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Autologous blood transfusion

Correspondence

Bandolier was delighted to receive the following letter from one of its Internet readers about a piece we carried in July 1995. That described a cost effectiveness analysis of autologous blood transfusion in the New England Journal of Medicine with results that suggested that it was not cost effective. Neil Blumberg disagrees. We reproduce his e-mail below, and then analyse the paper that Dr Blumberg and colleagues published this year which came to the opposite conclusion, that autologous blood transfusion is cost effective.

To the editor:

In Bandolier 17 you quote a study from the New England Journal of Medicine (332:719, 1995) purporting to demonstrate that autologous transfusion is not cost-effective. The authors of that study chose not to consider extensive data that patients receiving only autologous transfusions have much reduced morbidity and costs of hospitalisation. More recent analysis by our group based upon actual hospital data suggests that not only is autologous transfusion cost effective, it has the potential to dramatically reduce the cost of providing some surgical services (American Journal of Surgery 171: 324-330, 1996). Not to put too fine a point on it, the latter work is based upon actual evidence, whereas the New England Journal of Medicine report is based purely upon a theoretical analysis with no actual patient data. Neil Blumberg MD Director, Blood Bank/Transfusion Medicine Professor of Path. & Laboratory Medicine University of Rochester Med. Ctr. Box 608 Rochester, NY 14642 (USA)

The issue

Because of the (real or imaginary) dangers of viral infection (hepatitis, HIV) from normal donated blood transfused during an operation (allogenic transfusion), some people deposit their own blood to be used, collected before the operation (autologous transfusion). This takes time and money. The cost effectiveness argument has concentrated on the costs of collecting an individuals blood compared with the possible benefits from avoiding an infection, and the costs associated with that. Blumberg and colleagues were unable to perform a randomised trial because the practice of autologous transfusion was routine, so used survey data.

Cost analysis of autologous and allogenic transfusion in hip-replacement surgery

Hip replacement was chosen because it is the most common indication for autologous transfusion. The two randomised trials comparing autologous with allogenic transfusion were done in colorectal surgery, so Blumberg and colleagues [1] based their analyses on case-control studies in their own hospital setting, in which autologous blood collection is common. Costs of collecting autologous blood were conservative. They did not include any costs of discarding autologous blood, but neither did they include savings from not having to test the blood for viral diseases. Data were collected for 140 patients in 1992, as well as an historical cohort from 1986 to 1988 (with costs adjusted for inflation).

Results

1992 Cohort

Patients receiving autologous plus allogenic transfusions (n = 30) spent significantly longer in hospital (mean 15 days) than those receiving only autologous or no transfusion (mean 9 days). Each incremental unit of allogenic blood transfused increased the length of hospital stay. Autologous transfusion of up to 5 units did not increase hospital stay. Total mean charges for autologous plus allogenic recipients were $26,000, significantly greater than for those receiving only autologous or no transfusion ($19,000). Extra costs arose from haematology, chemistry and blood gas tests, and extra charges from blood banking and pharmacy.
On average each allogenic transfusion was associated with additional actual costs of about $1,500, compared with a maximum of $50 for each autologous unit collected.

1986/8 Cohort

Because present practice of autologous transfusion did not allow a direct comparison of allogenic with autologous transfusion, records from a previous study were examined for a comparison of 33 patients having 2 or 3 units of autologous blood only and 49 patients having 2 or 3 units of allogenic blood only. The patients were well matched for age, sex, duration of surgery, blood loss and days of wound drainage. The rate of infection was 32% in those receiving allogenic transfusions, but only 3% in those receiving autologous blood.
Recipients of autologous transfusion had reduced hospital stay (12.1 versus 13.5 days for allogenic transfusions), and reduced hospital cost of $4,800. Extra costs arose from microbiology, haematology and blood gas tests, and extra charges from blood banking and pharmacy. On average each allogenic transfusion was associated with additional actual costs of about $1,050.

Comment

These analyses are based on real data, albeit on a small number of patients. Cost is an issue, but not the most important. The consistent finding that autologous transfusions result in lower short term morbidity is important. Blumberg and colleagues highlight other studies, retrospective and randomised, that come to similar conclusions. Avoiding low risks of very unpleasant diseases may be one driving force for autologous transfusions. Producing lower postoperative morbidity generally has much wider implications. Any cost savings would be a useful spin off. Bandolier originally thought this to be an interesting, but somewhat recherché topic. Reading Blumberg's paper suggests that it would repay a more thorough review, with particular implications for purchasers.

Reference:

  1. N Blumberg, SA Kirkley, JM Heal. A cost analysis of autologous and allogenic transfusions in hip-replacement surgery. American Journal of Surgery 1996 171:324-30.



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