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Are autologous blood transfusions cost-effective?

Health care is full of hard decisions. Those decisions are often made harder by the glare of media attention, and an inadequate assessment of risk by patients and doctors. An example might be the patient who is awaiting an operation and has been concerned by the risk of blood-borne infection of hepatitis or HIV from blood transfusions.

The obvious answer is for the patient to donate his or her own blood before the operation, to be used during the operation - autologous blood transfusion. That would avoid the danger of infection, and nothing could be simpler.

Not quite, according to a study from Los Angeles published in the New England Journal of Medicine [1]. This report used a decision-analysis method to determine the cost-effectiveness of autologous transfusions for four different operations, total hip replacement, coronary artery bypass grafting, abdominal hysterectomy and transurethral prostatectomy.

Decision-analysis

The methods they used were essentially simple. What were the costs associated with autologous blood collection and transfusion - how much was actually used during the operation balanced against the cost of screening ordinary blood donations. What were the risks of developing hepatitis C or B or HIV or HTLV? How might the blood-borne acquisition of these viruses affect a patient's life in the years remaining, and so on. The details are fascinating for those wanting themselves to consider decision-analysis methods in other contexts.

Major determinants

What are the major determinants of costs and effectiveness?

First is the fact that not all of the autologous blood collected is used - 84% in the case of hip replacement, but only 4% for prostatectomy; the unused blood is almost always discarded rather than used for other patients.

Then there is the probability of catching something nasty from ordinary blood transfusions - pretty remote in Los Angeles, it would seem - with a 3 in 10,000 chance of getting hepatitis C, a 5 in 1,000,000 chance of getting hepatitis B and HIV.

Age is a factor - the more years of life remaining, the more chance there is that hepatitis or HIV will significantly affect that life - and most people having these operations will be in their sixth and seventh decades of life.

Results

So the result is that the cost is actually surprisingly high. The cost effectiveness of autologous blood transfusion for each quality-adjusted year of life (QALY) is some $235,000 for hip-replacement, but 100 times more at $24,000,000 for prostatectomy. Sensitivity analysis showed that however the case was argued, the cost was still high.

British experience?

These are US figures which do not always translate well to the British experience. Nevertheless, they offer an order-of-magnitude estimate of the actual costs of autologous transfusion programs, and provide a starting point for considering such a programme.

Reference:

  1. J Etchason, L Petz, E Keeler et al. The cost effectiveness of preoperative autologous blood donations. New England Journal of Medicine 1995 332: 719-24.



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