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The Cost of Blood Collection in Greece: An Economic Analysis
Clinical Therapeutics/Volume 36, Number 7, 2014
The Cost of Blood Collection in Greece: An Economic Analysis Vassilis Fragoulakis1; Kostas Stamoulis2; Elisabeth Grouzi3; and Nikolaos Maniadakis1 1
National School of Public Health, Athens, Greece; 2National Blood Centre (EKEA), Athens, Greece; and 3Transfusion Service of “Agios Savvas” Regional Cancer Hospital, Athens, Greece
ABSTRACT Objective: The goal of this study was to estimate the cost of production of 1 unit of blood from a National Health Service perspective in Greece. Methods: In agreement with guidelines, the cost of blood production in this study accounted only for the resources expended for collection, processing, laboratory testing, and storage. Hence, the costs associated with donor recruitment, pretransfusion preparation, transfusion administration, follow-up management of adverse events, and other long-term relevant costs were not taken into consideration. The indirect cost of blood donations for donors (productivity loss) was also considered. A questionnaire was used to collect data regarding personnel time, annual blood quantities collected, percentage of wastage, utilization of consumables, institutional overhead, information technology expenditure, medical equipment utilized, nuclear acid tests, and other factors. Data gathered by 53 hospitals across the country were assessed. A model was constructed with economic data collected by the National School of Public Health and the Ministry of Health. All data refer to the year 2013. Results: The weighted mean direct cost of producing 1 unit of blood was estimated at €131.49 (SD, €22.12; minimum/maximum, €94.96–€239.20). The mean total indirect cost was estimated at €34 per unit of blood. The cost distribution was positively skewed (skewness, 1.642 [0.327]). The major cost component was the cost of personnel, accounting for 32.5% of total costs, and the average of blood unit wastage was estimated at 4.90%. There were no differences between the cost of producing 1 unit of blood in Athens compared with the rest of the country (Mann-Whitney test, P ¼ 0.341). Conclusions: This study suggests that the cost of producing 1 unit of blood is not insignificant. These figures need to be complemented with those concerning the cost of transfusion to have a complete picture of producing and using 1 unit of blood locally. (Clin Ther. 2014;36:1028– 1036) & 2014 Elsevier HS Journals, Inc. All rights reserved. Key words: blood, blood unit, cost of blood.
INTRODUCTION Blood and its components are vital health care commodities that are becoming increasingly scarce.1 The need for blood and blood products is rising in all parts of the world. In high- and middle-income countries, with advancements in health care systems and improved health coverage, this need is increasingly being driven by sophisticated medical and surgical procedures.2 Because the blood donor pools are shrinking (owing to population aging and restrictions on blood donor eligibility), the cost of an additional unit donated is considerably high around the world. In Greece, the blood donation system is decentralized and hospital based; it consists of 103 hospital transfusion services under the supervision of the Ministry of Health. Each transfusion service is an integrated part of a public hospital and has the responsibility for recruiting blood donors, collecting and testing blood, and processing that blood into its product supply so that it can be provided to the hospital clinics.3 To design and organize a centralized system in accordance with the European Commission directive 2002/98/EC, a new law came into effect in 2005 regarding the organization of blood transfusion services. This law designated the Hellenic National Blood Center (E.KE. A) as the competent authority for the organization, management, and control of the national blood transfusion system. E.KE.A is a public entity of the Ministry of Health and Social Solidarity. In 2012, a total of 608,000 units of whole blood were collected from all over the country. Greece has a blood donor index of 6 blood donors per 100 citizens and ranks second among European Union member states in the number of people who have donated blood at least once in the past (Eurobarometer 2003); in addition, although Greece is first in the proportion Accepted for publication May 5, 2014. http://dx.doi.org/10.1016/j.clinthera.2014.05.003 0149-2918/$ - see front matter & 2014 Elsevier HS Journals, Inc. All rights reserved.
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V. Fragoulakis et al. of voluntary donors who have at least considered giving blood (Eurobarometer 2005), the country (with a population of 11,000,000)4 often finds the number of annual blood donations insufficient to cover the high national transfusion needs. From an economic point of view, the system is totally funded by the state budget and the value to users is free of charge, but the necessity to control costs and restrain expenditures has been acknowledged in the literature.5 In the presence of scarce resources, several economic analyses have been conducted worldwide to estimate the cost of blood transfusions, using different analytical aims, perspectives, and methods.6–14 All these analyses are very useful; nonetheless, their main methodologic concerns involve the fact that the transfusion-related costs captured with varying degrees of rigor and the determination of transfusion-related adverse events, which are the costliest contributors to health care expenditures, are not accurately estimated.15 To devise a comprehensive and standardized method that will improve on existing estimates, several economic models have been developed, modified, or updated.8,15,16 In the main “consensus” economic model (which is the most prominent for the estimation of blood cost), a process flow model that describes all the major steps involved in collecting, processing, and transfusing blood (eg, donor recruitment, follow-up of transfusion sequelae) should be constructed. This model is broad based and should serve societal, provider, and payer perspectives for future cost studies. Detailed analysis of this model can be found elsewhere.15,16 Because the cost of blood is likely to be underappreciated by using a cost analysis, the present model for the case of Greece was based solely on the widely accepted standard method mentioned earlier, whereas the majority of cost elements were based on real local data. Simply stated, we attempted to use all the recommended steps for the cost calculation, while substituting simplified assumptions with local data; in the absence of available data, we excluded costs (which are clearly stated in the article). Detailed analysis of our model is described in the Materials and Methods section. In terms of previous estimates of blood costs in Greece, a sole economic analysis by Kanavos et al17 was conducted to calculate the costs associated with the collection, testing, storage, distribution, delivery, and transfusion of blood. This model was based on several assumptions, however; direct costs and some indirect costs were included, while intangible costs
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were excluded as nonquantifiable with an acceptable degree of accuracy. Data used came from only 3 Greek hospitals (2 public and 1 private). The cost of a blood transfusion unit was estimated at €294.83 and €339.83, respectively, for the 2 public hospitals and €413.93 for the private hospital. Because Greece has been affected more by the financial turmoil beginning in 2007 than any other European country and is still subjected to enormous scrutiny of resources, the main economic indicators and the entire economic environment have been reversed.18 Thus, it is paramount to deliver health care services at a reduced cost without compromising safety issues and maximizing health benefits for patients. Moreover, it is crucial to reestimate accurately, and in the present environment, the cost of producing 1 unit of whole blood. It must be noted that in the case of “blood markets,” there is no typical market price (at least not reflecting a currency-based transaction). Therefore, the estimated costs of blood reflect the resources required to make 1 unit of blood available for use. Hence, in the present analysis, the “cost” being estimated is the value of resources necessary to supply or make available 1 unit of blood, and this cost is paid by the health system, donor, and by the public sector in general. The present article describes the findings of a project with the participation of E.KE.A, which attempted to determine the cost of blood unit production across the majority of public hospitals in the country. The aim of the present study was to estimate the cost of production of 1 unit of blood from a National Health Service perspective in Greece.
MATERIALS AND METHODS Analysis and Data Collection In accordance with guidelines, we used a 9-step process flow model (Figure 1), which captures both direct and indirect cost elements concerning the cost of blood transfusion.16 The left panel of the diagram reflects the cost elements associated with a blood collection facility and the right panel reflects the transfusion service. In the present analysis, we have captured only the cost of “blood collection (2),” the cost of “blood processing (3a),” the cost of “laboratory testing (3b),” the cost of “blood destruction (4),” and the cost of “blood collection center inventory and storage (5),” excluding the cost of transporting in the processing area due to lack of detailed data. In Greece, there are no separate blood bank centers that operate as a
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Blood center/collection facility
Transfusion service
1. Donor recruitment and qualification 9. Long-term outcomes tracking
2. Blood collection 3a. Blood processing
8. Transfusion administration and follow-up
3b. Laboratory testing
No
3c. Blood passes all screening tests and is labeled for release
4. Blood destruction, donor notification, and tracking
Yes
5. Blood collection center inventory, storage, and transport
Societal costs (steps 1-4): Donor opportunity Productivity losses/labor Blood center volunteers
7. Pretransfusion preparation
6. Transfusion service inventory and storage
Societal costs (steps 7-9): Tracsfusion recipient opportunity Productivity losses/labor Transfusion service volunteers
Figure 1. Blood collection and transfusion flowchart.16
supplier for local hospitals, and thus, there are no costs such as “transfusion service storage and inventory.”6 However, there are some transport operations between hospitals, but because of a lack of robust data, this cost was not taken into consideration. Due to the question at hand, the cost associated with “pretransfusion preparation (7),” “transfusion administration and follow-up (8),” and “other long-term relevant costs (9)” were also not included in the present analysis. In addition, owing to the severe restraints in health budgets, the cost of “donor recruitment and qualification (1)” incurred by the Ministry of Health was extremely low, and it has been excluded without any loss in accuracy of presented results. The algorithm used to estimate the direct cost of blood collection is presented in detail in Supplemental Table I (see the online version at http://dx.doi.org/10. 1016/j.clinthera.2014.05.003). Data concerning reagent costs, the type of equipment used by hospitals, the percentage of wastage of blood units, yearly blood
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production, the cost of nucleic acid test per unit, and other tests were collected by using a structured Excelbased questionnaire and fulfilled with the data stored in the database of E.KE.A (see Supplemental Table II in the online version at http://dx.doi.org/10.1016/j. clinthera.2014.05.003). Appropriate data were gathered by 53 hospitals (related to 373,310 units of bloods) in the country. Data entry in a separate Excelbased platform was performed between February and March 2013 by 2 full-time employees of Ε.ΚΕ.Α under the supervision of their scientific director (K.S.). Data concerning the gross monthly salaries came from a survey conducted with the staff of “Agios Savvas” Regional Cancer Hospital of Athens. In the absence of detailed records, sociodemographic characteristics (eg, age, sex, educational level, gross income) of this sample were reasonably considered representative of the profile of the rest of the employees in blood centers across the country. It must be noted that the Greek Ministry of Health lacked the appropriate infrastructure for collecting
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V. Fragoulakis et al. complete data from hospitals, which is a common issue in “small” countries such as Greece.19 Despite the fact that the Ministry of Health successfully developed and implemented an operational webbased facility20 to overcome the aforementioned limitation, some necessary datasets are still missing. In this light, some input parameters in the present model were based on simplified assumptions in accordance with advice from local experts (K.S. and E.G.). For instance, the cost of laboratory tests per unit of blood, the computerization cost (inventory and maintenance) of blood establishments, the price of different types of equipment, the remaining life cycle (measured in years) for medical equipment, and the price of blood collection bags and the various types used were roughly estimated (on average) and were assumed identical across all the country’s hospitals (details are given in Table I). The institutional overhead costs, which are related to electricity, cleaning, security, administration, and all other supportive services allocated to blood establishments, were gathered from the Ministry of Health and refer to 2011. As a standard approach for this type of study, the weighted parameter for institutional overhead costs was considered the m2. To investigate cost differences among the different types of hospitals, we used the Mann-Whitney test. This test is a nonparametric test of the null hypothesis that 2 populations are the same against an alternative hypothesis, especially that a particular population tends to have larger values than the other. This test is used mainly on nonnormal distributions, which is the case here. The indirect cost of blood donor’s productivity loss was estimated separately based on data gathered from 2 public hospitals in Greece. In particular, a structure questionnaire was distributed to a sample of 172 blood donors in “KAT Hospital” and “Agios Savvas” Regional Cancer Hospital in Athens. The goal of the questionnaire was to capture all indirect costs, including: (1) the time spent by the donor and/or his/her relatives for donating blood during working hours (opportunity cost); (2) transportation costs; (3) day off work (opportunity cost); and (4) other relevant expenses. The necessary data were collected by using face-to-face interviews (of 10 minutes’ duration each) by the medical and nursing staff of every blood donation establishment. All participants were informed regarding the scope of this interview, while researchers did not interfere or guide the answers throughout the
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process. The questionnaires were clear, well understood, and answered in a completely anonymous mode. A simplified form of this questionnaire can be found at Supplemental Table III in the online version at http:// dx.doi.org/10.1016/j.clinthera.2014.05.003. To provide adequate protection against improper conclusions, all analyses presented here report only aggregated information or specific data from separate hospitals in an anonymous mode. All statistical calculations were performed by using Microsoft Excel 2007 (Microsoft Corporation, Redmond, Washington).
RESULTS Forty-four hospitals from the region of Athens and 9 hospitals from the rest of the country were included in the present analysis. The sample also included 7 university hospitals and 3 oncology hospitals. Based on the total units of blood collected, the present sample incorporates 61.5% of the whole blood collection in Greece for 2012. The detailed results of our model concerning the cost of collecting 1 unit of blood are presented in Table II and Figure 2. In particular, the weighted mean direct cost of producing 1 unit of blood was estimated at €131.49 (SD, €22.12; minimum/maximum, €94.96–€239.20). The unweighted mean direct cost was slightly higher and was estimated at €144.37 (27.16) for the entire sample. The major cost component was the cost of personnel, accounting for 32.46% of the total expenses, followed by the nuclear acid testing and the cost of laboratory tests, which represent 27.97% and 27.65% of total costs, respectively. The unweighted cost of producing 1 unit of blood in a university hospital was €133.36 (SD, €18.43; minimum/maximum, €113.99–€161.31); it was estimated at €169.05 (SD, €31.16; minimum/ maximum, €138.91–€201.15) for oncology hospitals. There were no differences between the cost of producing 1 unit of blood in Athens compared with the rest of the country (Mann-Whitney test, P ¼ 0.341). The cost distribution across all the hospitals included in the sample was positively skewed (skewness, 1.642 [0.327]), a finding that is common in similar analyses due to a low percentage of hospitals incurring relatively high costs to produce 1 unit of blood. The average of blood unit wastage was estimated at 4.90% or 18,292 blood units for the entire sample. There was a weak positive correlation between the blood wastage and the total blood units gathered by each center (ρ ¼ 0.290) (Figure 3). The cost data for
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Table I. Main input parameters used in the model. Cost per Unit Laboratory tests* HIV HBV HCV HTLV-I/II Syphilis ABO Rhesus D C c E e Kell
Staff General supervisor Directors Medical Doctor Α’ Class Medical Doctor Β’ Class Doctors in training Health Visitors University education Technical education Secondary education
Type of blood bags Blood bag 35 days with ACD Blood bag 42 days (with additive solution) Bag of whole blood with prestorage leukoreduction of packed red blood cells (42 days) Bag of whole blood with prestorage leukoreduction of 3 components (42 days)
Type of equipment Centrifuge for blood components preparation Refrigerator for blood storage (1–6 oC) Plasma freezer Platelet agitator Plasma extractor Mixer/monitor volume of blood drawn Centrifuge for test tubes Dielectric sealer Consumables The determination of consumables was roughly estimated by experts
4.25 3.49 4.91 2.04 0.3 4.9 0.6 0.5 0.49 0.71 0.42 Gross Income per Month, € (WagesOpportunity Cost)
% of People Subjected to Blood Testing
100 100 100 100 100 100 100 60 60 60 60 Technicians
Wages
1900 € 1700 € 1400 €
Cost per Bag (€)
University education Technical education Secondary education Others University education Technical education Secondary education Nurses University education Technical education Secondary education % of Use Per Hospital
7 8 29
76.35 10.14 8.45
73
5.07
Cost (€)
Life Cycle (y)
61,500 18,450 10,000 6150 615 350 10,000 400
10 10 10 10 10 10 10 10
3200 3100 2600 2100 1900 1900 1700 1400
1900 € 1700 € 1400 € 1900 € 1700 € 1400 €
HBV ¼ hepatitis B virus; HCV ¼ hepatitis C virus; HTLV-I/II ¼ human T-lymphotropic virus type I/II; C = C antigens; c = c antigens; E = E antigens; e = e antigens; Kell = Kell antigens. * More data can be provided upon request.
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Table II. Total cost per item for collecting 1 unit of blood in Greece. Description Unweighted cost Personnel Overheads Consumables Computerization Blood bag Cost of laboratory tests Nuclear acid tests Equipment Total direct cost Indirect costs Total cost Weighted cost Personnel Overheads Consumables Computerization Blood bag Cost of laboratory test Nuclear acid tests Equipment Total direct cost Indirect cost Total cost
Mean (€)
SD (€)
46.86 2.88 1.09 0.92 12.30 39.92 40.38 0.04 144.37 34.00 178.37
24.86 1.86 0.32 1.22 NA NA 2.68 0.03 27.16 49.23 NA
35.23 2.54 1.07 0.62 12.30 39.92 39.78 0.02 131.49 34.00 165.49
20.14 1.63 0.20 0.73 n/a n/a 2.55 0.02 22.12 49.23 NA
NA ¼ not applicable.
each of the participating hospitals are presented in Supplemental Table IV (see the online version at http://dx.doi.org/10.1016/j.clinthera.2014.05.003). For the determination of indirect costs, we collected data from 172 participants who had a mean age of 37.6 (10) years; 78% of the participants were employees, 9.3% were unemployed, and 6% were students. The mean total indirect cost was estimated at €34 per unit and is distributed as follows: cost of transportation/expenses accounts, €2.15 (3.5); productivity loss, €9.27 (11.37); the opportunity cost of “days off with compensation,” €20.26 (45.67); and the productivity loss of relatives/families, €2.33 (7.35). The productivity loss in terms of actual hours absent from work was estimated at 1.97 hours. It is noteworthy that 19.19% of participants were civil servants and
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took 2.36 days off from work, on average, with compensation; 10% of the civil servants voluntarily did not use the right of a day off for the blood donation and returned normally in their jobs.
DISCUSSION The present study was designed to estimate the cost of a blood unit production across public hospitals in Greece. The present analysis was conducted in accordance with the “blood consensus model” mentioned above, which is broad-based and should serve as a gold standard approach for this type of cost studies. We must emphasize that not all type of costs connected with transfusion services were taken into consideration, and thus this cost might be considerably higher compared with the estimation presented here for the cost of collecting 1 unit of whole blood. As mentioned in the Introduction, the cost of blood transfusion varies among health care systems. Nonetheless, it has been acknowledged that the use of blood is characterized by inherent risks, high costs, and inventory constraints.21 It must also be noted that the cost of a blood transfusion unit estimated in other countries might be irrelevant for the case of Greece, because the management of donors, the relative prices, and the perspective of analysis differ between countries or economic models. However, given the risks of this procedure, several clinical guidelines reflect the increasing interest of appropriate blood utilization by professional societies.22–27 In the current context of politico-economic crisis, Greece’s coalition government agreed to a reform program with the “troika,” with the goal of reducing total public health care expenditures in the country (The troika is a term referred to three international organizations: the European Commission (EC), the International Monetary Fund (IMF), and the European Central Bank (ECB).).28 Hence, the determination of relative strengths and weaknesses of the management system of Greek blood establishments is crucial to cope with increased regulatory and operational complexities, and to optimize efficiency and minimize health care costs. To the best to our knowledge, this is the first study conducted in Greece that determined the cost of blood based on a large dataset afforded by the official management of E.KE.A. Our goal, with the method used, was to determine the cost of blood collection more thoroughly compared with previous attempts and in that sense, several cost components were estimated with an
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0.03%
27.97%
32.46%
1.99% 27.65%
8.52%
0.75% 0.64%
Personnel
Overhead
Consumables
Computerization
Blood bag
Cost of laboratory tests
Nuclear acid tests
Equipment
Figure 2. Distribution of total direct costs of blood collection per item.
acceptable level of accuracy. Other cost components related to the transfusion process, which cannot be captured relatively accurately at this moment, were excluded and must be analyzed in the future by other researchers. It should be noted that in analyses similar to those discussed here, the “cost” of blood incorporates those expenses associated with materials (eg, blood
bags) and “opportunity cost,” which measures costs based on the wages for nurses and medical staff. According to the results of our analysis, there are considerable variations in the cost of blood production among the Greek hospitals. The primary reason for these variations is related to the differences in labor productivity among hospitals. In technical terms, labor
30,000
Blood Unit Production
25,000 20,000 15,000 10,000 5000 0
0
1
2
3
4 5 6 7 8 Percentage of Blood Wastage
9
10
11
Figure 3. Blood production and percentage of blood wastage across the sample of hospitals.
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V. Fragoulakis et al. productivity is defined as the number of blood products collected per employee per unit of time; the main factors that influence labor productivity are the training and skill level of collection staff, workflow variables (eg, space, travel, equipment), and the error rates in the blood collection process.29 For instance, the ratio of blood unit per employee per year in the present sample was estimated at 331 units (SD, 185 units; minimum/ maximum, 90/1230) with a %CV of 56%. This finding probably indicates the differences in slack time across the blood establishment staff in Greece (“slack” is a term which indicates that worker are not busy and show little activity in their job), due to the multitask responsibilities of all working staff in the field of transfusions, which is a consequence of limited qualified personnel. In addition, it is one of the main reasons that the blood transfusion system in Greece is an extremely decentralized, hospital-based organization involving different types of hospitals, patients, and staffs. To overcome the difficulties caused by limited resources, the strategic plan of the E.KE.A is based on the efficient provision of a safe and sustainable supply of blood, blood components, and services that meet all safety, quality, and compliance standards. Its primary focus is to modernize each stage of the blood supply chain: from the collection of blood (focusing on the donor’s experience of giving blood) to the processing and testing of blood in a centralized environment and its issue and delivery to hospitals. In addition, a primary goal is the establishment of E. KE.A as an effective, responsive organization focused on the changing needs of donors and hospitals. From a technical point of view, any economic analysis is, by necessity, a simplification of the process it tries to emulate, and it was necessary to make assumptions when constructing the present model. For instance, a common issue in studies that use similar methods lies in the fact that the estimation of blood cost is based only on red blood cells production, without taking into consideration other blood products (eg, fresh frozen plasma, platelets). In addition, several cost elements were considered invariant due to lack of detailed records from the hospitals. Hence, the main parameters that determined the variation in cost among hospitals were the number of staffs employed in blood centers, the number of blood units produced, and the percentage of wastage of blood units. Third, it was assumed that collected blood was subjected to uniform testing, despite the fact that there are differences in the type of testing used across the
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country. In addition, the cost of blood collected from mobile collection units was not included in the analysis. A further limitation of our study is that the recruitment costs for donors were not considered here because of lack of data. Because the cost of acquiring a marginal donor might be increasing due to demographic reasons, it must be noted that the current marginal cost estimates would increase (with scale) with respect to donor recruitment in the future. Finally, we must also note that the functional costs of E.KE.A or other governmental services that are related to blood production/distribution in Greece were not taken into account due to a lack of detailed available data in a form that could be useful for the present model.
CONCLUSIONS The findings of this study represent an update of previous estimates, as well as an improvement in methods used for the determination of the cost collection of blood in Greece. It must be stressed that the cost of producing a unit of blood is not insignificant. These figures need to be complemented with those concerning the cost of transfusion to have a complete picture of producing and using 1 unit of blood locally.
ACKNOWLEDGMENTS The study was funded by Genesis Pharma Hellas. The study sponsor had no involvement in the study design, data collection, or writing of the manuscript. Drs. Fragoulakis and Maniadakis have received unrestricted grants by Genesis in the past. The authors have indicated that they have no other conflicts of interest regarding the content of this article. Dr. Fragoulakis conducted the analyses, interpreted the results, and wrote the manuscript. Dr. Stamoulis supervised the data collection and contributed to the results interpretation. Dr. Grouzi supervised the data collection and contributed to the paper writing and results interpretation. Dr. Maniadakis supervised the study and is the guarantor for the overall content.
CONFLICTS OF INTEREST The study sponsor had no involvement in the study design, data collection, or writing of the manuscript.
SUPPLEMENTAL MATERIAL Supplemental tables accompanying this article can be found in the online version at doi:10.1016/j.clinthera. 2014.05.003.
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REFERENCES 1. Williamson LM, Devine DV. Challenges in the management of the blood supply. Lancet. 2013;381: 1866–1875. 2. World Health Organization. More voluntary blood donations essential.http://www.who.int/media centre/news/releases/2012/blood_ donation_20120614/en/. Accessed May 15, 2013. 3. Marantidou O, Loukopoulou L, Zervou E, et al. Factors that motivate and hinder blood donation in Greece. Transfus Med. 2007;17:443–450. 4. Hellenic Statistical Authority (EL. STAT.). Latest statistical data. http://www.statistics.gr/portal/page/ portal/ESYE. Accessed May 15, 2013. 5. Kyriopoulos JE, Michail-Merianou V, Gitona M. Blood transfusion economics in Greece. Transfus Clin Biol. 1995;2:387–394. 6. Forbes JM, Anderson MD, Anderson GF, et al. Blood transfusion costs: a multicenter study. Transfusion. 1991;31:318–323. 7. Mohandas K, Aledort L. Transfusion requirements, risks, and costs for patients with malignancy. Transfusion. 1995;35:427–430. 8. Cantor SB, Hudson DV Jr, Lichtiger B, Rubenstein EB. Costs of blood transfusion: a process-flow analysis. J Clin Oncol. 1998;16:2364–2370. 9. Cremieux PY, Barrett B, Anderson K, Slavin MB. Cost of outpatient blood transfusion in cancer patients. J Clin Oncol. 2000;18:2755– 2761. 10. Agrawal S, Davidson N, Walker M, et al. Assessing the total costs of blood delivery to hospital oncology and haematology patients. Curr Med Res Opin. 2006;22:1903–1909. 11. Glenngard AH, Persson U, Soderman C. Costs associated with blood transfusions in Sweden—the societal cost of autologous, allogeneic and perioperative RBC transfusion. Transfus Med. 2005;15: 295–306.
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12. Varney SJ, Guest JF. The annual cost of blood transfusions in the UK. Transfus Med. 2003;13:205–218. 13. Shander A, Hofmann A, Ozawa S, et al. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion. 2010;50: 753–765. 14. Abraham I, Sun D. The cost of blood transfusion in Western Europe as estimated from six studies. Transfusion. 2012;52:1983–1988. 15. Shander A, Hofmann A, Gombotz H, et al. Estimating the cost of blood: past, present, and future directions. Best Pract Res Clin Anaesthesiol. 2007;21:271–289. 16. The cost of blood: multidisciplinary consensus conference for a standard methodology. Transfus Med Rev. 2005;19:66–78. 17. Kanavos P, Yfantopoulos J, Vandoros C, Politis C. The economics of blood: gift of life or a commodity? Int J Technol Assess Health Care. 2006;22:338–343. 18. Kentikelenis A, Karanikolos M, Papanicolas I, et al. Health effects of financial crisis: omens of a Greek tragedy. Lancet. 2011;378:1457–1458. 19. Polyzos N, Karanikas H, Thireos E, et al. Reforming reimbursement of public hospitals in Greece during the economic crisis: implementation of a DRG system. Health Policy. 2013;109:14–22. 20. Hellenic Ministry of Health and Social Solidarity. ESY.net—introduction elements of health care. http://www.yyka.gov.gr/articles/esy net/311-esy-net-eisagwgh-stoixeiwnmonadwn-ygeias. Accessed March 15, 2013. 21. Goodnough LT, Levy JH, Murphy MF. Concepts of blood transfusion in adults. Lancet. 2013;381: 1845–1854.
22. National Blood Authority Australia. Patient blood management guidelines. http://www.nba.gov.au/ guidelines/review.html. Accessed May 15, 2013. 23. British Committee for Standards in Haematology (BCSH). Guideline on the administration of blood components. http://www.bcshguidelin es.com/documents/BCSH_Blood_ Admin_-_addendum_August_2012. pdf. Accessed May 15, 2013. 24. Ferraris VA, Brown JR, Despotis GJ, et al. update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011;91:944–982. 25. Liumbruno G, Bennardello F, Lattanzio A, et al. Recommendations for the transfusion of plasma and platelets. Blood Transfus. 2009;7: 132–150. 26. Zielinski MD, Park MS, Jenkins D. Appropriate evidence-based practice guidelines for plasma transfusion would include a high ratio of plasma to red blood cells based on the available data. Transfusion. 2010;50:2762. author reply 2763– 2764. 27. Roback JD, Caldwell S, Carson J, et al. Evidence-based practice guidelines for plasma transfusion. Transfusion. 2010;50:1227–1239. 28. Fragoulakis V, Kourlaba G, Goumenos D, et al. Economic evaluation of intravenous iron treatments in the management of anemia patients in Greece. Clinicoecon Outcomes Res. 2012;4:127– 134. 29. Bell AM, Kemp JD, Raife TJ. A comparative labor productivity analysis of blood collection centers. Transfusion. 2008;48:258–263.
Address correspondence to: Fragoulakis Vassilis, Department of Health Services and Management, National School of Public Health, Alexandras Av. 196, Athens 11521 Greece. E-mail: [email protected]
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Supplemental Table I. Algorithm used for the determination of blood unit cost collection. Type of Cost/(wages-opportunity costs) Personnel (wages-opportunity cost) No. of employers type_1 Annual gross income_1 ¼ No. of employers type_2 Annual gross income_2 ¼ ……………………… ………………………¼
IO Annual cost (€) for: Electricity Cleaning Security Administration Other supportive services
CONS Roughly estimated approximately at €1 per blood unit based on data on file and expert advice Cost of NAT As given by E.KE.A CC Cost per year ¼ (inventory and maintenance cost)/5 y Roughly estimated. No detailed data provided by the local companies concerning the actual charges to hospitals COL Tests HIV HBV HCV HTLV-I/II Syphilis Rhesus D þABO/D
(m2 (m2 (m2 (m2 (m2
blood_center)/(m2 blood_center)/(m2 blood_center)/(m2 blood_center)/(m2 blood_center)/(m2
hospital) hospital) hospital) hospital) hospital)
Total expenditure_1 (TE1) Total expenditure_2 (TE2) ……………………… TCOP (€) ¼ Sum(TE1 þ TE2 þ …) 1. Personnel ¼ TCOP/[(blood units)*(1-%blood wastage)]
¼ ¼ ¼ ¼ ¼
IO-1 IO-2 IO-3 IO-4 IO-5 2. IO ¼ SUM(IO-1…5)/[(blood units)*(1-%blood wastage)] 3. CONS ¼ [€1*(blood units)]/ [(blood units)*(1-%blood wastage)]
4. NAT
5. CC ¼ cost per year/[(blood units)*(1-%wastage)]
Cost (€) per test %Patients 4.26 100% ¼ 3.49 100% ¼ 4.9 100% ¼ 2.039 100% ¼ 0.298 100% ¼ 4.89 100% ¼
Product €4.25 €3.49 €4.91 €2.04 €0.30 €4.90 (continued)
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1036.e1
Clinical Therapeutics
Supplemental Table I. (continued) C C E E Kell It was assumed that a 12% of tests must be reevaluated Fixed cost (phenotype) Internal quality control Assumed common for all hospitals COBB Blood bag 35 d with ACD Blood bag 42 d (with additive solution) Bag of whole blood with prestorage leukoreduction of packed red blood cells (42 d) Bag of whole blood with prestorage leukoreduction of 3 components (42 d) Assumed common for all hospitals Equipment No. of equipment_ type_1
No. of equipment_ type_2
………………………
Total cost per unit
0.60 100% ¼ 0.50 60% ¼ 0.49 60% ¼ 0.71 60% ¼ 0.42 60% ¼ SUM ¼ Total subcost 1 corrected
€0.60 €0.30 €0.30 €0.43 €0.25 €21.75 21.75 * 1.12 ¼ €24.36
Total cost ¼
€7.08 8.48 COL ¼ €39.92
Price of blood bag % of use €7 74.4% ¼ €8 10.1% ¼
€52 €0.8
€29 8.4% ¼
€2.43
€73 5.1% ¼
€3.7
COBB ¼ €12.30
Total expenditure_1 Average yearly cost (maintenance and inventory) for equipment_ type_1, taking into account the life cycle of the product and a 3.5% discount rate Average yearly cost (maintenance and Total expenditure_2 inventory) for equipment_ type_2, taking into account the life cycle of the product and a 3.5% discount rate ……………………… ……………………… TCOE (€) 1. Equipment ¼ TCOE/[(blood units) * (1-%wastage)] TTPU ¼ personnel þ IO þ CONS þ NAT þ CC þ COL þ COBB þ equipment
ACD = Acid Citrate Dextrose; CC ¼ computerization costs; COBB ¼ cost of blood bags; COL ¼ cost for laboratory test; CONS ¼ consumables; HBV ¼ hepatitis B virus; HCV ¼ hepatitis C virus; HTLV-I/II ¼ human T-lymphotropic virus type I/II; IO ¼ institutional overhead; E.KE.A ¼ Hellenic National Blood Center; NAT ¼ nuclear acid test; TCOE ¼ total cost of equipment; TCOP ¼ total opportunity cost of personnel.
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Supplemental Table II. A simplified form of the questionnaire used in the present analysis. …
Hospital Name m2 (blood center)
Equipment Refrigerator for blood storage 1
No. in Use
(completed by hospitals) ‘’ ‘’
Refrigerator for blood storage 2 Refrigerator for blood storage 3
(completed by hospitals) ‘’ ‘’
‘’
Refrigerator for blood storage 4
‘’
m2 (hospital) Blood unit production in 2012 % of wastage in blood units Cost of NAT per unit Computerization? (yes/ no) Blood center staff
‘’ ‘’
Refrigerator for blood storage 5 Refrigerator for blood storage 6
‘’ ‘’
Number
‘’
Medical staff
‘’
General supervisors
‘’
Directors
‘’
Medical doctor Α’ class Medical doctor Β’ class Doctors in training Health visitors University education Technical education Secondary education Nurses University education
‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’
Technical education
‘’
Secondary education
‘’
Centrifuge for blood components preparation 1 Centrifuge for blood components preparation 2 Centrifuge for blood components preparation 3 Centrifuge for blood components preparation 4 Platelet agitator 1 Platelet agitator 2 Platelet agitator 3 Platelet agitator 4 Plasma extractor 1 Plasma extractor 2 Plasma extractor 3 Plasma extractor 4 Mixer/monitor volume of blood drawn 1 Mixer/monitor volume of blood drawn 2 Mixer/monitor volume of blood drawn 3 Mixer/monitor volume of blood drawn 4 Centrifuge for test tubes 1 Centrifuge for test tubes 2 Centrifuge for test tubes 3 Centrifuge for test tubes 4 Dielectric sealer 1 Dielectric sealer 2 Dielectric sealer 3
Technicians
‘’
University education Technical education Secondary education Auxiliary staff University education Technical education Secondary education
‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’
‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’
NAT ¼ nucleic acid test.
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Clinical Therapeutics
Supplemental Table III. A simplified form of the questionnaire used for the determination of direct costs to donors and indirect costs to society. 1. 2.
4. 3.
5. 6. 7. 8.
9. 10.
1036.e4
My age is….. I am… Employed (except of civil servant) Unemployed Soldier Student Housewife Retired Civil servant Your gross daily/monthly/weekly income? I came here with… My car Transportation Taxi On foot Other Distance? (km) How does it take to come here? (min/hours) How many working hours will you lose due to blood donation? Did you have any private expenses due to blood donation? Parking Tickets Child care costs Soft drinks/food Other not specified Day off with compensation due to blood donation? (if applicable) Did you come here with any relative/friend?
..…...years old □ □ □ □ □ □ □ ____€ □ □ □ □ □ ____km ____min/h ____hours ____€ ____€ ____€ ____€ ____€ ____days Yes □ , No □
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V. Fragoulakis et al.
Supplemental Table IV. Total cost per item for collecting 1 unit of blood in Greece (all hospitals).* ΝΑΤ þ Laboratory Tests þ Blood Bag Personnel Overhead Consumables Computerization þ Equipment 99.18 29.61 29.85 38.46 30.16 36.34 60.99 37.54 69.28 23.56 58.72 19.85 34.38 16.49 37.60 46.33 49.76 28.91 39.12 56.76 46.10 44.29 21.54 29.64 44.80 45.55 32.05 52.41 26.18 48.51 37.59 29.35 28.14 113.11 32.67 132.59 93.98 65.41 30.85 20.99 24.24 31.40 29.36 48.60 64.03 53.88 80.17 23.31 78.20 26.75 87.36 46.38 71.10
8.52 0.93 0.65 1.70 3.69 3.92 2.24 1.93 1.98 1.85 8.28 2.54 1.07 1.56 1.54 2.37 2.29 1.95 1.02 2.33 1.51 6.47 1.40 3.30 2.90 1.55 1.29 3.98 4.38 1.06 1.79 3.16 1.69 5.33 2.14 3.55 5.70 5.51 0.69 0.97 3.56 3.01 3.50 2.07 2.91 1.64 3.08 2.61 6.99 2.75 5.76 1.76 2.03
3.34 1.02 1.04 1.02 1.02 1.02 1.04 1.00 1.02 1.04 1.09 1.08 1.02 1.04 1.06 1.03 1.03 1.01 1.04 1.06 1.04 1.15 1.08 1.06 1.02 1.04 1.03 1.02 1.00 1.06 1.02 1.01 1.02 1.06 1.05 1.11 1.04 1.06 1.03 1.10 1.05 1.06 1.08 1.05 1.02 1.01 1.03 1.03 1.00 1.06 1.10 1.04 1.04
0.80 0.79 0.00 1.07 4.22 0.51 3.14 0.00 2.94 0.62 0.32 0.29 0.00 0.28 0.00 0.00 0.00 1.21 0.00 4.02 0.00 1.24 0.33 0.00 2.10 0.00 0.00 2.02 0.47 0.00 1.09 0.66 0.40 0.00 1.13 3.61 4.72 1.86 0.00 0.38 0.75 1.03 0.47 0.00 2.65 0.00 1.39 0.68 0.00 0.42 0.00 0.00 1.11
89.31 92.22 90.54 92.27 92.25 95.25 92.26 92.24 98.27 89.24 92.90 90.24 90.24 89.23 90.25 94.33 95.25 95.25 90.25 92.38 90.25 93.25 90.23 95.25 92.25 90.25 94.26 94.24 98.27 90.25 90.25 95.24 93.23 92.33 87.23 98.33 92.29 93.26 90.26 93.23 95.24 92.24 90.24 90.26 98.27 94.25 92.26 95.24 89.29 93.23 92.27 90.32 98.28
Total Cost
Athens ¼ 1/Rest of Greece
111.84 32.36 31.54 42.25 39.09 41.78 67.41 40.47 75.22 27.07 68.41 23.75 36.47 19.38 40.21 49.73 53.08 33.07 41.18 64.18 48.65 53.15 24.35 34.00 50.82 48.14 34.37 59.43 32.03 50.64 41.48 34.17 31.25 119.50 36.99 140.86 105.44 73.84 32.57 23.45 29.61 36.50 34.40 51.72 70.61 56.53 85.68 27.64 86.19 30.98 94.22 49.18 75.28
1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0
Oncology University Hospital Hospital ¼1 ¼1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0
NAT ¼ nucleic acid test. More data can be provided upon request.
*
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1036.e5
The Cost of Blood Collection in Greece: An Economic Analysis Vassilis Fragoulakis1; Kostas Stamoulis2; Elisabeth Grouzi3; and Nikolaos Maniadakis1 1
National School of Public Health, Athens, Greece; 2National Blood Centre (EKEA), Athens, Greece; and 3Transfusion Service of “Agios Savvas” Regional Cancer Hospital, Athens, Greece
ABSTRACT Objective: The goal of this study was to estimate the cost of production of 1 unit of blood from a National Health Service perspective in Greece. Methods: In agreement with guidelines, the cost of blood production in this study accounted only for the resources expended for collection, processing, laboratory testing, and storage. Hence, the costs associated with donor recruitment, pretransfusion preparation, transfusion administration, follow-up management of adverse events, and other long-term relevant costs were not taken into consideration. The indirect cost of blood donations for donors (productivity loss) was also considered. A questionnaire was used to collect data regarding personnel time, annual blood quantities collected, percentage of wastage, utilization of consumables, institutional overhead, information technology expenditure, medical equipment utilized, nuclear acid tests, and other factors. Data gathered by 53 hospitals across the country were assessed. A model was constructed with economic data collected by the National School of Public Health and the Ministry of Health. All data refer to the year 2013. Results: The weighted mean direct cost of producing 1 unit of blood was estimated at €131.49 (SD, €22.12; minimum/maximum, €94.96–€239.20). The mean total indirect cost was estimated at €34 per unit of blood. The cost distribution was positively skewed (skewness, 1.642 [0.327]). The major cost component was the cost of personnel, accounting for 32.5% of total costs, and the average of blood unit wastage was estimated at 4.90%. There were no differences between the cost of producing 1 unit of blood in Athens compared with the rest of the country (Mann-Whitney test, P ¼ 0.341). Conclusions: This study suggests that the cost of producing 1 unit of blood is not insignificant. These figures need to be complemented with those concerning the cost of transfusion to have a complete picture of producing and using 1 unit of blood locally. (Clin Ther. 2014;36:1028– 1036) & 2014 Elsevier HS Journals, Inc. All rights reserved. Key words: blood, blood unit, cost of blood.
INTRODUCTION Blood and its components are vital health care commodities that are becoming increasingly scarce.1 The need for blood and blood products is rising in all parts of the world. In high- and middle-income countries, with advancements in health care systems and improved health coverage, this need is increasingly being driven by sophisticated medical and surgical procedures.2 Because the blood donor pools are shrinking (owing to population aging and restrictions on blood donor eligibility), the cost of an additional unit donated is considerably high around the world. In Greece, the blood donation system is decentralized and hospital based; it consists of 103 hospital transfusion services under the supervision of the Ministry of Health. Each transfusion service is an integrated part of a public hospital and has the responsibility for recruiting blood donors, collecting and testing blood, and processing that blood into its product supply so that it can be provided to the hospital clinics.3 To design and organize a centralized system in accordance with the European Commission directive 2002/98/EC, a new law came into effect in 2005 regarding the organization of blood transfusion services. This law designated the Hellenic National Blood Center (E.KE. A) as the competent authority for the organization, management, and control of the national blood transfusion system. E.KE.A is a public entity of the Ministry of Health and Social Solidarity. In 2012, a total of 608,000 units of whole blood were collected from all over the country. Greece has a blood donor index of 6 blood donors per 100 citizens and ranks second among European Union member states in the number of people who have donated blood at least once in the past (Eurobarometer 2003); in addition, although Greece is first in the proportion Accepted for publication May 5, 2014. http://dx.doi.org/10.1016/j.clinthera.2014.05.003 0149-2918/$ - see front matter & 2014 Elsevier HS Journals, Inc. All rights reserved.
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V. Fragoulakis et al. of voluntary donors who have at least considered giving blood (Eurobarometer 2005), the country (with a population of 11,000,000)4 often finds the number of annual blood donations insufficient to cover the high national transfusion needs. From an economic point of view, the system is totally funded by the state budget and the value to users is free of charge, but the necessity to control costs and restrain expenditures has been acknowledged in the literature.5 In the presence of scarce resources, several economic analyses have been conducted worldwide to estimate the cost of blood transfusions, using different analytical aims, perspectives, and methods.6–14 All these analyses are very useful; nonetheless, their main methodologic concerns involve the fact that the transfusion-related costs captured with varying degrees of rigor and the determination of transfusion-related adverse events, which are the costliest contributors to health care expenditures, are not accurately estimated.15 To devise a comprehensive and standardized method that will improve on existing estimates, several economic models have been developed, modified, or updated.8,15,16 In the main “consensus” economic model (which is the most prominent for the estimation of blood cost), a process flow model that describes all the major steps involved in collecting, processing, and transfusing blood (eg, donor recruitment, follow-up of transfusion sequelae) should be constructed. This model is broad based and should serve societal, provider, and payer perspectives for future cost studies. Detailed analysis of this model can be found elsewhere.15,16 Because the cost of blood is likely to be underappreciated by using a cost analysis, the present model for the case of Greece was based solely on the widely accepted standard method mentioned earlier, whereas the majority of cost elements were based on real local data. Simply stated, we attempted to use all the recommended steps for the cost calculation, while substituting simplified assumptions with local data; in the absence of available data, we excluded costs (which are clearly stated in the article). Detailed analysis of our model is described in the Materials and Methods section. In terms of previous estimates of blood costs in Greece, a sole economic analysis by Kanavos et al17 was conducted to calculate the costs associated with the collection, testing, storage, distribution, delivery, and transfusion of blood. This model was based on several assumptions, however; direct costs and some indirect costs were included, while intangible costs
July 2014
were excluded as nonquantifiable with an acceptable degree of accuracy. Data used came from only 3 Greek hospitals (2 public and 1 private). The cost of a blood transfusion unit was estimated at €294.83 and €339.83, respectively, for the 2 public hospitals and €413.93 for the private hospital. Because Greece has been affected more by the financial turmoil beginning in 2007 than any other European country and is still subjected to enormous scrutiny of resources, the main economic indicators and the entire economic environment have been reversed.18 Thus, it is paramount to deliver health care services at a reduced cost without compromising safety issues and maximizing health benefits for patients. Moreover, it is crucial to reestimate accurately, and in the present environment, the cost of producing 1 unit of whole blood. It must be noted that in the case of “blood markets,” there is no typical market price (at least not reflecting a currency-based transaction). Therefore, the estimated costs of blood reflect the resources required to make 1 unit of blood available for use. Hence, in the present analysis, the “cost” being estimated is the value of resources necessary to supply or make available 1 unit of blood, and this cost is paid by the health system, donor, and by the public sector in general. The present article describes the findings of a project with the participation of E.KE.A, which attempted to determine the cost of blood unit production across the majority of public hospitals in the country. The aim of the present study was to estimate the cost of production of 1 unit of blood from a National Health Service perspective in Greece.
MATERIALS AND METHODS Analysis and Data Collection In accordance with guidelines, we used a 9-step process flow model (Figure 1), which captures both direct and indirect cost elements concerning the cost of blood transfusion.16 The left panel of the diagram reflects the cost elements associated with a blood collection facility and the right panel reflects the transfusion service. In the present analysis, we have captured only the cost of “blood collection (2),” the cost of “blood processing (3a),” the cost of “laboratory testing (3b),” the cost of “blood destruction (4),” and the cost of “blood collection center inventory and storage (5),” excluding the cost of transporting in the processing area due to lack of detailed data. In Greece, there are no separate blood bank centers that operate as a
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Clinical Therapeutics
Blood center/collection facility
Transfusion service
1. Donor recruitment and qualification 9. Long-term outcomes tracking
2. Blood collection 3a. Blood processing
8. Transfusion administration and follow-up
3b. Laboratory testing
No
3c. Blood passes all screening tests and is labeled for release
4. Blood destruction, donor notification, and tracking
Yes
5. Blood collection center inventory, storage, and transport
Societal costs (steps 1-4): Donor opportunity Productivity losses/labor Blood center volunteers
7. Pretransfusion preparation
6. Transfusion service inventory and storage
Societal costs (steps 7-9): Tracsfusion recipient opportunity Productivity losses/labor Transfusion service volunteers
Figure 1. Blood collection and transfusion flowchart.16
supplier for local hospitals, and thus, there are no costs such as “transfusion service storage and inventory.”6 However, there are some transport operations between hospitals, but because of a lack of robust data, this cost was not taken into consideration. Due to the question at hand, the cost associated with “pretransfusion preparation (7),” “transfusion administration and follow-up (8),” and “other long-term relevant costs (9)” were also not included in the present analysis. In addition, owing to the severe restraints in health budgets, the cost of “donor recruitment and qualification (1)” incurred by the Ministry of Health was extremely low, and it has been excluded without any loss in accuracy of presented results. The algorithm used to estimate the direct cost of blood collection is presented in detail in Supplemental Table I (see the online version at http://dx.doi.org/10. 1016/j.clinthera.2014.05.003). Data concerning reagent costs, the type of equipment used by hospitals, the percentage of wastage of blood units, yearly blood
1030
production, the cost of nucleic acid test per unit, and other tests were collected by using a structured Excelbased questionnaire and fulfilled with the data stored in the database of E.KE.A (see Supplemental Table II in the online version at http://dx.doi.org/10.1016/j. clinthera.2014.05.003). Appropriate data were gathered by 53 hospitals (related to 373,310 units of bloods) in the country. Data entry in a separate Excelbased platform was performed between February and March 2013 by 2 full-time employees of Ε.ΚΕ.Α under the supervision of their scientific director (K.S.). Data concerning the gross monthly salaries came from a survey conducted with the staff of “Agios Savvas” Regional Cancer Hospital of Athens. In the absence of detailed records, sociodemographic characteristics (eg, age, sex, educational level, gross income) of this sample were reasonably considered representative of the profile of the rest of the employees in blood centers across the country. It must be noted that the Greek Ministry of Health lacked the appropriate infrastructure for collecting
Volume 36 Number 7
V. Fragoulakis et al. complete data from hospitals, which is a common issue in “small” countries such as Greece.19 Despite the fact that the Ministry of Health successfully developed and implemented an operational webbased facility20 to overcome the aforementioned limitation, some necessary datasets are still missing. In this light, some input parameters in the present model were based on simplified assumptions in accordance with advice from local experts (K.S. and E.G.). For instance, the cost of laboratory tests per unit of blood, the computerization cost (inventory and maintenance) of blood establishments, the price of different types of equipment, the remaining life cycle (measured in years) for medical equipment, and the price of blood collection bags and the various types used were roughly estimated (on average) and were assumed identical across all the country’s hospitals (details are given in Table I). The institutional overhead costs, which are related to electricity, cleaning, security, administration, and all other supportive services allocated to blood establishments, were gathered from the Ministry of Health and refer to 2011. As a standard approach for this type of study, the weighted parameter for institutional overhead costs was considered the m2. To investigate cost differences among the different types of hospitals, we used the Mann-Whitney test. This test is a nonparametric test of the null hypothesis that 2 populations are the same against an alternative hypothesis, especially that a particular population tends to have larger values than the other. This test is used mainly on nonnormal distributions, which is the case here. The indirect cost of blood donor’s productivity loss was estimated separately based on data gathered from 2 public hospitals in Greece. In particular, a structure questionnaire was distributed to a sample of 172 blood donors in “KAT Hospital” and “Agios Savvas” Regional Cancer Hospital in Athens. The goal of the questionnaire was to capture all indirect costs, including: (1) the time spent by the donor and/or his/her relatives for donating blood during working hours (opportunity cost); (2) transportation costs; (3) day off work (opportunity cost); and (4) other relevant expenses. The necessary data were collected by using face-to-face interviews (of 10 minutes’ duration each) by the medical and nursing staff of every blood donation establishment. All participants were informed regarding the scope of this interview, while researchers did not interfere or guide the answers throughout the
July 2014
process. The questionnaires were clear, well understood, and answered in a completely anonymous mode. A simplified form of this questionnaire can be found at Supplemental Table III in the online version at http:// dx.doi.org/10.1016/j.clinthera.2014.05.003. To provide adequate protection against improper conclusions, all analyses presented here report only aggregated information or specific data from separate hospitals in an anonymous mode. All statistical calculations were performed by using Microsoft Excel 2007 (Microsoft Corporation, Redmond, Washington).
RESULTS Forty-four hospitals from the region of Athens and 9 hospitals from the rest of the country were included in the present analysis. The sample also included 7 university hospitals and 3 oncology hospitals. Based on the total units of blood collected, the present sample incorporates 61.5% of the whole blood collection in Greece for 2012. The detailed results of our model concerning the cost of collecting 1 unit of blood are presented in Table II and Figure 2. In particular, the weighted mean direct cost of producing 1 unit of blood was estimated at €131.49 (SD, €22.12; minimum/maximum, €94.96–€239.20). The unweighted mean direct cost was slightly higher and was estimated at €144.37 (27.16) for the entire sample. The major cost component was the cost of personnel, accounting for 32.46% of the total expenses, followed by the nuclear acid testing and the cost of laboratory tests, which represent 27.97% and 27.65% of total costs, respectively. The unweighted cost of producing 1 unit of blood in a university hospital was €133.36 (SD, €18.43; minimum/maximum, €113.99–€161.31); it was estimated at €169.05 (SD, €31.16; minimum/ maximum, €138.91–€201.15) for oncology hospitals. There were no differences between the cost of producing 1 unit of blood in Athens compared with the rest of the country (Mann-Whitney test, P ¼ 0.341). The cost distribution across all the hospitals included in the sample was positively skewed (skewness, 1.642 [0.327]), a finding that is common in similar analyses due to a low percentage of hospitals incurring relatively high costs to produce 1 unit of blood. The average of blood unit wastage was estimated at 4.90% or 18,292 blood units for the entire sample. There was a weak positive correlation between the blood wastage and the total blood units gathered by each center (ρ ¼ 0.290) (Figure 3). The cost data for
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Clinical Therapeutics
Table I. Main input parameters used in the model. Cost per Unit Laboratory tests* HIV HBV HCV HTLV-I/II Syphilis ABO Rhesus D C c E e Kell
Staff General supervisor Directors Medical Doctor Α’ Class Medical Doctor Β’ Class Doctors in training Health Visitors University education Technical education Secondary education
Type of blood bags Blood bag 35 days with ACD Blood bag 42 days (with additive solution) Bag of whole blood with prestorage leukoreduction of packed red blood cells (42 days) Bag of whole blood with prestorage leukoreduction of 3 components (42 days)
Type of equipment Centrifuge for blood components preparation Refrigerator for blood storage (1–6 oC) Plasma freezer Platelet agitator Plasma extractor Mixer/monitor volume of blood drawn Centrifuge for test tubes Dielectric sealer Consumables The determination of consumables was roughly estimated by experts
4.25 3.49 4.91 2.04 0.3 4.9 0.6 0.5 0.49 0.71 0.42 Gross Income per Month, € (WagesOpportunity Cost)
% of People Subjected to Blood Testing
100 100 100 100 100 100 100 60 60 60 60 Technicians
Wages
1900 € 1700 € 1400 €
Cost per Bag (€)
University education Technical education Secondary education Others University education Technical education Secondary education Nurses University education Technical education Secondary education % of Use Per Hospital
7 8 29
76.35 10.14 8.45
73
5.07
Cost (€)
Life Cycle (y)
61,500 18,450 10,000 6150 615 350 10,000 400
10 10 10 10 10 10 10 10
3200 3100 2600 2100 1900 1900 1700 1400
1900 € 1700 € 1400 € 1900 € 1700 € 1400 €
HBV ¼ hepatitis B virus; HCV ¼ hepatitis C virus; HTLV-I/II ¼ human T-lymphotropic virus type I/II; C = C antigens; c = c antigens; E = E antigens; e = e antigens; Kell = Kell antigens. * More data can be provided upon request.
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V. Fragoulakis et al.
Table II. Total cost per item for collecting 1 unit of blood in Greece. Description Unweighted cost Personnel Overheads Consumables Computerization Blood bag Cost of laboratory tests Nuclear acid tests Equipment Total direct cost Indirect costs Total cost Weighted cost Personnel Overheads Consumables Computerization Blood bag Cost of laboratory test Nuclear acid tests Equipment Total direct cost Indirect cost Total cost
Mean (€)
SD (€)
46.86 2.88 1.09 0.92 12.30 39.92 40.38 0.04 144.37 34.00 178.37
24.86 1.86 0.32 1.22 NA NA 2.68 0.03 27.16 49.23 NA
35.23 2.54 1.07 0.62 12.30 39.92 39.78 0.02 131.49 34.00 165.49
20.14 1.63 0.20 0.73 n/a n/a 2.55 0.02 22.12 49.23 NA
NA ¼ not applicable.
each of the participating hospitals are presented in Supplemental Table IV (see the online version at http://dx.doi.org/10.1016/j.clinthera.2014.05.003). For the determination of indirect costs, we collected data from 172 participants who had a mean age of 37.6 (10) years; 78% of the participants were employees, 9.3% were unemployed, and 6% were students. The mean total indirect cost was estimated at €34 per unit and is distributed as follows: cost of transportation/expenses accounts, €2.15 (3.5); productivity loss, €9.27 (11.37); the opportunity cost of “days off with compensation,” €20.26 (45.67); and the productivity loss of relatives/families, €2.33 (7.35). The productivity loss in terms of actual hours absent from work was estimated at 1.97 hours. It is noteworthy that 19.19% of participants were civil servants and
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took 2.36 days off from work, on average, with compensation; 10% of the civil servants voluntarily did not use the right of a day off for the blood donation and returned normally in their jobs.
DISCUSSION The present study was designed to estimate the cost of a blood unit production across public hospitals in Greece. The present analysis was conducted in accordance with the “blood consensus model” mentioned above, which is broad-based and should serve as a gold standard approach for this type of cost studies. We must emphasize that not all type of costs connected with transfusion services were taken into consideration, and thus this cost might be considerably higher compared with the estimation presented here for the cost of collecting 1 unit of whole blood. As mentioned in the Introduction, the cost of blood transfusion varies among health care systems. Nonetheless, it has been acknowledged that the use of blood is characterized by inherent risks, high costs, and inventory constraints.21 It must also be noted that the cost of a blood transfusion unit estimated in other countries might be irrelevant for the case of Greece, because the management of donors, the relative prices, and the perspective of analysis differ between countries or economic models. However, given the risks of this procedure, several clinical guidelines reflect the increasing interest of appropriate blood utilization by professional societies.22–27 In the current context of politico-economic crisis, Greece’s coalition government agreed to a reform program with the “troika,” with the goal of reducing total public health care expenditures in the country (The troika is a term referred to three international organizations: the European Commission (EC), the International Monetary Fund (IMF), and the European Central Bank (ECB).).28 Hence, the determination of relative strengths and weaknesses of the management system of Greek blood establishments is crucial to cope with increased regulatory and operational complexities, and to optimize efficiency and minimize health care costs. To the best to our knowledge, this is the first study conducted in Greece that determined the cost of blood based on a large dataset afforded by the official management of E.KE.A. Our goal, with the method used, was to determine the cost of blood collection more thoroughly compared with previous attempts and in that sense, several cost components were estimated with an
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Clinical Therapeutics
0.03%
27.97%
32.46%
1.99% 27.65%
8.52%
0.75% 0.64%
Personnel
Overhead
Consumables
Computerization
Blood bag
Cost of laboratory tests
Nuclear acid tests
Equipment
Figure 2. Distribution of total direct costs of blood collection per item.
acceptable level of accuracy. Other cost components related to the transfusion process, which cannot be captured relatively accurately at this moment, were excluded and must be analyzed in the future by other researchers. It should be noted that in analyses similar to those discussed here, the “cost” of blood incorporates those expenses associated with materials (eg, blood
bags) and “opportunity cost,” which measures costs based on the wages for nurses and medical staff. According to the results of our analysis, there are considerable variations in the cost of blood production among the Greek hospitals. The primary reason for these variations is related to the differences in labor productivity among hospitals. In technical terms, labor
30,000
Blood Unit Production
25,000 20,000 15,000 10,000 5000 0
0
1
2
3
4 5 6 7 8 Percentage of Blood Wastage
9
10
11
Figure 3. Blood production and percentage of blood wastage across the sample of hospitals.
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V. Fragoulakis et al. productivity is defined as the number of blood products collected per employee per unit of time; the main factors that influence labor productivity are the training and skill level of collection staff, workflow variables (eg, space, travel, equipment), and the error rates in the blood collection process.29 For instance, the ratio of blood unit per employee per year in the present sample was estimated at 331 units (SD, 185 units; minimum/ maximum, 90/1230) with a %CV of 56%. This finding probably indicates the differences in slack time across the blood establishment staff in Greece (“slack” is a term which indicates that worker are not busy and show little activity in their job), due to the multitask responsibilities of all working staff in the field of transfusions, which is a consequence of limited qualified personnel. In addition, it is one of the main reasons that the blood transfusion system in Greece is an extremely decentralized, hospital-based organization involving different types of hospitals, patients, and staffs. To overcome the difficulties caused by limited resources, the strategic plan of the E.KE.A is based on the efficient provision of a safe and sustainable supply of blood, blood components, and services that meet all safety, quality, and compliance standards. Its primary focus is to modernize each stage of the blood supply chain: from the collection of blood (focusing on the donor’s experience of giving blood) to the processing and testing of blood in a centralized environment and its issue and delivery to hospitals. In addition, a primary goal is the establishment of E. KE.A as an effective, responsive organization focused on the changing needs of donors and hospitals. From a technical point of view, any economic analysis is, by necessity, a simplification of the process it tries to emulate, and it was necessary to make assumptions when constructing the present model. For instance, a common issue in studies that use similar methods lies in the fact that the estimation of blood cost is based only on red blood cells production, without taking into consideration other blood products (eg, fresh frozen plasma, platelets). In addition, several cost elements were considered invariant due to lack of detailed records from the hospitals. Hence, the main parameters that determined the variation in cost among hospitals were the number of staffs employed in blood centers, the number of blood units produced, and the percentage of wastage of blood units. Third, it was assumed that collected blood was subjected to uniform testing, despite the fact that there are differences in the type of testing used across the
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country. In addition, the cost of blood collected from mobile collection units was not included in the analysis. A further limitation of our study is that the recruitment costs for donors were not considered here because of lack of data. Because the cost of acquiring a marginal donor might be increasing due to demographic reasons, it must be noted that the current marginal cost estimates would increase (with scale) with respect to donor recruitment in the future. Finally, we must also note that the functional costs of E.KE.A or other governmental services that are related to blood production/distribution in Greece were not taken into account due to a lack of detailed available data in a form that could be useful for the present model.
CONCLUSIONS The findings of this study represent an update of previous estimates, as well as an improvement in methods used for the determination of the cost collection of blood in Greece. It must be stressed that the cost of producing a unit of blood is not insignificant. These figures need to be complemented with those concerning the cost of transfusion to have a complete picture of producing and using 1 unit of blood locally.
ACKNOWLEDGMENTS The study was funded by Genesis Pharma Hellas. The study sponsor had no involvement in the study design, data collection, or writing of the manuscript. Drs. Fragoulakis and Maniadakis have received unrestricted grants by Genesis in the past. The authors have indicated that they have no other conflicts of interest regarding the content of this article. Dr. Fragoulakis conducted the analyses, interpreted the results, and wrote the manuscript. Dr. Stamoulis supervised the data collection and contributed to the results interpretation. Dr. Grouzi supervised the data collection and contributed to the paper writing and results interpretation. Dr. Maniadakis supervised the study and is the guarantor for the overall content.
CONFLICTS OF INTEREST The study sponsor had no involvement in the study design, data collection, or writing of the manuscript.
SUPPLEMENTAL MATERIAL Supplemental tables accompanying this article can be found in the online version at doi:10.1016/j.clinthera. 2014.05.003.
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REFERENCES 1. Williamson LM, Devine DV. Challenges in the management of the blood supply. Lancet. 2013;381: 1866–1875. 2. World Health Organization. More voluntary blood donations essential.http://www.who.int/media centre/news/releases/2012/blood_ donation_20120614/en/. Accessed May 15, 2013. 3. Marantidou O, Loukopoulou L, Zervou E, et al. Factors that motivate and hinder blood donation in Greece. Transfus Med. 2007;17:443–450. 4. Hellenic Statistical Authority (EL. STAT.). Latest statistical data. http://www.statistics.gr/portal/page/ portal/ESYE. Accessed May 15, 2013. 5. Kyriopoulos JE, Michail-Merianou V, Gitona M. Blood transfusion economics in Greece. Transfus Clin Biol. 1995;2:387–394. 6. Forbes JM, Anderson MD, Anderson GF, et al. Blood transfusion costs: a multicenter study. Transfusion. 1991;31:318–323. 7. Mohandas K, Aledort L. Transfusion requirements, risks, and costs for patients with malignancy. Transfusion. 1995;35:427–430. 8. Cantor SB, Hudson DV Jr, Lichtiger B, Rubenstein EB. Costs of blood transfusion: a process-flow analysis. J Clin Oncol. 1998;16:2364–2370. 9. Cremieux PY, Barrett B, Anderson K, Slavin MB. Cost of outpatient blood transfusion in cancer patients. J Clin Oncol. 2000;18:2755– 2761. 10. Agrawal S, Davidson N, Walker M, et al. Assessing the total costs of blood delivery to hospital oncology and haematology patients. Curr Med Res Opin. 2006;22:1903–1909. 11. Glenngard AH, Persson U, Soderman C. Costs associated with blood transfusions in Sweden—the societal cost of autologous, allogeneic and perioperative RBC transfusion. Transfus Med. 2005;15: 295–306.
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12. Varney SJ, Guest JF. The annual cost of blood transfusions in the UK. Transfus Med. 2003;13:205–218. 13. Shander A, Hofmann A, Ozawa S, et al. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion. 2010;50: 753–765. 14. Abraham I, Sun D. The cost of blood transfusion in Western Europe as estimated from six studies. Transfusion. 2012;52:1983–1988. 15. Shander A, Hofmann A, Gombotz H, et al. Estimating the cost of blood: past, present, and future directions. Best Pract Res Clin Anaesthesiol. 2007;21:271–289. 16. The cost of blood: multidisciplinary consensus conference for a standard methodology. Transfus Med Rev. 2005;19:66–78. 17. Kanavos P, Yfantopoulos J, Vandoros C, Politis C. The economics of blood: gift of life or a commodity? Int J Technol Assess Health Care. 2006;22:338–343. 18. Kentikelenis A, Karanikolos M, Papanicolas I, et al. Health effects of financial crisis: omens of a Greek tragedy. Lancet. 2011;378:1457–1458. 19. Polyzos N, Karanikas H, Thireos E, et al. Reforming reimbursement of public hospitals in Greece during the economic crisis: implementation of a DRG system. Health Policy. 2013;109:14–22. 20. Hellenic Ministry of Health and Social Solidarity. ESY.net—introduction elements of health care. http://www.yyka.gov.gr/articles/esy net/311-esy-net-eisagwgh-stoixeiwnmonadwn-ygeias. Accessed March 15, 2013. 21. Goodnough LT, Levy JH, Murphy MF. Concepts of blood transfusion in adults. Lancet. 2013;381: 1845–1854.
22. National Blood Authority Australia. Patient blood management guidelines. http://www.nba.gov.au/ guidelines/review.html. Accessed May 15, 2013. 23. British Committee for Standards in Haematology (BCSH). Guideline on the administration of blood components. http://www.bcshguidelin es.com/documents/BCSH_Blood_ Admin_-_addendum_August_2012. pdf. Accessed May 15, 2013. 24. Ferraris VA, Brown JR, Despotis GJ, et al. update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011;91:944–982. 25. Liumbruno G, Bennardello F, Lattanzio A, et al. Recommendations for the transfusion of plasma and platelets. Blood Transfus. 2009;7: 132–150. 26. Zielinski MD, Park MS, Jenkins D. Appropriate evidence-based practice guidelines for plasma transfusion would include a high ratio of plasma to red blood cells based on the available data. Transfusion. 2010;50:2762. author reply 2763– 2764. 27. Roback JD, Caldwell S, Carson J, et al. Evidence-based practice guidelines for plasma transfusion. Transfusion. 2010;50:1227–1239. 28. Fragoulakis V, Kourlaba G, Goumenos D, et al. Economic evaluation of intravenous iron treatments in the management of anemia patients in Greece. Clinicoecon Outcomes Res. 2012;4:127– 134. 29. Bell AM, Kemp JD, Raife TJ. A comparative labor productivity analysis of blood collection centers. Transfusion. 2008;48:258–263.
Address correspondence to: Fragoulakis Vassilis, Department of Health Services and Management, National School of Public Health, Alexandras Av. 196, Athens 11521 Greece. E-mail: [email protected]
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Supplemental Table I. Algorithm used for the determination of blood unit cost collection. Type of Cost/(wages-opportunity costs) Personnel (wages-opportunity cost) No. of employers type_1 Annual gross income_1 ¼ No. of employers type_2 Annual gross income_2 ¼ ……………………… ………………………¼
IO Annual cost (€) for: Electricity Cleaning Security Administration Other supportive services
CONS Roughly estimated approximately at €1 per blood unit based on data on file and expert advice Cost of NAT As given by E.KE.A CC Cost per year ¼ (inventory and maintenance cost)/5 y Roughly estimated. No detailed data provided by the local companies concerning the actual charges to hospitals COL Tests HIV HBV HCV HTLV-I/II Syphilis Rhesus D þABO/D
(m2 (m2 (m2 (m2 (m2
blood_center)/(m2 blood_center)/(m2 blood_center)/(m2 blood_center)/(m2 blood_center)/(m2
hospital) hospital) hospital) hospital) hospital)
Total expenditure_1 (TE1) Total expenditure_2 (TE2) ……………………… TCOP (€) ¼ Sum(TE1 þ TE2 þ …) 1. Personnel ¼ TCOP/[(blood units)*(1-%blood wastage)]
¼ ¼ ¼ ¼ ¼
IO-1 IO-2 IO-3 IO-4 IO-5 2. IO ¼ SUM(IO-1…5)/[(blood units)*(1-%blood wastage)] 3. CONS ¼ [€1*(blood units)]/ [(blood units)*(1-%blood wastage)]
4. NAT
5. CC ¼ cost per year/[(blood units)*(1-%wastage)]
Cost (€) per test %Patients 4.26 100% ¼ 3.49 100% ¼ 4.9 100% ¼ 2.039 100% ¼ 0.298 100% ¼ 4.89 100% ¼
Product €4.25 €3.49 €4.91 €2.04 €0.30 €4.90 (continued)
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Supplemental Table I. (continued) C C E E Kell It was assumed that a 12% of tests must be reevaluated Fixed cost (phenotype) Internal quality control Assumed common for all hospitals COBB Blood bag 35 d with ACD Blood bag 42 d (with additive solution) Bag of whole blood with prestorage leukoreduction of packed red blood cells (42 d) Bag of whole blood with prestorage leukoreduction of 3 components (42 d) Assumed common for all hospitals Equipment No. of equipment_ type_1
No. of equipment_ type_2
………………………
Total cost per unit
0.60 100% ¼ 0.50 60% ¼ 0.49 60% ¼ 0.71 60% ¼ 0.42 60% ¼ SUM ¼ Total subcost 1 corrected
€0.60 €0.30 €0.30 €0.43 €0.25 €21.75 21.75 * 1.12 ¼ €24.36
Total cost ¼
€7.08 8.48 COL ¼ €39.92
Price of blood bag % of use €7 74.4% ¼ €8 10.1% ¼
€52 €0.8
€29 8.4% ¼
€2.43
€73 5.1% ¼
€3.7
COBB ¼ €12.30
Total expenditure_1 Average yearly cost (maintenance and inventory) for equipment_ type_1, taking into account the life cycle of the product and a 3.5% discount rate Average yearly cost (maintenance and Total expenditure_2 inventory) for equipment_ type_2, taking into account the life cycle of the product and a 3.5% discount rate ……………………… ……………………… TCOE (€) 1. Equipment ¼ TCOE/[(blood units) * (1-%wastage)] TTPU ¼ personnel þ IO þ CONS þ NAT þ CC þ COL þ COBB þ equipment
ACD = Acid Citrate Dextrose; CC ¼ computerization costs; COBB ¼ cost of blood bags; COL ¼ cost for laboratory test; CONS ¼ consumables; HBV ¼ hepatitis B virus; HCV ¼ hepatitis C virus; HTLV-I/II ¼ human T-lymphotropic virus type I/II; IO ¼ institutional overhead; E.KE.A ¼ Hellenic National Blood Center; NAT ¼ nuclear acid test; TCOE ¼ total cost of equipment; TCOP ¼ total opportunity cost of personnel.
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Supplemental Table II. A simplified form of the questionnaire used in the present analysis. …
Hospital Name m2 (blood center)
Equipment Refrigerator for blood storage 1
No. in Use
(completed by hospitals) ‘’ ‘’
Refrigerator for blood storage 2 Refrigerator for blood storage 3
(completed by hospitals) ‘’ ‘’
‘’
Refrigerator for blood storage 4
‘’
m2 (hospital) Blood unit production in 2012 % of wastage in blood units Cost of NAT per unit Computerization? (yes/ no) Blood center staff
‘’ ‘’
Refrigerator for blood storage 5 Refrigerator for blood storage 6
‘’ ‘’
Number
‘’
Medical staff
‘’
General supervisors
‘’
Directors
‘’
Medical doctor Α’ class Medical doctor Β’ class Doctors in training Health visitors University education Technical education Secondary education Nurses University education
‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’
Technical education
‘’
Secondary education
‘’
Centrifuge for blood components preparation 1 Centrifuge for blood components preparation 2 Centrifuge for blood components preparation 3 Centrifuge for blood components preparation 4 Platelet agitator 1 Platelet agitator 2 Platelet agitator 3 Platelet agitator 4 Plasma extractor 1 Plasma extractor 2 Plasma extractor 3 Plasma extractor 4 Mixer/monitor volume of blood drawn 1 Mixer/monitor volume of blood drawn 2 Mixer/monitor volume of blood drawn 3 Mixer/monitor volume of blood drawn 4 Centrifuge for test tubes 1 Centrifuge for test tubes 2 Centrifuge for test tubes 3 Centrifuge for test tubes 4 Dielectric sealer 1 Dielectric sealer 2 Dielectric sealer 3
Technicians
‘’
University education Technical education Secondary education Auxiliary staff University education Technical education Secondary education
‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’
‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’ ‘’
NAT ¼ nucleic acid test.
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Supplemental Table III. A simplified form of the questionnaire used for the determination of direct costs to donors and indirect costs to society. 1. 2.
4. 3.
5. 6. 7. 8.
9. 10.
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My age is….. I am… Employed (except of civil servant) Unemployed Soldier Student Housewife Retired Civil servant Your gross daily/monthly/weekly income? I came here with… My car Transportation Taxi On foot Other Distance? (km) How does it take to come here? (min/hours) How many working hours will you lose due to blood donation? Did you have any private expenses due to blood donation? Parking Tickets Child care costs Soft drinks/food Other not specified Day off with compensation due to blood donation? (if applicable) Did you come here with any relative/friend?
..…...years old □ □ □ □ □ □ □ ____€ □ □ □ □ □ ____km ____min/h ____hours ____€ ____€ ____€ ____€ ____€ ____days Yes □ , No □
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Supplemental Table IV. Total cost per item for collecting 1 unit of blood in Greece (all hospitals).* ΝΑΤ þ Laboratory Tests þ Blood Bag Personnel Overhead Consumables Computerization þ Equipment 99.18 29.61 29.85 38.46 30.16 36.34 60.99 37.54 69.28 23.56 58.72 19.85 34.38 16.49 37.60 46.33 49.76 28.91 39.12 56.76 46.10 44.29 21.54 29.64 44.80 45.55 32.05 52.41 26.18 48.51 37.59 29.35 28.14 113.11 32.67 132.59 93.98 65.41 30.85 20.99 24.24 31.40 29.36 48.60 64.03 53.88 80.17 23.31 78.20 26.75 87.36 46.38 71.10
8.52 0.93 0.65 1.70 3.69 3.92 2.24 1.93 1.98 1.85 8.28 2.54 1.07 1.56 1.54 2.37 2.29 1.95 1.02 2.33 1.51 6.47 1.40 3.30 2.90 1.55 1.29 3.98 4.38 1.06 1.79 3.16 1.69 5.33 2.14 3.55 5.70 5.51 0.69 0.97 3.56 3.01 3.50 2.07 2.91 1.64 3.08 2.61 6.99 2.75 5.76 1.76 2.03
3.34 1.02 1.04 1.02 1.02 1.02 1.04 1.00 1.02 1.04 1.09 1.08 1.02 1.04 1.06 1.03 1.03 1.01 1.04 1.06 1.04 1.15 1.08 1.06 1.02 1.04 1.03 1.02 1.00 1.06 1.02 1.01 1.02 1.06 1.05 1.11 1.04 1.06 1.03 1.10 1.05 1.06 1.08 1.05 1.02 1.01 1.03 1.03 1.00 1.06 1.10 1.04 1.04
0.80 0.79 0.00 1.07 4.22 0.51 3.14 0.00 2.94 0.62 0.32 0.29 0.00 0.28 0.00 0.00 0.00 1.21 0.00 4.02 0.00 1.24 0.33 0.00 2.10 0.00 0.00 2.02 0.47 0.00 1.09 0.66 0.40 0.00 1.13 3.61 4.72 1.86 0.00 0.38 0.75 1.03 0.47 0.00 2.65 0.00 1.39 0.68 0.00 0.42 0.00 0.00 1.11
89.31 92.22 90.54 92.27 92.25 95.25 92.26 92.24 98.27 89.24 92.90 90.24 90.24 89.23 90.25 94.33 95.25 95.25 90.25 92.38 90.25 93.25 90.23 95.25 92.25 90.25 94.26 94.24 98.27 90.25 90.25 95.24 93.23 92.33 87.23 98.33 92.29 93.26 90.26 93.23 95.24 92.24 90.24 90.26 98.27 94.25 92.26 95.24 89.29 93.23 92.27 90.32 98.28
Total Cost
Athens ¼ 1/Rest of Greece
111.84 32.36 31.54 42.25 39.09 41.78 67.41 40.47 75.22 27.07 68.41 23.75 36.47 19.38 40.21 49.73 53.08 33.07 41.18 64.18 48.65 53.15 24.35 34.00 50.82 48.14 34.37 59.43 32.03 50.64 41.48 34.17 31.25 119.50 36.99 140.86 105.44 73.84 32.57 23.45 29.61 36.50 34.40 51.72 70.61 56.53 85.68 27.64 86.19 30.98 94.22 49.18 75.28
1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0
Oncology University Hospital Hospital ¼1 ¼1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0
NAT ¼ nucleic acid test. More data can be provided upon request.
*
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