Newer Transfusion Method Saves Lives, Lowers Costs
Wednesday, June 25, 2003
Removing white cells from blood before it is used in a transfusion most likely saved the lives of 50 to 60 heart surgery patients at Strong Memorial Hospital since 1998 and reduced the cost of treatment. These results, and a review of this scientifically proven but controversial procedure--leukocyte-reduced transfusions--appear in the September 2002 issue of the American Journal of Clinical Pathology.
Scientific research demonstrates that many complications of surgery are not due to bad luck, surgical accidents, inadequate hand-washing or antibiotic-resistant bacteria, but rather to previously unrecognized adverse effects of transfused white cells on the patient's immune system. The presence of foreign transfused white cells compromises the ability to fight off the bacteria that are always present in our bodies and environment. The use of simple, safe and relatively inexpensive filters to remove the white cells from transfused blood not only reduces post-operative complications and deaths, but actually reduces the overall costs of medical care.
Lead author Neil Blumberg, M.D., director of the Transfusion Unit and Blood Bank at Strong Memorial Hospital of the University of Rochester Medical Center, says other medical institutions will almost certainly save money and reduce patient complications if they switch from using unmodified blood to leukocyte-reduced blood.
Doctors at Strong Memorial have been world leaders in scientific and clinical studies of this "transfusion immunomodulation" effect for 20 years. Strong was among the earliest hospitals in the nation to use leukocyte-reduced blood in cardiac surgery, starting in July 1998. The Food and Drug Administration's Blood Products Advisory Committee advocated this approach in September 1998. The Health and Human Services Advisory Committee on Blood Safety and Availability also voted overwhelmingly in favor of universal leukocyte-reduction for transfusions in January 2001.
The committees' decisions were based on abundant data from randomized trials suggesting that using leukocyte-reduced blood decreases the risk of post-operative infection, and may lower death rates by as much as 50 percent to 60 percent in heart surgery. Currently, most American Red Cross blood centers nationwide provide only leukocyte-reduced transfusions, as do many other blood centers. However, some in the medical community remain unconvinced. Organizations such as the American Hospital Association and American Medical Association, for example, have opposed the recommendation for universal leukocyte-reduction, claiming it would inflate costs unnecessarily.
Leukocyte-reduction adds $25 to $35 to the price of each unit of blood. The FDA does not yet mandate universal leukocyte-reduction of transfusions as a regulatory requirement. Thus, Blumberg and his colleagues at Rochester, leaders in the field and advocates of leukocyte-reduction, sought to analyze the economic consequences and clinical outcomes of their early adoption of this technology.
"This is an excellent example of the value of having a university teaching hospital in our community," Blumberg says. "We were able to move forward on an important patient-care issue, while also testing its cost effectiveness." Using existing data at Strong, they studied two groups: patients undergoing cardiac surgery (coronary artery bypass, valve replacement or both) from July to December 1998 using leukocyte-reduced blood, versus a control group from the same period in 1997 who were transfused with unmodified blood. In an attempt to reduce bias in the data, Blumberg's study included only adults with similar demographic characteristics whose surgeries were performed by two cardiac surgeons with long-established practices, co-authors George Hicks Jr., M.D., and William Risher, M.D.
In addition to improved outcomes, the cost of treating the recipients of leukocyte-reduced blood dropped by about $1,700 in each case despite the effects of cost inflation and new technologies. Blumberg attributed the savings to fewer hours in the ICU, less use of antibiotics and a decrease in length of stay. By July 2000, Strong Hospital began using leukocyte reduced blood for all hospitalized patients. Despite the expense of the filters, the overall cost savings in cardiac surgery alone are estimated at between $500,000 and $1 million a year, Blumberg says.
Due to differences in clinical practice and patient conditions at hospitals across the U.S., Blumberg notes that "our favorable experiences may not be applicable to other institutions in all cases. Nevertheless, our study provides some evidence in support of the five randomized trials that found benefit in leukocyte-reduction of transfusions to surgical patients."