length of stay (LOS) shortened. In cost-utility analyses, incremental benefits are adjusted to common units, i.e., the

Medical implications

Any evaluation of the cost of blood must consider the costs of treating and managing adverse events that can result from transfusions, of which there are many.*4, *10 The costs of some adverse consequences found in the literature provide some perspective (Table 3).90, 91, 92, 93, 94, 95 The probability of sustaining an adverse event is usually factored into any decision-tree analysis; most risks occur with low probability.96 For example, death immediately following or directly linked to

Future: COBCON 2

The importance of establishing a baseline cost of any particular blood product from which all future cost-effectiveness analyses could be determined cannot be overemphasized. In light of the foregoing discussion, we can now unequivocally assert that arriving at a dollar figure for the cost of blood is a complex undertaking. Moreover, for such a baseline to be meaningful, it should be customized for individual circumstance. Building upon the work product initiated by COBCON 1, a subset of

Conclusions

Blood, from its acquisition to transfusion through follow-up, is costly to society. Blood is not a resource to be taken for granted, used liberally without accountability, or wasted. Determining the cost of blood from a societal perspective is a complex undertaking that requires consideration of all relevant cost elements, many of which have not been identified previously. At a minimum, we estimate that the cost of blood to society is twofold higher than calculations derived from previous

Summary

The use of blood and blood products throughout the world's health-care systems contributes substantially to overall health-care costs. Although many prior and worthwhile attempts to estimate the cost of blood have been made, a comprehensive “vein-to-vein” approach that assumes a societal perspective is still needed. Beginning with the costs of donor recruitment, and encompassing all tasks, personnel, and infrastructures associated with blood collection, processing, distribution, pre transfusion

Acknowledgements

The authors wish to thank the New Jersey Institute for the Advancement of Blooldless Medicine and Surgery and OrthoBiotech for a grand that helped support the preparation of this manuscript and Kathryn J. Lucchesi, PhD, RPh, of DesignWrite, LLC, for providing editorial and writing assistance.

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