Journal of Clinical Oncology, Vol 18, Issue 14
(July), 2000: 2755-2761
© 2000 American Society for Clinical Oncology
Cost of Outpatient Blood Transfusion in Cancer Patients
By Pierre-Yves Crémieux,
Barbara Barrett,
Kenneth Anderson,
Mitchell B. Slavin
From Analysis Group/Economics, Cambridge, and Dana-Farber Cancer Institute, Boston, MA; Université du Québec à Montréàl, Montreal, Canada; and Ortho Biotech, Inc, Raritan, NJ.
Address reprint requests to Pierre-Yves Crémieux, PhD, Analysis Group/Economics, One Brattle Square, 5th Floor, Cambridge, MA 02138; email pcremieux{at}ag-inc.com
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ABSTRACT
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PURPOSE: To determine the cost of outpatient RBC transfusion from the provider’s perspective at a major urban, academic cancer center.
PATIENTS AND METHODS: We retrospectively studied 517 cancer patients with hematologic or solid tumors who received blood during fiscal year 1995 to 1996. A process-flow diagram was developed, and cost and utilization data for 12 months were collected and analyzed. A structured interview process was used to identify all direct and indirect costs from within the inpatient unit, blood bank, and outpatient clinic. Average costs were computed for the entire sample and for specific subgroups.
RESULTS: In 1998 dollars, the average cost per RBC unit was $469 for adults and $568 for pediatric cancer patients. Adults and children generally received two and one RBC units per transfusion, respectively. Therefore, the average cost of a two-unit transfusion was $938 for adults. Patients with hematologic tumors required more RBC units (7.1 RBC units per year) at a higher average cost ($512 per RBC unit) than patients with solid tumors (4.7 RBC units per year, $474 per RBC unit). Further variations across tumor types were observed. Overhead, direct material, and direct labor represented 46%, 19%, and 35% of total costs respectively.
CONCLUSION: The cost of outpatient RBC transfusions in cancer patients is higher than previously reported, in part because overhead costs and fixed costs might have been underestimated in previous studies. Furthermore, age, tumor type, and geographic variations in the cost of fixed assets and labor have a substantial impact on the cost of blood. The results indicate that the cost-effectiveness of alternatives to transfusions in the management of cancer patients may have been underestimated in the existing literature.
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INTRODUCTION
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THERE IS LIMITED literature on the cost of blood transfusions for patients with cancer. Table 1 presents results from three previously published studies. To facilitate comparison among studies, results are stated in 1998 dollars and converted to a per-unit-transfused basis. Among available published studies, the methodologies, units of measurement, and results vary widely. With newly available therapies that offer alternatives to transfusions for patients with cancer, an accurate estimate of the cost of blood is necessary to compare the cost-effectiveness of the alternative therapies.
The present study calculates the cost of blood transfusion for adults and children with cancer treated at the Dana-Farber Cancer Institute (DFCI), a major urban academic cancer center. The availability of high-quality electronic information, together with a relatively large and heterogeneous patient population, allowed analyses of subgroups of patients to a greater degree than was possible in previous studies.
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PATIENTS AND METHODS
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The study population of 517 patients included all patients who received one or more RBC transfusions during fiscal year 1996 (October 1995 through September 1996). Table 2 presents the characteristics of the study population.
Based on interviews with key personnel at the cancer center, a detailed flow diagram was created to capture all processes associated with RBC transfusions from the initial patient administration procedure to the transfusion (Fig 1). All products and services associated with the process flow were then identified and classified into three major phases: (1) testing, ie, initial complete blood count, typing, cross-matching, and other interventions performed on the patient’s blood and/or the RBC units to be transfused; (2) product and product preparation, ie, purchased RBCs (100% of the RBC units transfused by DFCI were purchased from third parties), storage and handling, washing, and other value-added activities that are performed on the RBCs to be transfused; and (3) infusion, ie, labor and materials associated with infusing RBCs into the patient and any immediate follow-up.
Table 3 lists the specific products and services that occur in each of the three phases and distinguishes routine interventions from those performed only on a subset of patients. Some patients with relatively complex blood chemistry, specific medical conditions, or unusual personal characteristics require additional processing of the blood product or special care at the time of delivery. This raises the cost of transfusions compared with the costs for average patients. Patients who received blood that had undergone particular testing, product preparation, or infusion procedures that were performed in less than one third of the transfused population were categorized as "complex patients." Where specified, these complex patients were analyzed separately from other patients. A complete file of electronic invoice records, as well as clinical and patient demographic data, was obtained for each patient included in the study. Outpatient blood transfusion volumes were obtained from blood bank files and cross-checked against electronic invoices. Cost data were used in this analysis to reflect a provider’s perspective. On average, costs represented 92% of charges. Costs were adjusted to 1998 dollars using the consumer price index for medical services.
DFCI’s standard costing system relies on a structured interview approach to allocate all organizational costs at the level of products and services, including those listed in Table 3 that are associated with blood transfusion. Costs were grouped into four major categories according to the following distinctions: (1) direct material cost, ie, purchased products directly involved in any phase of the transfusion process (eg, purchased blood products, test kits, materials used in administering the transfusion); (2) variable direct labor cost, ie, personnel directly involved in any phase of the transfusion process and whose required services vary with the number of transfusions (eg, laboratory technicians, phlebotomists, nurses); (3) fixed direct labor cost, ie, personnel directly involved in any phase of the transfusion process but whose required services do not vary with the number of transfusions (eg, administrators); and (4) overhead, ie, all other costs, including property and equipment, utilities, and personnel from other departments (eg, hospital administrators, receptionists, and janitors).
P values were calculated to test the significance of differences between subgroups.
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RESULTS
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In 1998 dollars, the average cost of a two-unit transfusion at the DFCI was $982 (adult and pediatric patients combined). However, this average cost conceals significant differences across patients because of age, disease stage, blood chemistry, and tumor type.
Overall, 88% of adult RBC transfusions were two-unit transfusions, and 65% of pediatric RBC transfusions were one-unit transfusions (Fig 2). Table 4 shows the average number of RBC units transfused, average cost per RBC unit, and the total annual cost for each major patient subgroup analyzed. Children required significantly (P < .01) fewer RBC units than adults, but cost per RBC unit was significantly (P < .01) higher than that for adults. High RBC unit costs in children ($568) compared with adults ($469) resulted primarily from the cost difference in the administration of a one-unit RBC transfusion ($199) versus a two-unit RBC transfusion ($250). Because most of the cost in the clinic does not vary with the number of RBC units transfused (eg, administration, registration, checking of vital signs), a modest increase in the cost of administering a second unit was expected.
Relative to typical patients, complex patients required significantly (P < .01) more RBCs, had significantly (P < .01) higher RBC unit costs, and had significantly (P < .01) higher total costs. Unusual products or services administered in complex cases did not result in a corresponding reduction in the use of the more common products and services.
Compared with patients with solid tumors, patients with hematologic tumors required significantly (P < .01) more RBC units and had significantly higher RBC unit (P < .01) and total costs (P < .01). The higher costs for patients with hematologic tumors results from higher volumes of nonstandard products and services. For example, RBC washing, cytomegalovirus screening, HLA matching, antigen typing, and transfusion reaction workups accounted for 55% of the $38 difference between per-unit transfusion costs for hematologic and nonhematologic patients. These differences were consistent with those observed in the analysis by more narrowly defined tumor type (Fig 3). For example, 35% of the $84 difference in per-unit transfusion costs between leukemia patients and lung cancer patients is explained by the higher incidence of RBC washing, cytomegalovirus screening, HLA matching, transfusion reaction workups, and use of deglycerolized RBCs among patients with leukemia. Differences between tumor types were not always statistically significant because of the smaller sample sizes. In general, the types of malignancies and patient age will affect the average cost of transfusion at different locations.
Figure 4 shows a breakdown of RBC transfusion costs by cost categories (material, overhead, variable direct labor, and fixed direct labor). In this setting, overhead costs comprised nearly half of total costs. When costs were analyzed by different processes in addition to cost categories (Fig 5), product and product preparation costs accounted for approximately 50% of the total cost of an RBC transfusion and included overhead (19.1%), purchased materials (18.0%), and direct labor (11.9%). If the DFCI had purchased higher value–added products (eg, washed cells, deglycerolized cells) instead of performing the work in-house, the material cost would have represented a higher percentage of total cost, with labor and overhead costs proportionately lower.
In 1998 dollars, the average cost of transfusion per unit of blood at DFCI was $469 for adult patients and $568 for pediatric patients. Cancer centers in some urban areas (eg, Washington, DC, New York, NY, and San Francisco, CA) may have higher costs than those reported in this study, depending on the actual cost of labor and overhead in those locations. Similarly, cancer centers in other cities (eg, Dallas, TX, Houston, TX, Minneapolis–St Paul, MN, Cincinnati, OH, and Kansas City, MO) may have lower costs. Table 5 illustrates the geographic variation for these types of costs. For example, in Houston, where the study by Cantor et al3 was conducted, office rents are approximately 60% less costly than those in Boston, MA. This should translate into significantly lower overhead costs. However, since labor is only marginally less costly, the fixed and variable direct labor costs can be expected to be similar.
Minor adverse reactions occurred in approximately 6% of transfusions (Table 6). While serious adverse events, such as AIDS or hepatitis, can result from transfusions, none occurred in this sample. Furthermore, their occurrence in the general population is so infrequent that the costs associated with these events are negligible. The costs of screening the blood supply for viruses that cause serious adverse reactions were captured previously in the material cost.
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DISCUSSION
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As indicated previously, this study adopts the provider’s perspective. Other perspectives (eg, the patient’s, society’s) tend to result in higher costs than those calculated. For example, from either the patient’s or society’s perspective, it would be appropriate to include opportunity costs of time spent receiving a transfusion. In many cases, an entire day is required to administer a blood transfusion; consequently, the opportunity costs of transfusion can be substantial, particularly for an employed patient. The psychologic costs incurred by patients who dislike transfusions are among the costs not considered here. To the extent that patients would be willing to pay to avoid the procedure and achieve the same result, that cost would be included from a patient’s perspective.
Despite adopting the provider’s perspective, and thereby omitting some of the social costs associated with blood transfusions, an important finding in the present study is that transfusion costs may be higher than previously reported by Forbes et al1 and Cantor et al,3 but are generally consistent with the results of Mohandas and Aledort.2 Even after controlling for inflation, significant differences remain. They can be attributed in part to overlooked fixed costs, particularly when these results are compared with those of Forbes et al. The results suggest that incorrectly accounting for overhead and fixed costs can lead to an underevaluation of the overall cost of blood transfusion by up to 50%.
Our results may be consistent with those obtained by Cantor et al3 when considering the evidence for regional variation in the cost of fixed assets (ie, land, buildings, and equipment) and labor. Significant variations in local real estate costs and local labor costs can significantly affect the cost of blood transfusion. In its original form, the material cost of an RBC unit is negligible because the unit and much of the collection labor are generally donated. Most of the added cost results from paid workers in the collection, storage, handling, and transfusion processes, as well as overhead associated with fixed assets at each of these stages.
Beyond potential geographical variations in the costs of blood, another important result of this analysis is that the average cost of a two-unit transfusion does not reflect the wide variation in costs across age groups, patients, and types and stages of cancer. Younger patients require fewer blood units infused at any one time (typically one instead of two units), thereby raising the unit cost of transfusion. Similarly, patients who require transfusions with more complex blood products may receive transfusions that cost 20% more than the cost to typical patients. Finally, patients with hematologic tumors receive transfusions that are nearly 10% more expensive per unit than those for patients with nonhematologic tumors.
Together, these results show that transfusions are costly, that the direct cost of the raw product is only a small fraction of the total cost of administering a two-unit blood transfusion, and that cost differences across patient groups are significant. An important implication of these results is that previous estimates of the cost-effectiveness of alternatives to transfusions, such as growth factor or erythropoietin therapy, may have been understated because the cost of transfusions was only partially captured. One study, which found that transfusions were less costly than erythropoietin therapy in oncology patients, used costs per unit of blood transfused ($373) that are 24% less than those found here ($491).4 A subsequent study, which found that erythropoietin therapy in oncology patients was cost-effective compared with transfusions, relied on a cost per unit of blood ($354) that was 28% below that reported here.5 Finally, the higher cost of blood associated with complex patients,he matologic patients, pediatric patients, and patients treated in expensive urban settings also suggests that these populations might be particularly attractive candidates for alternative therapies.
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ACKNOWLEDGMENTS
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We thank Maryanne Mullen, Manager, Financial Decision
Support Systems; Bill Clarke, Corporate Team Leader, Information Systems; Tom Kloss, Director of Adult Ambulatory Nursing; Linda Perellin, Inpatient Clinical Nurse Specialist; and Beryl Davis, Head Nurse, Dana I Adult Clinic.
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NOTES
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Research was supported in part by Ortho Biotech, Inc, Raritan, NJ.
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REFERENCES
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1.
Forbes JM, Anderson MD, Anderson GF, et al: Blood transfusion costs: A multicenter study. Transfusion 31:318-323, 1991[Medline]
2.
Mohandas K, Aledort L: Transfusion requirements, risks, and costs for patients with malignancy. Transfusion 35:427-430, 1995[Medline]
3.
Cantor SB, Hudson DV Jr, Lichtiger B, et al: The costs of blood transfusion: A process-flow analysis. J Clin Oncol 16:2364-2370, 1998[Abstract]
4.
Sheffield RE, Sullivan SD, Saltiel E, et al: Cost comparison of recombinant human erythropoietin and blood transfusion in cancer chemotherapy induced anemia. Ann Pharmacother 31:15-22, 1997[Abstract]
5.
Cremieux PY, Finkelstein SN, Berndt ER, et al: Cost-effectiveness, quality-adjusted life years, and supportive care: Recombinant human erythropoietin as treatment of cancer-associated anemia. Pharmacoeconomics 16:459-472, 1999[Medline]
Submitted August 26, 1999;
accepted March 16, 2000.
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TOP
ABSTRACT
INTRODUCTION
