The role of decision analysis in transfusion medicine

Cost-effectiveness of testing for human immunodeficiency virus and hepatitis C virus among blood transfusion recipients

OBJECTIVE

To choose the most cost-effective option for detecting human immunodeficiency virus (HIV-1) and hepatitis C virus (HCV) among blood transfusion recipients.

DESIGN

Cost-effectiveness analysis. Effectiveness was expressed as the number of HIV-1 or HCV infections detected, regardless of whether they were related to transfusion. To estimate costs, we assumed hospital insurance would cover costs related to detection and compensation, when granted.

SETTING

A 2,890-bed acute care teaching hospital in Bordeaux, France.

METHODS

Eight options were defined, from the simplest, which would be to do nothing, to a maximal approach, which would be to keep a serum sample in a serum library for a lookback and perform tests for antibody to HIV-1 and to HCV before and 3 months after transfusion. Data on probabilities and costs were taken from the literature and experiences of French hospitals.

RESULTS

The most cost-effective option was to perform viral antibody testing before transfusions (option 3), which would detect 27 infections per 1,000 patients, for an expenditure of US $1,260 per detected patient Option 6, obtaining a serum sample before transfusion and performing tests for antibody to HIV-1 and to HCV 3 months after transfusion, had a similar cost-effectiveness ratio but detected only 16 infections per 1,000 patients. Performing tests before and 3 months after transfusion (option 4), compared with option 3, would detect 1 additional infection for an additional cost of US $8,322.

CONCLUSION

The most cost-effective options are not specific to blood transfusion recipients and might be more suited to all hospitalized patients.

Cost-Effectiveness of Testing for Human Immunodeficiency Virus And Hepatitis C Virus Among Blood Transfusion Recipients

Objective:

To choose the most cost-effective option for detecting human immunodeficiency virus (HIV-1) and hepatitis C virus (HCV) among blood transfusion recipients.

Design:

Cost-effectiveness analysis. Effectiveness was expressed as the number of HIV-1 or HCV infections detected, regardless of whether they were related to transfusion. To estimate costs, we assumed hospital insurance would cover costs related to detection and compensation, when granted.

Setting:

A 2,890-bed acute care teaching hospital in Bordeaux, France.

Methods:

Eight options were defined, from the simplest, which would be to do nothing, to a maximal approach, which would be to keep a serum sample in a serum library for a lookback and perform tests for antibody to HIV-1 and to HCV before and 3 months after transfusion. Data on probabilities and costs were taken from the literature and experiences of French hospitals.

Results:

The most cost-effective option was to perform viral antibody testing before transfusions (option 3), which would detect 27 infections per 1,000 patients, for an expenditure of US $1,260 per detected patient Option 6, obtaining a serum sample before transfusion and performing tests for antibody to HIV-1 and to HCV 3 months after transfusion, had a similar cost-effectiveness ratio but detected only 16 infections per 1,000 patients. Performing tests before and 3 months after transfusion (option 4), compared with option 3, would detect 1 additional infection for an additional cost of US $8,322.

Conclusion:

The most cost-effective options are not specific to blood transfusion recipients and might be more suited to all hospitalized patients.

Blood transfusion in a random sample of hospitals in France

BACKGROUND

Representative information on blood use is scarce. A large-scale study of blood recipients and blood use in France was conducted.

STUDY DESIGN AND METHODS

Based on a random sampling, this study was carried out in teaching and other hospitals between March and December 1997. In each hospital, a patient was included if he or she received an allogeneic or an autologous transfusion during the observation period for that hospital. For each recipient, product and patient characteristics for 24 hours after inclusion were collected.

RESULTS

From the 175 hospitals that had given a transfusion to at least one patient during the observation period, 3206 patients were included. Most transfusion recipients (57%) were over 65 years old; 42 percent were in teaching hospitals and 53 percent in medical wards. Among the 3044 adults, 91 percent received an allogeneic transfusion. Fifty-three percent of allogeneic units were WBC reduced. The indications most frequently reported for allogeneic transfusion were neoplasms (48%) and those for autologous transfusion were disorders of musculoskeletal (63%) or circulatory (15%) systems. The patients in nonteaching hospitals were more often transfused during surgery and were more likely to be aged and to have a musculoskeletal disorder than were patients in teaching hospitals.

CONCLUSION

General collection of such data, within a system of traceability, could provide relevant denominators from which to interpret adverse-reaction data.

[Feasibility of following up transfused patients]

The aim of this study was to assess the natural history of patients after transfusion and the acceptability of a standardized biological follow-up. In 1995, during 1 month, in 13 French hospitals, a follow-up at 3 and 6 months after blood transfusion was proposed to all blood recipients who had not received any blood transfusion within the past 6 months (eligible patients): screening for red cell antibodies, alanine aminotransferase (ALT) activity and specific viral markers of hepatitis B (hepatitis B surface antigen and antibody to hepatitis virus core antigen), of hepatitis C (antibodies) and of Human Immunodeficiency Virus (antibodies). At the beginning of the study, 296 patients were followed for 6 months. A complete follow-up was available at 3 months for 183 patients (62%), at 6 months for 168 (57%) and after 6 months, 198 patients (67%) have been once followed. Of eligible patients, 76% were alive at six months. After transfusion, the incidence of red cell alloantibodies and elevated ALT concentration were respectively 4% and 17%. At 6 months, one patient had Hepatitis B surface antigen; the responsibility of blood transfusion was excluded. Within the first 24 hours, 68 patients (23%) required another blood transfusion and 42% of units were transfused to patients with malignant disease. Our study quantifies in real conditions the difficulty of a biological follow-up in a transfused population, mostly composed of patients that could not be followed in the hospital where they were transfused.

[Screening and early detection in blood transfusion: when are they indicated?]

Screening is proposed to allow an early intervention concerning a diseased individual, but its public health consequences are seldom considered. We propose criteria to judge whether a screening program can be associated to a benefit to patients or society. These criteria refer to the magnitude of disease, the characteristics of the pre-clinical stage, the availability of reliable and valid tests, the effectiveness and risk for all individuals, whether they are diseased or not, and acceptability to the health-care system and to individuals. We illustrate the application of these criteria to screening of human immunodeficiency virus among blood donors, hepatitis among recipients of labile blood products, and bacterial contaminations among febrile recipients. These criteria should be considered in decision analyses including alternatives to screening and all aspects of safety regarding patients and population.