RAND Corporation From the SelectedWorks of Emmett Keeler March , 1995 The Cost Effectiveness of Preoperative Autologous Blood Donations

Background. Since the recognition that human immunodeficiency virus is transmissible by blood transfusion there has been increasing public and professional support for autologous blood donations before elective surgery. Autologous blood donation is, however, a more expensive process than the donation of allogeneic blood by community volunteers. Furthermore, there have been recent improvements in the safety of the volunteer blood supply. Methods. We used a decision-analysis model to assess the cost effectiveness of donating autologous blood for four surgical procedures. Cost data were collected from the observation of transfusion practice at the University of California, Los Angeles, in 1992. Estimates of the risks of transfusion-associated diseases and the costs of treating them came from the medical literature. Cost effectiveness was expressed in dollars per quality-adjusted year of life saved. We performed sensitivity analyses of the variables in our model and examined the effect of strategies suggested to reduce costs. Results. Substituting autologous for allogeneic blood resulted in little expected health benefit (0.0002 to 0.00044 quality-adjusted year of life saved) at considerable additional cost ($68 to $4,783 per unit of blood). The additional cost of autologous blood was primarily a function of the discarding of units that were donated but not transfused and of a more labor-intensive donation process. The cost-effectiveness values ranged from $235,000 to over $23 million per quality-adjusted year of life saved. Conclusions. Given the improved safety of allogeneic transfusions today, the increased protection afforded by donating autologous blood is limited and may not justify the increased cost. (N Engl J Med 1995;332:719-24.) From the Division of General Internal Medicine, West Los Angeles Veterans Affairs Medical Center and the UCLA School of Medicine (J.E.); the Department of Pathology and Laboratory Medicine (L.P., L.C., S.K.) and the Departments of Medicine and Health Services (A.F., R.B.), UCLA Center for Health Sciences — all in Los Angeles; and RAND, Santa Monica, Calif. (J.E., E.K., C.S., R.B.). Address reprint requests to Dr. Etchason at the Division of General Internal Medicine, West Los Angeles Veterans Affairs Medical Center, 11301 Wilshire Blvd., Los Angeles, CA 90073. Supported in part by a grant from the Robert Wood Johnson Clinical Scholars Program (to Dr. Etchason) and by a Transfusion Medicine Academic Award (K07 HL02151, to Dr. Petz and Ms. Calhoun) from the National Heart, Lung, and Blood Institute. T HE epidemic of the acquired immunodeficiency syndrome (AIDS) has increased concern about the risk of transmitting infectious diseases through blood transfusion. In response to this concern, there has been a dramatic increase in preoperative autologous blood donations over the past decade. 1-4 Although sensationalized reports of the dangers of blood transfusion continue in the lay press, 5 there have been great improvements in the safety of the blood supply, primarily because of rigorous donor screening and sensitive serologic tests for the human immunodeficiency virus (HIV) and for hepatitis C virus. 6 Autologous blood is more costly than allogeneic blood. Its donation entails greater administrative expense and a longer, more labor-intensive process of collection. Moreover, the frequency of positive tests for infectious disease in autologous units 7,8 has raised questions about the safety of transfusing unused autologous units into patients other than the donor. Because of this concern, 85 percent of U.S. blood centers do not retain unused autologous units for other patients, but rather destroy them. 9 This practice has substantially raised the cost of autologous transfusion. The current national debate on health care reform makes this an appropriate time to analyze the cost effectiveness of autologous blood donation. In our study, we determined the costs of providing patients with autologous blood and used decision-analysis techniques to calculate the cost effectiveness of substituting autologous for allogeneic blood. We also analyzed the value of various strategies to minimize the costs of autologous-donation programs.