Blood, Esa’s and Costs
Authors: Brilhante Dialina , Macedo Ana , Harfouche Ana 
Published: April 2020

Background: The demand for allogeneic blood (packed red blood cells) has been progressively increasing. The introduction of safety measures substantially increased its cost and limited the available supply. Because both supply and demand for blood has not yet reached a plateau, namely in Portugal, the introduction and adoption of treatments that reduce transfusion, such as Erythropoiesis Stimulating Agents (ESA’S) for patients with chemotherapy induced anemia (CIA) is a welcome strategy to manage the hospital blood supply. Recently an advisory panel to the US Food and Drug Administration has recommended that the agency further limit the use of ESA’S, and in Europe, the European Medicines Agency (EMEA) emitted a statement that “cancer patients with a reasonably long life expectancy” should receive blood transfusions rather than take drugs for anemia. With these warnings we are probably going to see an increase in demand for blood. Estimating blood costs is a complex undertaking, surpassing simple versus demand economics, and is not simple or straightforward; the underlying issue is whether hospitals are billing appropriately for blood products and how extensively its value is calculated. The National Health Care System is making a huge effort to control the rising costs associated with the delivery of health services, namely developing a new allocation method for hospitals. Activity-based costing (ABC) is an approach to the management of resources that allows the ‘real’ resource costs and time of a service activity to be estimated. Traditional costing systems often group many costs together as overheads. The Accounting System for Activities in the Hospitals (SCAH) is outlined to evaluate detailed cost elements, understanding cost behaviour, which can facilitate future policy decisions, because policy makers have the opportunity to more fully understand the implications of incremental changes. We applied the SCAH to the Blood Bank of IPOFG Lisbon, in order to evaluate a far more accurate appraisal of the actual cost of the blood. The cost of correcting CIA is an open issue as both ESAS’S and Transfusion may offer symptomatic benefit. In Portugal the price of ESA’S, Erythropoietin alfa decreased almost 50% from 2000–2008, not including the final price, negotiated in each hospital. On the other hand, the price of one unit of packed RBCs continues to rise, and with different values, depending on the methodology used.

Purpose: Evaluation of the costs of both alternatives to increase 1g of haemoglobin, in a hemato-oncological hospital, belonging to National Health Service and not for profit.

Methods: We analysed the official prices of ESA’S between 2000–2008 published by the Ministry of Health. We used an activity – based approach to more fully account for the cost of blood, than present estimates, derived from the concept of activity-based costing (ABC). We applied this method to the process Chart flows of activities associated with blood collection facility and the others associated to the transfusion service.

Results: Prices of Epoeitin - a (1000 UI/5μg) and Darbepoeitin according to National Catalogue Prices

2000 2001 2002 2003 2004 2005 2006 2007 2008 Epoietin-a €11,17 €7,20 €6,73 €6,52 €6,52 €6,12 €6,12 €6,12 €6,12 Darbepoeitin - - - €7,80 €7,00 €6,52 €6,52 €6,12 €6,12

Price of Packed RBC (2007), calculated using ABC methodology

% Price (€) Personnel 25,32 90,26 Material to blood collection 6,47 23,07 Equipment 1,03 3,67 Common Costs 5,03 17,92 Reagents 3,69 13,15 Outsourcing 1,83 6,52 Structures 1,01 3,60 Laboratory analysis 15,85 56,50 Transfusion Session 39,77 141,75 Total 100% 356,44

Increment of 1g haemoglobin

1 unit of Packed RBC and transfusion session 30.000 UI EPO-a (fixed dose every week) 150 mg Darbepoeitin (fixed dose every week) €356.44 + €30* €183,6 × 2 = €367,2 * Haemovigilance network €183,6 × 4 = €734,4

The cost of 1 unit of packed RBC is equivalent a two fixed doses of EPO- a and Darbepoitin, respectively (30000 UI and 150 mg). Each hospital can negotiate catalogue adjusted prices for ESA’s, so if we presume that these values can be reduced by half, the price of 1 unit of packed RBC is equivalent to 4 fixed doses of treatment with ESA’s.

Conclusions: Once the ability of ESA’s to reduce transfusions requirements has been documented in the literature, the costs of ESA’S and Transfusion might be another factor in determining which approach should be used.