Comparison of Graft Acquisition and Early Direct Charges of Haploidentical Related Donor Transplantation versus Umbilical Cord Blood Transplantation

Alternative donor allogeneic hematopoietic cell transplants (HCTs), such as double umbilical cord blood transplants (dUCBT) and haploidentical related donor transplants (haplo-HCT), have been shown to be safe and effective in adult patients who do not have an HLA-identical sibling or unrelated donor available. Most transplant centers have committed to 1 of the 2 alternative donor sources, even with a lack of published randomized data directly comparing outcomes and comparative data on the cost-effectiveness of dUCBT versus haplo-HCT. We conducted a retrospective study to evaluate and compare the early costs and charges of haplo-HCT and dUCBT in the first 100 days at 2 US transplant centers. Forty-nine recipients of haplo-HCT (at 1 center) and 37 with dUCBT (at another center) were included in the analysis. We compared graft acquisition, inpatient/outpatient, and total charges in the first 100 days. The results of the analysis showed a significantly lower cost of graft acquisition and lower total charges (for 100-day HCT survivors) in favor of haplo-HCT. Importantly, to control for the obvious shortcomings of comparing costs at 2 different transplant centers, adjustments were made based on the current (2018) local wage index and inflation rate. In the absence of further guidance from a prospective study, the cost analysis in this study suggests that haplo-HCT may result in early cost savings over dUCBT and may be preferred by transplant centers and for patients with more limited resources.

From waste to (fool's) gold: promissory and profit values of cord blood

According to biomedical discourse, cord blood has been transformed from 'waste' to 'clinical gold' because of its potential for use in treatments. Private cord blood banks deploy clinical discourse to market their services to prospective parents, encouraging them to pay to bank cord blood as a form of 'biological insurance' to ensure their child's future health. Social scientists have examined new forms of (bio)value produced in biological materials emergent with contemporary biotechnologies. This paper contributes to this literature by examining the social and technical production of value in cord blood units collected for private banking. Value, in this paper is defined as a socio-cultural concept in which an object is made meaningful, or valuable, through its relations with social actors and within specific regimes of value. I draw on in-depth interviews with women who banked cord blood and key informants in private banks in Canada, to analyze how social actors produced cord blood as a valuable biological object. I show that a cord blood unit holds promissory value for women who bank and profit value for private banks and that these values are folded into each other and the biological material itself. Analyzing how specific cord blood units are made valuable provides insight into the multiple and possibly competing values of biological materials and the tensions that may arise between social actors and forms of knowledge during the valuing process.

Design of a cost-effectiveness analysis alongside a randomized trial of transplantation using umbilical cord blood versus HLA-haploidentical related bone marrow in advanced hematologic cancer

BACKGROUND

BMT CTN 1101 is a Phase III randomized controlled trial evaluating the comparative effectiveness of double unrelated umbilical cord blood (dUCB) versus HLA-haploidentical related donor bone marrow (haplo-BM) donor cell sources for blood or bone marrow transplantation (BMT) in patients with hematologic malignancies. Herein, we present the rationale, design and methods of the first cost-effectiveness analysis to be conducted alongside a BMT trial.

METHODS

Consenting patients will provide health insurance information to allow calculation of direct medical costs from reimbursement records, and will provide out-of-pocket costs, time costs and health-related quality of life measures through an online survey. These outcomes will inform a cost-effectiveness analysis comparing dUCB and haplo-BM donor cell sources from patient, payer and societal perspectives.

CONCLUSION

Novel approaches may significantly change the cost, outcomes or availability of BMT. The results of this analysis will be the first to provide a comprehensive evaluation of the comparative effectiveness of these approaches from multiple perspectives.

Contradictions of value: between use and exchange in cord blood bioeconomy

Umbilical cord blood (CB) has become established as an increasingly viable clinical alternative to bone marrow in the treatment of leukaemia leading to the construction of a global network of CB banks promoted through a moral ethos of gift. Additionally, some banks offer the opportunity to retain stem cells privately. CB is discursively presented as clinical 'waste', a 'by-product' of birthing. In this way CB units are made available to a global exchange-based bioeconomy. Crucially, CB collection has developed in parallel with several necessary obstetric practices, especially the immediate clamping of the cord following delivery, essential to high volume collection. However, this article strongly suggests the promotional basis of CB banking (such as by gift, waste or donation) is in tension with the growing preference of new parents to delay cord clamping. Based on focus groups with expectant parents, the promotion of CB banking can in fact be seen to feed into critical reflection on the value of CB for newborn infants, potentially reinvigorating a tradition of delayed umbilical cord clamping. Theoretically, these contradictory systems of valuing are conceptualised through recent literature on bioeconomy and Marx's writings on the contrasting tensions between use and exchange value.

Cord blood banking activities at a university hospital in northeast Mexico: an 8-year experience

BACKGROUND

Umbilical cord blood (UCB) represents an alternative source of stem cells for transplantation for the treatment of hematologic malignancies and genetic disorders. There is scarce information detailing cord blood bank (CBB) collection and transplantation activities from developing countries. We documented our experience at a public university hospital in northeast Mexico.

STUDY DESIGN AND METHODS

We carried out a retrospective and descriptive analysis of our CBB activity during an 8-year period from May 2002 to September 2010. Collection, processing, and cryopreservation of CB were carried out following standard operating procedures. The minimum volume and total nucleated cell (TNC) content for cryopreservation were 80 mL and 8.0 × 10(8) , respectively.

RESULTS

A total of 1256 UCB units were collected; 428 (34%) were banked and 828 (66%) were discarded. The main reason for exclusion was biologic: low volume and/or low number of TNC accounted for 84% of the total discarded units. Cryopreserved cord blood units (CBUs) had a median volume of 113.8 mL (range, 80-213.2 mL) and 13.0 × 10(8) (range, 8 × 10(8) -36.6 × 10(8) ) TNCs. Cell viability was 99.3% (88-100%). The median CD34+ cell content was 4.0 × 10(6) (0.46 × 10(6) -19.38 × 10(6) ). Sixteen units have been released for transplantation, leading to a utilization rate of 3.7%.

CONCLUSION

CBB demands considerable human and financial resources; it is then essential for centers at developing countries to share their experience, results, and databases to increase the probability of finding matching units for their patients. Efforts to create and maintain CBBs allow to offer this therapeutic option at an affordable cost.

Costs and cost-effectiveness of hematopoietic cell transplantation

Interest is growing in economic and comparative effectiveness analyses, with increasing emphasis on optimizing healthcare resources and costs. Limited information is available on the economic aspects of hematopoietic cell transplantation (HCT). We review contemporary literature on the costs and cost-effectiveness of HCT in the United States and worldwide. Published studies confirm the high costs associated with HCT, although the reported costs are highly variable, related to the differing methodologies used across studies. We examine the challenges in reviewing costs and cost-effectiveness across studies specific to HCT and highlight factors identified as associated with higher costs of HCT. We also discuss opportunities for future research in this area.

Umbilical cord blood banks. Ethical aspects. Public versus private banks

The creation of umbilical cord blood (UCB) banks raises interesting medical, social, economic and ethical issues. This paper reviews the ethical problems specifically. In this respect, it evaluates: a) whether there are advantages to the use of UCB compared to bone marrow, b) whether or not it is ethical to create UCB banks, c) whether their creation is ethically acceptable in terms of their clinical usefulness or d) the use made of them for therapeutic purposes, and finally e) whether their creation is ethically justified from a cost/profitability point of view. We focus primarily on evaluating the ethical controversy between public and private banks, particularly on whether it is ethical to bank autologous blood in private UCB banks, on the basis of its limited possibilities for use by the cord blood donor. We can conclude that, from an ethical point of view, autologous blood banks have limited acceptance among specialised researchers, scientific societies and other public institutions. Therefore, we believe that it is ethically more acceptable to support the creation of public UCB banks for medical and social reasons and, above all, based on the principle of justice and human solidarity. Nevertheless, there is no definitive ethical argument why a couple, according to their autonomy and freedom, cannot bank their child's UCB in a private bank. An equally acceptable solution could be the creation of mixed banks, such as that proposed by the Virgin Health Bank or like the Spanish system where autologous samples can be stored in public banks but with the proviso that if at any time the stored sample is required by any person other than the donor, it would have to be given to them.

Family-directed umbilical cord blood banking

Umbilical cord blood transplantation from HLA-identical siblings provides good results in children. These results support targeted efforts to bank family cord blood units that can be used for a sibling diagnosed with a disease which can be cured by allogeneic hematopoietic stem cell transplantation or for research that investigates the use of allogeneic or autologous cord blood cells. Over 500 patients transplanted with related cord blood units have been reported to the Eurocord registry with a 4-year overall survival of 91% for patients with non-malignant diseases and 56% for patients with malignant diseases. Main hematologic indications in children are leukemia, hemoglobinopathies or inherited hematologic, immunological or metabolic disorders. However, family-directed cord blood banking is not widely promoted; many cord blood units used in sibling transplantation have been obtained from private banks that do not meet the necessary criteria required to store these units. Marketing by private banks who predominantly store autologous cord blood units has created public confusion. There are very few current validated indications for autologous storage but some new indications might appear in the future. Little effort is devoted to provide unbiased information and to educate the public as to the distinction between the different types of banking, economic models and standards involved in such programs. In order to provide a better service for families in need, directed-family cord blood banking activities should be encouraged and closely monitored with common standards, and better information on current and future indications should be made available.

Business on hope: a case study on private cord blood stem cell banking

Traditionally, medical practice has been recognized as one of the professional practices with high honors. The interaction between physicians and patients is to provide health care services without the profit orientation. In modernized economy and in today's world of business, the relationship between doctors and patients has been dramatically changed. This transformation is very obvious in the private sector. Health care providers sell their services. Patients have been approached as customers. Decisions to make an investment on new medical technologies or new services would accompany with careful consideration on cost-benefit ratio, on marketing and also on short and long term return of the investment. However most of the medical services available in the past were focusing on the "real" and "tangible" products. This means that the patients or the customers would obtain diagnosis, treatment, palliation or prevention for the fees they paid. They can at least obtain and can feel some direct or indirect health benefits from the services. With the advancement of science and technology, there is recently a new model of business that sells only the hope for future use. Private cord blood stem cell banking is a good example for this business model. Actually, business on hope is not the brand new business model. Insurance is a well-known classical prototype of business on hope. However, when this kind of business model is applied for medical services, there should be some precautions and also intervention including an oversight system from the government sector to make sure that all the information delivered to the clients and family is accurate and unbiased. From the public policy perspective, this business of hope should be appropriately regulated to preserve consumer rights while promoting the advancement of science and technology through sustainable business development.

NHS maternity units should not encourage commercial banking of umbilical cord blood

Storing cord blood at birth as insurance against future disease may sound like a good idea to parents, but it has worrying implications for NHS services and little chance of benefit