[original research * nouveautes en recherche I

COST OF ALLOGENEIC AND AUTOLOGOUS

BLOOD TRANSFUSION IN CANADA
Roma Tretiak, MHA; Andreas Laupacis, MD, MSc, FRCPC; Marc Riviere, MD; Krista McKerracher, MBA;
Eric Souetre, MD, MBA, PhD; and the Canadian Cost of Transfusion Study Groupp*

Objective: To determine the cost, from a societal perspective, of blood transfusion in Canada.
Study design: Cost-structure analysis.
Setting: Data were collected from eight hospitals and from six blood centres operated by the Canadian
Red Cross Society in four provinces.
Outcome measures: Costs associated with four stages of transfusion - collection, production, distribu-
tion and delivery - in 1993 were assessed. Costs were divided into the following categories: person-
nel, purchases, external services, overhead, donors' time, patients' time (for autologous transfusion),
wastage and infection.
Results: The mean overall cost of a transfusion performed on an inpatient basis was $210 per unit of red
blood cells for an allogeneic transfusion and $338 per unit of blood for an autologous transfusion. The
mean cost of an allogeneic transfusion performed on an outpatient basis was $280 per unit of red blood
cells.
Conclusion: The costs determined in this study can be used in future studies comparing the cost-effective-
ness of allogeneic transfusion with that of alternative methods.

Objectif: Determiner le cout, pour la societe, des transfusions de sang au Canada.

Conception Analyse de structure des co'uts.
Contexte: On a obtenu des donnees de huit hopitaux et de six centres transfusionnels de la Societe cana-
dienne de la Croix-Rouge dans quatre provinces.
Mesures des resultats: On a evalue les coiuts lies 'a quatre stades de la transfusion - collecte, production,
distribution et livraison - en 1993. Les cotuts ont ete repartis entre les categories suivantes: personnel,
achats, services exterieurs, frais generaux, temps des donneurs, temps des patients (dans le cadre de Ia
transfusion autologue), gaspillage et infection.
Resultats: Le cofut global moyen d'une transfusion executee en service aux hospitalises s'est etabli 'a 210 $
l'unite de globules rouges dans le cas d'une transfusion allogene et 'a 338 $ l'unite de sang dans celui
d'une transfusion autologue. Le co(ut moyen d'une transfusion allogene executee en service externe s'est
etabli a 280 $ l'unite de globules rouges.
Conclusion Les co(uts etablis dans cette etude pourront servir dans le cadre d'etudes futures comparant
l'efficacite des couits des transfusions allogenes 'a celles d'autres methodes.

he recent public scnrtiny of Canada's blood system poietin, administration of drugs (e.g., aprotinin) to de-
1has led to increased interest in alternatives to allo- crease blood loss during surgery, hemodilution, use of
geneic red blood cell (RBC) transfusion: autologous perfluorocarbon emulsions and use of hemoglobin solu-
blood donation, cell savers, use of recombinant erythro- tions.i-2 To assess the cost-effectiveness of these new
Ms. Tretiak and Dr. Riviere are with the Benefit Research Group, Montreal, Que.; Dr. Laupacis is director of the Clinical Epidemiology Unit, Loeb Medical Research Institute, Ottawa Civic Hospital,
Ottawa, Ont; Ms. McKerracher is with Ortho Biotech, Don Mills, Ont; and Dr. Souetre is with the Benefit Research Group, Gennevilliers, France.

*Members. Dr. Lynn Boshkov, University ofAlberta Hospitals, Edmonton, Alta.; Dr. Gershon Growe, Vancouver Hospital and Health Sciences Centre, Vancouver, BC; Dr. John Kitts, Ottawa Civic
Hospital, Ottawa, Ont; David Home, Oshawa General Hospital, Oshawa, Ont; Dr. Yves Lapointe, Hdpital Notre-Dame, Montreal, Que.; Dr. Peter Pinkerton, Sunnybrook Health Science Centre, North
York, Ont; Dr. Renaud Whittom, Hopital Saint Fran,ois dAssise, Quebec, Que.; and Dr. Muhammad Zahir, Royal Inland Hospital, Kamloops, BC

Reprint requests to: Ms. Roma Tretiak, Benefit Research Group, Canada, 1402-2000 Mansfield St., Montreal QC H3A 3A2; fax 514 843-6645

0 1996 Canadian Medical Association (text and abstract/resumd)

CAN MED ASSOC J * MAY 15, 1996; 154 (10) 1501

 technologies, the costs of allogeneic and autologous blood transfusion centres or in hospitals (in the case
blood transfusions must be known. of autologous blood).
The Canadian blood system is not for profit and re- * Production: all steps in processing the blood after it
lies on unpaid, volunteer donors. The system is managed has been collected and before it is distributed to hos-
nationally by the Canadian Red Cross Society (CRCS) pitals, including testing for transmissible diseases and
through 17 regional blood centres and is financed by the separation of blood components.
provincial and territorial governments through the * Distribution: the transportation of units of RBCs from
Canadian Blood Agency. There is no charge to health regional blood centres to hospitals.
care facilities or patients for blood products. * Delivery: all handling of blood (including laboratory
In the 1993-94 fiscal year, 1 045 749 units of whole tests) from arrival at the hospital to its administration
blood were collected and processed by the CRCS, from to the patient.
which 821 763 units of allogeneic packed RBCs were de- All data were from the 1993-94 fiscal year and were
rived and used for transfusions in hospitals.3 Autologouscalculated in 1993 Canadian dollars.
whole-blood donation services are administered both by Eight hospitals in four provinces participated in the
the CRCS blood centres and by individual hospitals. The study: Vancouver Hospital and Health Sciences Centre;
CRCS reported that it had collected 13 433 units of autol-
Royal Inland Hospital, Kamloops, BC; University of Al-
ogous blood in 1993-94; however, the amount collected berta Hospitals, Edmonton; Sunnybrook Health Science
through programs in individual hospitals is unknown. Centre, North York, Ont.; Oshawa General Hospital,
Several studies have assessed the cost of allogeneic Oshawa, Ont.; Ottawa Civic Hospital; Hopital Notre-
RBC" and autologous whole-blood7 transfusion. Forbes Dame, Montreal; and Hopital Saint Francois d'Assise,
and associates4 calculated the mean hospital cost of allo-
Quebec. Six are teaching hospitals and two (Royal Inland
geneic RBCs used in transfusions to be $155 (US) per Hospital and Oshawa General Hospital) are community
unit in 1988, and Lubarsky and collaborators5 deter- hospitals. Hospitals willing to participate in the study
mined it to be $151 (US) per unit in 1991. These studies were selected to represent a range of size and type of hos-
considered hospital costs only, whereas Sheingold and pitals. The hospitals represented all regions of the country
colleagues,6 with the use of a costing system developed except Atlantic Canada.
for Chedoke-McMaster Hospitals, Hamilton, Ont., cal- The national office of the CRCS provided data on
culated the mean cost of all aspects of allogeneic RBC the six CRCS transfusion centres affiliated with the eight
transfusion in Chedoke-McMaster Hospitals and CRCS participating hospitals.
centres to be $210 per unit. Data from the transfusion centres concerned the col-
Etchason and coworkers7 estimated the cost of collec-lection, production and distribution stages, whereas hos-
tion and production of allogeneic RBCs to be $150 (US) pitals provided data on the cost of the delivery stage.
per unit in 1992 and of autologous blood to be $198 The delivery-stage cost was assessed for several depart-
(US) per unit. ments in each hospital: hematology/oncology, surgery,
To date, there has been no published assessment of operating room, intensive care unit, general medicine,
the cost of allogeneic or autologous transfusion for all of
emergency and ambulatory care. We used a step-down
Canada. analysis of accounting data, which assigned costs to task
Our study determined the costs associated with blood(e.g., production) or type of product (e.g., RBCs) or
transfusion in the Canadian health care system. We as- both.
sessed the costs of all stages of transfusion, from collec- The total cost of each stage of transfusion was broken
down into the following categories: purchases, external
tion of blood to transfusion to the recipient, for inpatient
and outpatient transfusion and for allogeneic RBC and services, personnel, overhead, donors' time, patients'
autologous blood transfusion. In addition to calculating time, wastage and infection. The two time categories are
the cost per unit of blood, we calculated the cost for two
explained as part of the appropriate stages later in this
units of blood, since most patients receive two units dur-
article. The final two categories applied to the delivery
ing a transfusion.8 Costs were determined from the over- stage only. Purchases included all small equipment, sup-
all perspective of society, as recommended in the Guide- plies and the depreciation of capital equipment. External
lines for Economic Evaluation of Pharmaeeuticals: Canada .9
services included any service or portion of the activities
in a given centre provided from outside the organization
METHODS (e.g., a service contract for the maintenance of equip-
ment). Personnel costs included direct and indirect (e.g.,
We divided the blood system into the following four management) labour costs. Overhead costs included all
stages. nonlabour costs that could not be attributed directly to
* Collection: the collection of blood from donors at the any stage of transfusion. At the CRCS, overhead costs

1502 CAN MED ASSOC J * 15 MAI 1996; 154 (10)

included the costs incurred by the medical director's of- Data on autologous blood collection were obtained
fice, the blood donor recruitment office and the national from two participating hospitals that operate autologous
office as well as computer services and maintenance of blood collection programs (CRCS data on autologous
the premises at each centre. In hospitals, overhead costs blood collection were not available). It was assumed that
included the nonlabour costs of corporate overhead the time required for a patient to give a unit of autolo-
(such as the president's office and the department of fi- gous blood is the same as that required for allogeneic
nance) and support services (such as housekeeping and blood collection.
laundry). The overhead components provided by the
CRCS and the hospitals initially included both labour COST OF PRODUCTION
and nonlabour costs. However, in order to group all per-
sonnel costs, 65% of the overhead component was trans- Costs included in the production stage for allogeneic
ferred to the cost of personnel unless otherwise speci- transfusion were quality control, component processing,
fied. This proportion was based on information provided testing for transmissible diseases (HIV- 1, HIV-2, hepati-
by the finance departments of the participating hospitals tis C virus, human T-cell lymphotropic virus, Treponema
and the CRCS. pallidum and hepatitis B surface antigen), blood banking
These costs were used to calculate a cost per unit of and serologic testing of RBCs.
blood used in transfusions. The total cost of transfusion For autologous transfusion, we assumed that the first
was also calculated for two units of blood. Excluded unit of autologous blood was tested for transmissible dis-
from the costs of the second unit were costs of drawing a eases at the nearest CRCS centre and that the transfu-
sample from the patient for cross-matching and for sion took place at the hospital where the blood was col-
blood administration. The distribution cost and the cost lected. The mean cost of transmissible-disease testing
of testing for transmissible diseases during the produc- was obtained from the CRCS.
tion stage were also excluded for the second unit of au-
tologous blood (these costs would be included in the COST OF DISTRIBUTION
cost of the second unit if collection took place through a
CRCS centre). Distribution costs included all costs associated with
transporting blood or RBCs from the CRCS centres to
COST OF COLLECTION the participating hospitals. The cost of transporting au-
tologous blood from the hospital to the CRCS for trans-
For allogeneic transfusion, costs included in the col- missible-disease testing was assumed to be the same as
lection stage were blood-donor recruitment, donor the distribution cost of allogeneic RBCs.
screening, collection of blood at the transfusion centres
or at mobile clinics and transportation associated with COST OF DELIVERY
the mobile clinics. Costs were allocated to RBCs,
platelets, plasma and cryoprecipitate on the basis of the We calculated the mean cost per unit of RBCs for
number of units of each produced. The CRCS uses vol- blood banks in each hospital from hospital budgets for
unteers to perform some phases of blood collection as personnel and purchases. Costs were allocated on the
well as to donate blood. We included the cost of non- basis of the time spent by the laboratory staff to prepare
donor volunteers' and donors' time in the analysis, in ac- RBC units and the volume of units prepared, in compari-
cordance with the societal perspective of the study. The son with the time spent on and volume prepared of
nondonor volunteers' time was calculated from responses other products (i.e., platelets, plasma and plasma prod-
to a questionnaire concerning the number of volunteer ucts). We thereby determined the proportion of the
hours logged during 1 year, completed by five CRCS budget spent on RBC units. In two cases, the hospital
blood centres. The cost of this time was based on the budget for the blood bank was unavailable, so costs were
salaries and benefits that would be paid to CRCS em- estimated with the help of charge technologists.
ployees performing the same functions. Hourly wages Personnel time was assessed from data gathered dur-
varied from $8 to $13. A weighted mean cost was calcu- ing face-to-face interviews with nurses. The nurses were
lated on the basis of the number of units produced by asked to estimate the time required by all staff members
each centre. The cost of donors' time, valued on the ba- to administer blood or RBCs to a patient. Staff members
sis of the mean Canadian income,"1 was also included in included orderlies and porters, who transport blood or
the cost of collection. The transfusion centres estimated RBCs from the blood bank to the wards, and ward
that a donor spends approximately 2.5 hours donating clerks, who receive the blood or RBCs and communicate
blood, including time spent giving blood and travelling with the hospital blood bank. The cost of staff time was
to and from the centre. evaluated on the basis of the mean salaries and benefits

CAN MED ASSOC J * MAY 15, 1996; 154 (10) 1503

 for these employees; these data were obtained from the
finance department of each hospital. For outpatient
transfusion, the time required for a patient to receive a
transfusion was estimated to be approximately 4 hours
(including transportation time) by the nurse manager of
the sole outpatient transfusion clinic in our study. Patient
time was valued on the basis of the mean income in
Canada."
The cost of materials used to administer blood or
RBCs was provided by the purchasing departments of
the participating hospitals. A mean ratio of overhead
costs to direct medical-services costs was applied to all
of the wards in each hospital to calculate the overhead
component. A mean cost of delivery for all inpatient
wards was used, since costs did not vary significantly
from one type of ward to another. The delivery cost of
autologous transfusion was calculated on the basis of the
cost of delivery during surgery.
Included in the cost of delivery was the cost of
wastage, defined as any unit of blood or RBCs that could
not be used for a transfusion because it was out of date
or otherwise unusable. Information on the number of
units of allogeneic RBCs and autologous blood wasted in
each hospital was obtained from blood-bank records. A
weighted mean proportion of blood or RBCs wasted was
calculated on the basis of the number of units available
for transfusion in each centre. Then the cost of wastage
was calculated by multiplying the cost per unit of collec-
tion, production and distribution but not delivery by the
proportion of wastage.
We also included the cost of infection acquired from
transfusion as part of the cost of delivery. In this regard,
hepatitis C and HIV infection were the only infections
considered.
We could find no recent studies on the cost of infec-
tion with hepatitis C. We therefore used data on the
clinical course, management and associated costs of
hepatitis B from a recent US article by Bloom and associ-
ates.'2 Their data were obtained through a review of the
literature and were reviewed by an expert panel with the
use of a modified Delphi technique. We then assumed
that the cost of infection with hepatitis B and hepatitis C
were the same.
We used the lifetime cost of HIV infection calculated
by Hellinger,'3 who estimated the total charges associated
with the various stages of HIV infection in the United
States in 1992.
We assumed that the patterns of treatment of these
two infections were similar across Canada and the
United States. The costs of infection included the direct
medical costs of these diseases and excluded their indi-
rect costs. All future costs were discounted at a fixed an-
nual rate of 5%.
We estimated the risk of hepatitis C infection from
1504 CAN MED ASSOC J * 15 MAI 1996; 154 (10)
transfusion to be 3 in 10 000 units'4 and of HIV infection
to be 1 in 200 000 units.'5
SENSITIVI[Y ANALYSIS
Three sensitivity analyses were performed. In the
first, the cost of each stage of transfusion was varied ac-
cording to the minimum and maximum costs obtained
from the participating centres for each stage of allo-
geneic and autologous transfusion. The cost of wastage
was held constant in this analysis. In the second analysis,
the proportion of wastage was varied according to the
lowest and highest proportion of wastage reported by
the hospitals for allogeneic RBCs and autologous blood.
The costs of collection, production and distribution
were held constant in this analysis. In the third analysis
we assumed that autologous blood collected in hospital
was not tested for transmissible diseases and that the
production cost was therefore equal to zero.
RESULTS
The mean cost of transfusing, on an inpatient basis,
one unit of allogeneic RBCs was $210 and of autologous
blood was $338. The difference in cost was mainly due
to the differences in the cost of collection between
CRCS centres and hospitals and in the cost of wastage
between allogeneic and autologous transfusion (2% of
the total cost for allogeneic transfusion and 18% of the
cost for autologous transfusion). The mean cost of trans-
fusion of two units of blood was $392 for allogeneic
RBCs and $619 for autologous blood.
The mean cost of allogeneic blood collection at a
CRCS centre was $64 per unit. Included in this cost was
nondonor volunteer time ($5 per unit) and donor time
($30 per unit). In the case of autologous blood collec-
tion, the mean cost of hospital-based collection was
$135 per unit, which included the patient's time, valued
at $30 per unit.
The mean costs per unit of inpatient allogeneic and
autologous transfusion by stage are shown in Table 1.
The greatest variation in the cost of transfusion was
found in the cost of delivery, mainly in the cost of
preparing a unit of RBCs in the hospital blood banks.
Hospitals that prepared relatively high volumes (more
than 8000 units) of RBCs benefited from economies of
scale and therefore had lower costs.
For both inpatient allogeneic and autologous transfu-
sion, personnel and purchases were the biggest cost dri-
vers, representing 60% and 16% respectively of the cost
per unit of allogeneic RBCs and 52% and 12% respec-
tively of the cost per unit of autologous blood (Table 2).
The difference in the cost of inpatient and outpatient
transfusion (Table 3) was mainly due to the cost of the
 $158 to $309 per unit, and that of autologous transfu-
patients' time. Because an extra visit is required to re-
ceive an outpatient transfusion, the cost of the patients'
sion from $281 to $420 per unit. These variations were
time was included in the analysis for outpatients. In con-
mainly due to differences in costs of delivery and of per-
trast, the cost of inpatients' time was not included be-
sonnel. The difference in the mean cost of delivery of al-
cause these patients were already in the hospital. logeneic and autologous transfusion ($50) was less than
The mean cost of wastage was $5 per unit for allo- the difference in the mean cost of wastage between the
geneic RBCs and $61 per unit for autologous blood two types of transfusion ($56). The cost of delivery of
(Table 4). The mean rate of wastage was 5% for allo- autologous blood was calculated on the basis of the cost
geneic RBCs and 37% for autologous blood. The of transfusion in the operating room only, whereas that
wastage figures for both allogeneic RBCs and autologousof allogeneic RBCs was based on the mean cost from all
blood used in these calculations were obtained from alldepartments. Delivery costs were slightly lower in the
participating hospitals. The CRCS wastage figures for operating room than in other departments because pa-
hospitals show that the national rate of wastage was 12%
tients undergoing surgery are continually evaluated,
for allogeneic RBCs and approximately 60% for autolo- whether or not they receive a transfusion. The cost of
gous blood collected by the CRCS in 1993-94. continuous monitoring cannot be fully attributed to the
transfusion. In contrast, if a patient receives a transfusion
SENSITIVITY ANALYSIS in a ward, a nurse must spend time by the patient's bed-
side during the transfusion. This entails a cost that
The total cost of allogeneic transfusion varied from would not otherwise exist.

Type of transfusion
Allogeneic Autologous
Mean cost, $ Range of Mean cost, $ Range of
Stage (and % of total) cost, $ (and % of -total) cost, $
Collection 64 (31) 55-72 135 (40) 128-167
Production 17 (8) 14-23 24 (7) -t
Distribution 5 (2) 3-8 5 (2) 3-8
Delivery 124 (59) 86-206 174 (52) 150-245
Total 210 (100) 158-309 338 (1Ot) 281420
*See Methods for explanation of stages.
tA natdonal mean was obtained from the Canadian Red Cross Society.
*Figures do not sum to 100 due to runding.

(ad,
Mean C .I O total)
Cost category Allogeneic transfusion Autologous transfusion
Purchases 33 (16) 42 (12)
External services 1 (1) 1 (0)
Personnel (incIuding
nondonor volunteers) 127 (60) 174 (52)
Overhead' 14 (7) 30 (9)
Donors' time - 30 (14) 30 (9)
Wastage 5 (2) 61 (18)
Riskof infection 1 (1) 0
Patients' time 0 0
Total 211 (lOOt) 338 (100)
*See Methods for explanation of categories.
tFigures do not sum to 100 due to rounding.

CAN MED ASSOC J * MAY 15, 1996; 154 (10) 1505

 The mean proportion of wastage for allogeneic RBCs always be higher than that of collecting allogeneic blood
varied from 1% to 18% among hospitals, for a variation because of the specialized service associated with this
in cost from $1 to $16 per unit. For autologous blood, the "custom-made" product.
mean proportion of wastage varied from none to 64%, Transfusion of allogeneic RBCs was considerably
for a variation in cost from no cost to $104 per unit. more expensive on an outpatient basis than on an inpa-
The results of the sensitivity analysis of the cost of tient basis because the cost of the patients' time associ-
autologous blood are shown in Table 5. If autologous ated with the clinic visit was included in the cost of out-
blood collected in hospitals were not tested for transmis- patient transfusion. For inpatients, patients' time was not
sible diseases, the total cost of transfusion would de- included because we assumed that patients were already
crease from $338 to $309 per unit. in hospital for another reason. However, if patients were
admitted for the purpose of receiving an elective transfu-
DISCUSSION sion, the cost of their time and of the hospital stay
would need to be included. In this case, the total cost of
As expected, the mean cost of a unit of autologous inpatient transfusion would be significantly higher than
blood was higher than that of a unit of allogeneic RBCs. that of outpatient transfusion. If the costs of outpatient
Collection and delivery account for most of the costs of transfusion and its alternative (e.g., use of recombinant
both types of transfusion. The cost of the personnel human erythropoietin) were compared, the patients'
needed for collection of autologous blood was higher time required to receive either treatment would need to
than that of personnel to collect allogeneic blood. How- be considered.
ever, this difference was due to the collection of autolo- The cost of blood varied among blood centres and
gous blood in hospitals; it may be cheaper to collect au- hospitals, mainly as a result of differences in hospital
tologous blood at regional CRCS centres. One reason size, type of patients and salaries paid to employees. For
that collecting autologous blood at the CRCS centres inpatient transfusion of allogeneic RBCs, the sensitivity
may be less costly is that the CRCS has strict eligibility analysis found a $151 -per-unit difference in cost be-
criteria for donation and accepts only healthy donors. tween the maximum and minimum values for each of the
By contrast, hospital programs require enhanced support four stages of transfusion. The corresponding difference
in order to collect blood safely from patients who would in cost for inpatient transfusion of autologous blood was
be considered ineligible by CRCS criteria. The cost of $139 per unit. These wide ranges in costs must be taken
the patients' time for autologous donation was assumed
to be similar to the cost of the volunteer donors' time
for allogeneic donation. Wastage of autologous blood
because patients did not ultimately require a transfu-
sion contributed considerably to the cost of this blood. Mean cost (and range), $
This finding supports the selection for autologous
blood donation programs of patients who are most Allogeneic Autologous
likely to need blood during or after surgery. However, Stage transfusion transfusion
the cost of collecting autologous blood will probably Collection 4 (1-12) 50 (0-86)
Production 1 (0-3) 9 (0-15)
Distribution 0 (0-1) 2 (0-3)
mean cost, $ (ana % ot total) Total 5 (1-16) 61 (0-104)
Inpatient - Outpatient
Cost category transfusion transfusion
Purchases 17 (14) 25 (13)
External services 0 0
Personnel 90 (73) 102 (53) Cost with Cost without
Overhead 11 (9) 13 (7) Stage testing, $ testing, $
Wastage 5 (4) 5 (3) Collection 135 135
Risk of infection 1 (1) 1 (1) Production 24 0
Patients' time 0 48 (25) Distribution .1.....
5 0
Total 124 (100*) 194 (100*) Delivery 174 174
*Figures do not sum to 100 due to rounding. Total 338 309

1506 CAN MED ASSOC J * 15 MAI 1996; 154 (10)

into account when the results of our analysis are used in of blood products.' The cost of transfusion reactions was
decision making in individual centres and hospitals. also omitted, since such reactions were not accurately
As we discussed earlier, two recently published stud- recorded in hospital records. One study has estimated
ies have examined the costs associated with allogeneic that the cost of such reactions adds an additional $3 (US)
RBC transfusion.4' The studies used different methods to per unit to the total cost.5 The cost of a specialist consul-
calculate costs and included different direct and indirect tation for autologous donation was also omitted. There-
costs, making comparison difficult. In both studies only fore, the costs reported in this study are an underestimate
the hospital costs were determined and the hospitals' of the true societal cost of transfusion.
cost of acquiring a blood unit from the blood centre was Fourth, we calculated the cost of autologous transfu-
used as a proxy for the costs of collecting, processing sion in two hospitals, rather than in CRCS blood cen-
and distributing the unit. tres. Because hospitals have higher overhead and fewer
Etchason and coworkers7 estimated the direct health economies of scale than blood centres, the direct costs
care costs of collection (recruitment, screening and in- of collection of autologous units by the CRCS would
terviewing of donors, administrative record keeping and likely be lower than those of hospitals. However, if au-
phlebotomy) and of production (testing for transmissible tologous blood donation was available only through
diseases and compatibility, processing and inventory CRCS blood centres, the cost saving would possibly be
management) at $150 (US) for allogeneic transfusion offset by higher patient costs, especially travel time, be-
and $198 (US) for autologous transfusion in 1992. cause there are fewer centres (17 CRCS blood centres)
Given the differences in methods and in the health care than there are local hospitals.
systems of the two countries, our results are comparable The costs of allogeneic and autologous transfusion
with those of the studies previously published. are borne by several organizations and individuals, in-
The only Canadian study that has costed RBC trans- cluding the CRCS, hospitals, volunteers and patients.
fusion was conducted by Sheingold and colleagues.6 Thus, when examining the costs of blood and consider-
These investigators estimated the costs to the CRCS of ing any future changes to the transfusion system in
collection, processing and distribution. The study Canada, it is important to take into account the overall
showed that the direct cost of each unit transfused was societal costs and the potential transfer of costs from one
$180 and the expected cost of transfusion-related illness sector to another. Our results are important not because
was $30 per unit, for a total of $210 per unit transfused of the costs themselves, but because these costs can be
in 1991. The high cost of transfusion-related illness was incorporated into economic evaluations that consider
due to the high estimate of the rate of hepatitis C infec- both costs and consequences."' Only by comparing the
tion from transfusion (5%). This risk has decreased since cost-effectiveness of allogeneic transfusion with altema-
the introduction of screening tests for the hepatitis C tives such as autologous transfusion, use of recombinant
virus. erythropoietin, administration of aprotinin during sur-
There are limitations to our study. First, neither the gery, cell savers and other technologies can informed de-
blood centres nor the hospitals were chosen randomly. cisions be made about their use.
Rather, the hospitals were selected to provide a variety
of sizes and types. They represented all regions of the
thank the staff members of the National Office of the Canadian Red
country except Atlantic Canada. Because most of the We Cross Society and of the Canadian Blood Agency for their excellent co-
participating hospitals transfuse large volumes of RBCs, operation; without their input, we could not have completed this study
they likely represent the settings in which most blood is successfully. We also thank the charge technologists, nurses and the staff
of finance departments of the participating hospitals and centres, who
transfused. Therefore, the weighted mean costs likely also facilitated the successful completion of this study.
represent a true mean cost of blood transfusion in This study was supported by a grant from Ortho Biotech, Don Mills,
Canada. However, the cost of transfusion in remote Ont.
areas is likely higher.
Second, estimates of the mean time spent by staff
members during the delivery stage as well as time spent
by outpatients were obtained from interviews with 1. Perioperative red cell transfusion. NIH Consens Statement 1988;
nurses. The nurses may have overestimated or underesti- 7 (4): 1-6
mated the total time. 2. American College of Physicians: Practice strategies for elec-
Third, not all costs were included in the study. We did tive red blood cell transfusion. Ann Intern Med 1992; 1 16:
not include the costs of administration of the Canadian 404-406
Blood Agency, of research and development of blood 3. 1993-1994 Statistical Report, Blood Services, Canadian Red Cross
products, of transport of blood between hospitals, of le- Society, Ottawa, 1995
gal costs associated with the blood system and of misuse 4. Forbes JM, Anderson GF, Anderson GC et al: Blood transfu-

CAN MED ASSOC J * MAY 15, 1996; 154 (10) 15071

 sion costs: a multicentre study. Transfusion 1991; 31:
318-323
5. Lubarsky DA, Hahn C, Bennett DH et al: The hospital cost
(fiscal year 1991/92) of a simple perioperative allogeneic red
blood cell transfusion during elective surgery at Duke Uni-
versity. Anesth Analg 1994; 79: 629-637
6. Sheingold S, Churchill D, Muirhead N et al: The impact of
recombinant human erythropoietin on medical care costs for
hemodialysis patients in Canada. Soc Sci Med 1992; 34:
983-991
7. Etchason J, Petz L, Keeler E et al: The cost-effectiveness of
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8. Ghali WA, Palepu A, Paterson WG: Evaluation of red blood
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510-5101 Buchan St., Montreal QC H4P 2R9; website: http://www2.uu.se:80/insts/radiol/

June 9-12, 1996: 4th Canadian Conference on
Health Promotion - Health Promotion and
Population Health: a Meeting of Ideals (pre-
sented by the Montreal Health Promotion Re-
search Centre in collaboration with the Inter-
disciplinary Health Research Group of the
University of Montreal)
Montreal
Louise Potvin, 4th Canadian Conference on
Health Promotion, Interdisciplinary Health Re-
search Group, University of Montreal, PO Box
6128, Station Centre-ville, Montreal QC
H3C 3J7
Du 9 au 12 juin 1996 : 4e Congres canadien
sur la promotion de la sante - la promotion
de la sante et la sant6 des populations : au
confluent des visions (pr6sent6 par le Centre
de recherche en promotion de la sante de
Montreal en collaboration avec le Groupe de
recherche interdisciplinaire en sante de l'Uni-
versite de Montr6al)
Montreal
Louise Potvin, 4e Congres canadien en pro-
motion de la sante, Groupe de recherche inter-
disciplinaire en sante, Universite de Montreal,
CP 6128, Succursale Centre-ville, Montreal QC
H3C 3J7
June 9-13, 1996: Canadian Association of Ra-
diologists 59th Annual Meeting
Vancouver
Canadian Association of Radiologists,
tel 514 738-3111, fax 514 738-5199
Du 9 au 13 juin 1996: 59e assembles annuelle
de l'Association canadienne des radiologistes
Vancouver
Association canadienne des radiologistes,
510-5101, rue Buchan, Montreal QC H4P 2R9;
tel 514 738-3111, fax 514 738-5199
June 10-11, 1996: Animal Welfare and Toxi-
cology Studies: Current Issues and Trends for
the Next Century
Baltimore
Conferences, Scientists Center for Animal
Welfare, Golden Triangle Building One,
340-7833 Walker Dr., Greenbelt MD 20770; tel
301 345-3500, fax 301 345-3503
June 10-12, 1996: Occupational and Environ-
mental Medical Association of Canada Confer-
ence 1996
St. John's
Dr. Ciaran O'Shea, OEMAC '96, PO Box 2442,
Station C, St. John's NF A1C 6E7; tel 709
722-4074; fax 709 722-6801; coshea@public.
compusult.nf.ca
June 11-14, 1996: Scandinavian Society of
Radiology 52nd Congress
Uppsala, Sweden
Hakan Ahistrbm, scientific secretary, or
Christl Richter-Frohm, secretary, Department of
Diagnostic Radiology, University Hospital, S-
751 85 Uppsala, Sweden; tel 46 18 66-4757,
fax 46 18 55-7279; Hakan.Ahistrom@radiol.
uu.se or Christl. Richter Frohm@radiol.uu.se;i
kongress.html
June 13-16, 1996: Beyond Medical Care
Policies for Health
Montreal
International Association of Health Policy, tel
514 343-6492, fax 514 343-6544; congres
@ere.umontreal.ca
June 14, 1996: 38th Annual Departmental Re-
search Day and 16th Clement McCulloch Lec-
ture
Toronto
Guest speaker: Prof. D. McLeod, FRCS,
FRCOphth
Dr. David S. Rootman, Department of Oph-
thalmology, University of Toronto, 115-1 Spad-
ina Cres., Toronto ON M5S 2J5; tel 416
603-5401
Judy Cardwell, coordinator, tel 416
978-2635, fax 416 978-1522; J.Cardwell
@utoronto.ca
Du 16 au 19 juin 1996 : Assemblee generale
annuelle et congres biennal de l'Association
des infirmieres et infirmiers du Canada
Halifax
Patricia Mohr, coordonnatrice de con-
ferences, Association des infirmieres et infir-
miers du Canada, 50, the Driveway, Ottawa ON
K2P 1E2; tel 613 237-2133 ou 800 361-8404,
fax 613 237-3520; CNA@magi.com

1508 CAN MED ASSOC J 15 MAI 1996; 154 (10) For prescribing information see page 1546
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