I read the on-going debate about the true cost of blood. I tis fascinating to me to see how carefully people are thinking aobut this question and the costs in Australia. One cost we don't have here in the US is the air-transport costs.  The biggest cost is the cost of adverse outcome in patients who recieved blood. Those adverse event costs need to be carefully modeled by computer modelings. But, the only way to get near accurate data on those is to truly find the defining point of when a patient ("needs" a unit of blood.  That means we have to hone in on the inflection point of a mortality  v. Hgb curve.

There simply are no studies done on that yet. It is interesting to think about Hebert's TRICC study wherein mortality was almost always better in patients who got less blood. They took the trigger for transfusion down to 7gm/dl v. 10gm/dl.  I would put out to the reading audience that we have always looked at transfusion based upon a surogate measure- hemoglobin or hemtocrit. That is a surrogate for tissue oxygen delivery. What we need is an imporved way of concieving of when to transfuse and an improved monitoring system to allow us to estimate tissue oxygen needs/deficit. It is very clear that most of our transfusions are not "life-saving". Therefore, with most of them we buy the risks and probably very few benefits. 

Some very , very smart people need to think about how to get at this most basic question and then to re-focus research energies into defining our transfusion triggers- probably not therefore based upon Hgb. If we did that then we might make some progress about costs.  Blood acquisition costs will certainly rise. There is no way ever it will get cheaper. There is however a way to reduce adverse events and that is to hone our technology and skills in terms of when we use this precious resource.

Bruce Spiess, MD

I think the most important cost is the 'cost' to the patient.

Not monetary, but practical, ie do they need the product to improve, maintain their life or quality of life?

Unfortunately I have seen that even though the intention of allocating Blood Budgets to Area Health Services in NSW was to send price signals to the clinicians & then hopefully make them question the appropriateness of transfusion, in fact it has become merely a bugeting exercise with Area Health Services trying to make their books balance.

This is because there was no thought put into ensuring that systems were available to the Area Health Services to track who the actual end user is!

eg. a patient may have their Group & Save collected in a pre-op clinic, but then may be transfused in Theatre, then Recovery, then ICU, then in the ward. Most LIS or Pathology systems find it difficult if not impossible to track all these events, so in effect what happens is that the Area Health Services allocate the charges to the Hospital who ordered the products from the ARCBS even though they may not have been the end user, so price signals are NOT send to the appropriate area.

Unfortunatley without the 'drive' to develop a national, universal, specialised  Blood Transfusion system the current impetus to graft this required functionality into current systems is destined to fail.

My apologies- in my previous post I quoted the incorrect study.  The one you are after is as follows:

Estimating the cost of Blood: past, present and future directions, Best practice and Research Clinical Anaesthesiology, Vol. 21, No.2, pp-27-289, 2007.

Again, if you cannot find it please contact me at bloodwatch@cec.health.nsw.gov.au

Thank you for your post and interest in this debate.

The study which is referred to in Shander's ASH abstract is the Austrian benchmark study into the costs of transfusion.  The full title is : Blood use in Elective Surgery: the Austrian benchmark study, TRANSFUSION, VOL 47(8) AUGUST 2007 p 1468-1480.  If you are still unable to locate it, please email me at bloodwatch@cec.health.nsw.gov.au and I can send the article  to you.

A similar study has recently been conducted in an Australian setting and whilst it has been referred to in presentations by the Australian Red Cross Blood Service and Mr Axel Hoffmann ( co-author of the Austrian study), it is yet to be published. However I believe it's publication is imminent.

Carolyn, Blood Watch, Clinical Excellence Commission

As a health administration graduate student, I too am interested in seeking the true cost of a red blood cell transfusion. I believe that by using best practices to control or prevent bleeding events, we could link an economic savings and prove to hospital administrators that there is not only a clinical, but also an economic benefit to reducing transfusions. Dr. Shander's articles (as Dr. Spiess referenced) have been rather insightful on the subject as I dig to find the true cost of transfusions. Recently, I came across a poster abstract from the 50th ASH Annual Meeting and Exposition, where I believe Dr. Shander gave a presentation titled "The True Cost of Red Blood Cell Transfusion In Surgical Patients." The abstract describes a 2005 study conducted at an unidentified hospital which analyzed all component costs of a transfusion (from receiving the blood from blood banks to disposing of it). He reported the value of a unit of transfused red blood cells to be approximately $1158. I am interested to read the actual study and look at the breakdown of costs which contribute to that final figure, as I believe this to be a recent estimate of the true cost. However, through exhaustive database searches, I have been unable to find the study that he referenced published anywhere. Has anyone read this study that could direct me as to the correct title or journal in which it was published?

Here is the link to the intersting abstract I found:

http://ash.confex.com/ash/2008/webprogram/Paper11293.html

Thank you in advance for any insight you may provide.

The true cost of blood is really quite hard to nail down. In different societies it costs different amounts. With that in mind I highly recomend Shander A. financial and clinical outcomes associated with surgical bleedin complications. Surgery 2007;142:S20-5.

This is an article packed with facts. They are up to date and many are from very valuable sources. The collection of blood samples from a recipient, the collection from donors, testing, processing etc takes at least 60 human interactions. Each of these humans has training, inherent employment costs, overhead etc. The more you have in personnel dedicated to the "blood process" the higher the cost. Economy of scale is worth it only so far. There is definite data to suggest that adverse event costs from longer times in hospital, more immunosuppresion and TRALI like events can be tracked. These costs may be as high as $2000.00 US per unit. In orthopedics it ahs been shown that transfused versus not transfused has about a minimum $1500.00 difference in hospital costs above and beyond the costs of blood.

Also the costs of NAT testing for HIV and Hpe B/C are astounding. We often talk about life year costs- that amount of money spent to save one human life. It is about $11.5 million US in terms of NAT testing to save one life. That is in comparison to seat belts (about 500 dollars) and Pap smears about 1000 dollars). What is the cost of a human life? In US courts it is usally around 1 million dollars. So, as suggested in the Shander article maybe the 11.5 million is the cost of fear in society!  That being said, what will be the costs when SARS, Avian Flu, some parasitic disease etc strikes the world blood supply. How much is too much to pay from society.

Once about 8 years ago the United States Congress tried to legislate "the blood system must be safe". Well that shows the brilliance of our government. Write a law and it will be so. We will never have a "safe blood supply". Making it safer will always cost larger and larger sums for incrmental changes. But, blood management and decreasing the need for transfusion cna be extremely cost effective and very, very good medicine.

Those cost estimates are rather alarming; currently NSW and the NBA are funding the direct cost of the product only. Therefore on these estimates the global hospital budgets in NSW are funding many 'indirect costs' of transfusion. With the evidence being put forward by the experts in addition to improving the quality and safety of care we have a wonderful opportunity to conserve a scarce resource, blood products, and also have more health budget available for under funded areas of health care. I think as clinicians it behoves us have an eye on the total impact of clinical decision making on all health services, rather than only focussing on the patient in front of us, particularly if the evidence does not support current practice.  

I have figures relevant to Australia:

• $200 per unit is the cost of the collecting bag and serological testing;
• $260  is the price that Australian Air Express charges for a blood esky to be delivered door-to-door anywhere in NSW.  This is a surrogate price, if you will, for the cost of cold-chain logistics.  Refrigerated delivery vans and urgent taxis in Metropolitan areas are probably comparable;
• Medicare Benefits Schedule (MBS) item no 73930 covers specimen collection and delivery to the lab: $18;
• MBS item no 65099 covers crossmatching: $113;
• MBS item no 13706 covers administration of blood already collected: $76;
• NSW Health charges overseas residents not covered by a reciprocal agreement with Australian Medicare $541 per day for a hospital bed.

Many (including the AMA) claim that the MBS is an under-estimate of the true cost of providing a professional service, but it is a figure published by the Commonwealth.  There is no allowance in there for the cost of centre-city real estate (Red Cross) or their staff and volunteers, wastage and complications of transfusion.

Thus, the minimum cost of a two-unit transfusion, (either in a day-only bed or adding another day to the hospital stay) is $1,406

Do we know what the true cost of blood is? We know that devolved blood bugets in the public sector is giving us some indicators of product cost but surely this in not the only cost of transfusion, what about the indirect costs?  Has that data been derived in Australia?