Cost-effectiveness analysis and the selection of blood products

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

Understanding the costs associated with blood products requires sophisticated knowledge about transfusion medicine and is attracting the attention of clinical and administrative healthcare 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.

Costs and benefits of bacterial culturing and pathogen reduction in the Netherlands

BACKGROUND

Bacterial contamination is a life-threatening risk of blood transfusion, especially with platelet (PLT) transfusions. Bacterial culturing (BCU) of PLTs as well as pathogen reduction (PRT) reduce the likelihood of such contamination. The cost-effectiveness (CE) of these interventions was analyzed after the introduction of the diversion pouch during blood collection.

STUDY DESIGN AND METHODS

The balance between costs and benefits of preventing adverse events due to PLT transfusion was assessed with a mathematical decision model and Monte Carlo simulations. Model parameters were obtained from the literature and from Dutch Sanquin blood banks. The balance between costs and benefits is assessed in terms of costs per quality-adjusted life-year (QALY).

RESULTS

The costs per 100,000 PLT concentrates in the Netherlands are estimated at $3,277,032 (euro2,520,794) for BCU and at $18,582,844 (euro14,294,495) for PRT. In comparison to the situation without BCU and PRT, costs per QALY are estimated at $90,697 (euro69,767) for BCU (95% confidence interval [CI], $18,149-$2,088,854) and at $496,674 (euro382,057) for PRT (95% CI, $143,950-$8,171,133). The ratio of differences in costs and QALYs between BCU and PRT (the relative CE) is estimated at $3,596,256 (euro2,766,351; 95% CI, $1,100,630-$24,756,615). Large uncertainty in sepsis complication rates and PLT recipient survival exist, causing large uncertainties in the absolute CE for both interventions.

CONCLUSIONS

As a result of the unknown probability of sepsis complications and PLT recipient survival, the CE ratios of BCU and PRT in the Dutch setting are highly uncertain. Despite these large uncertainties, it can be concluded that BCU is without doubt more cost-effective than PRT.

The cost of blood: multidisciplinary consensus conference for a standard methodology

Prior attempts to account for the cost of blood have varied in economic perspective, methodology, and scope and may have underestimated both direct and indirect costs associated with transfusions. To devise a comprehensive and standardized methodology for the United States that will improve upon existing estimates, a panel of experts in blood banking and transfusion medicine was assembled and participated in consensus deliberations using modified Delphi methods. As a first step, a process-flow model that describes all the major steps involved in collecting, processing, and transfusing blood such as donor recruitment and follow-up of transfusion sequelae was constructed. Next, interdependencies were outlined and detailed cost elements within each step were itemized. The relative importance of each element was rated. Personnel, screening for infectious agents, information systems, laboratory evaluations, management of transfusion reactions, and equipment were ranked as the most important factors to capture but, in an effort to be all-inclusive, even minor elements were included. This consensus model is broad-based and should serve societal, provider, and payer perspectives for future cost studies. Recognizing the limitations of process-flow models, the next iteration will use an activity-based approach to more fully account for the cost of blood than present estimates.

The use of intraoperative autotransfusion during cranial vault remodeling for craniosynostosis

Intraoperative autotransfusion salvages blood shed during surgery for use in immediate resuscitation of the patient. The purpose of this study was to determine whether such autotransfusion decreases the volume of homologous blood transfused in patients undergoing primary cranial vault remodeling for craniosynostosis. The Cobe-Bret 2 autologous blood recovery system (Hemo Concepts, Union, N.J.) was used in 11 cases, and an equal number of consecutive cases did not receive intraoperative autotransfusion. There were no significant differences between the groups with respect to age, sex, and weight. Mean estimated blood loss was 43.2 ml/kg (range, 20.3 to 65.0 ml/kg) in the intraoperative autotransfusion group and 40.2 ml/kg (range, 6.8 to 72.3 ml/kg) in the control group (not statistically significant; p < 0.05). There was no significant difference in volume of homologous blood transfusion between the two groups. The autotransfusion group received 34.1 ml/kg of homologous blood (range, 0 to 60.7 ml/kg), and the control group received a mean of 32.7 ml/kg (range, 14.5 to 60.2 ml/kg). The autotransfusion group received a mean of 10.4 ml/kg of recovered autologous blood (range, 0 to 21.4 ml/kg). In four of the 11 autotransfusion patients, insufficient autologous blood was recovered intraoperatively to warrant transfusion. Results of this study suggest little benefit for the use of intraoperative autotransfusion in primary cranial vault remodeling for craniosynostosis in the young patient. It was hypothesized that this finding was a result of the following: (1) intraoperative autotransfusion blood was usually available only toward the end of the procedure, after homologous blood had already been administered, and (2) the volume of recovered intraoperative autotransfusion blood is minimal, compared with the homologous transfusion volume requirements during an extensive cranial vault remodeling and fronto-orbital advancement procedure. In the context of unproven cost benefit and increasing similar evidence from other comparative studies, emphasis should be directed to other medical and surgical strategies to minimize the need for perioperative blood transfusion.