8. General evaluation and recommendations
8.2. Recommendations
1. Aggregating information necessary for donors
Currently the information about blood centres is scattered on websites of hospitals and on the website verekeskus.ee in the case of PERH blood centre.
For developing donation and creating a shared image, it is necessary to gather the information regarding blood centres and donation into one website (e.g. www.doonor.ee). This helps to promote donation better (e.g. banners online, which lead to one common webpage instead of a certain blood centre), is easier for people and economically more reasonable.
The shared website should have information about blood donation locations and schedules of mobile collection visits (e.g. for the next quarter), which would enable permanent donors to plan their time ahead. A similar blood centre website about donation is created in Sweden (geblod.nu), where the blood service is also decentralized. The website could compile relevant information (contacts of blood centres, information about blood supplies) and other topics important to donors and people considering donation. Latter has been done to some extent in the website verekeskus.ee.
Blood services need to cooperate in order for a collective website to work properly, a coordinating and responsible role should be given to one blood centre (together with separate finances) or it could be the task of a coordinator at the Ministry of Social Affairs.
2. Determining on the role of a central coordinator
Currently there is no central coordination and planning done on a state level. If no reorganisation of blood service is planned, the solution would be the creation of the position of a blood service specialist at the Ministry of Social Affairs. The specialist’s tasks would be the coordination of the work of blood centres, donation promotion, blood service information system development, planning the demand of blood products on a state level and finding solutions for areas in need of development. Joint procurements should also be considered for certain materials. The role of the coordinator could be given to one of the blood centres (together with separate finances), but in this case it would be difficult to implement decisions, as the blood centres, i.e. hospitals, are private organizations.
3. Purchase of blood vehicles
Currently, mobile collection means transportation of staff and equipment to certain destinations. This requires previous inspection and evaluation of suitability of the facilities. Such arrangements also require time for preparing blood collection sites and, later on, for gathering equipment and materials.
Therefore, purchase of special blood vehicles should be considered, which would enable mobile collection visits to places that would not be suitable for blood collection otherwise (e.g. shopping centres). Mobile vehicles are also necessary for potential crisis situations.
The cost of purchasing 2 vehicles is estimated to 2 million Euros (State program of blood donation development and blood product self-supplying for 2010-2015), but the actual cost of blood vehicles would require an independent analysis.
4. Inactivating blood products
Inactivated blood products are used in several European countries and, for example, Finland has completely switched to inactivated plasma (Octapharma product Octaplas). The use of inactivated blood products is scarce in Estonia.
Inactivated blood products help to reduce the virus transfer risk arising from window-period and, in case of Octaplas, a decrease in the risk of TRALI due to pooling is also thought to occur (q.v. chapter 2.2). As inactivated products are expensive, the cost-effectiveness should be considered compared to fresh frozen plasma, by comparing the costs and benefits of obtaining both of the blood products. Benefits are often expressed in life years gained (LYG or QALY – quality adjusted life years), in the case of Octaplas life years are also affected by the lower probability of viral or TRALI transferral. In the table below, six researches are presented, where the cost-effectiveness of fresh frozen plasma and solvent-detergent plasma are compared.
Table 28. Cost-effectiveness of fresh frozen plasma and inactivated plasma
Author, year, state, financer Clinical outputs
SD-FP/Octaplas vs FFP
Conclusion of authors
QALY ICER per QALY*
1 AuBuchon, Birkmeyer (1994), USA Financer not stated
Viral infections
0.000067 $289 300 SD-FP produces small income and high costs
2 Pereira (1999), Spain
Spanish government (partially)
Viral infections
0.00014 $2 156 398 Virus-inactivated plasma produces little income and very high cost
3 Riedler et al (2003), UK Octapharma Viral infections, TRALI $22 728 (newborns) – $98 465 (70-y- o) SD-FP is cost-effective in patients < 48 years old and in older patients with good clinical prognosis 4 van Eerd MC et al (2010), UK Octapharma Viral infections, TRALI
0.03 $1632 Octaplas is cost-effective when compared to FFP at a threshold of $47 548 per QALY 5 Membe et al (2011), Canada
Canadian government (partially)
Viral infections, TRALI
0.0002 $934 000 Octaplas is more costly than FFP and is associated with negligible increases in QALYs
6 van Eerd MC (2011), USA
Octapharma Viral infections, TRALI 0.012 ─$29 906 Octaplas is a cost-effective alternative compared to FFP
Source: AuBuchon, Birkmeyer (1994), Pereira (1999), Riedler et al (2003), van Eerd et al (2010), Membe et al (2011), van Eerd (2011)
Note: *excl. Rielder et al (2003) – ICER per LY. SD-FP: solvent-detergent plasma, FFP: fresh frozen plasma. Interpretation: QALY – how many quality-adjusted life years are gained more from solvent-detergent plasma compared to fresh frozen plasma; ICER per QALY – how much solvent-detergent plasma costs more or less per one QALY compared to fresh frozen plasma
The previous overview implies that the conclusions about the cost-effectiveness of solvent-detergent plasma are controversial. Four articles find that solvent-detergent plasma is not cost-effective compared to fresh frozen plasma, as it is a lot more expensive and does not bring forth any remarkable benefit in gained life years. Two articles (from the same author) have come to the opposite conclusion and both researches were financed by Octapharma. The reasons could lie in different assumptions in models. For example, Riedler et al (2003) has noted that some earlier research (e.g. AuBuchon, Birkmeyer 1994, Pereira 1999) have underestimated the advantages of solvent-detergent plasma in their research as they have not considered the possible decrease in transfusion reactions using solvent-detergent plasma. AuBuchon (2011) has brought out, that inactivation does not bring along a remarkable extra cost- effectiveness, as methods for avoiding most risk factors have already been implemented, inactivation helps to avoid bacterial contamination and not as much viral infections. In addition, the evaluation for the cost-effectiveness of solvent-detergent plasma depends on the context i.e. the situation of blood safety in a state – the more there are viral infections and events of TRALI, the larger the theoretical benefit of using solvent-detergent plasma.
Considering the more complicated epidemiologic situation of Estonia and the larger probability of viral infection risks, the use of inactivated products should be considered. Today there are two options – inactivation industrially (only for plasma, Octapharma product Octaplas) or inactivation in the blood centre (both plasma and platelets). As both plasma and platelets inactivation is done with the same device and the only difference is in the additional set for the processing, it would be economically more reasonable to either inactivate both components in the blood centre or not buy the device when purchasing Octaplas (and platelets would not be inactivated).
In the decision, whether to start using inactivated products and which method to prefer, the following circumstances should be taken into account:
erythrocytes (most used blood component) cannot be inactivated, therefore traditional testing would remain;
inactivating platelets is necessary to decrease risk of both viral infections and bacterial contamination;
inactivating in the blood centre would prolong processing, which decreases the time period during which platelets can be used;
inactivation does not eliminate all viruses (effect is smaller in case of non-enveloped viruses (Member et al 2011)), on the other hand, not all viruses are tested today;
purchasing Octaplas could become the prerequisite of Octapharma for buying plasma. The costs of Octaplas and inactivating in blood centres also differ.
Table 29. Costs of Octaplas and inactivating in blood centres (thousand Euros)
Yearly extra cost
Octaplas (additional cost compared to fresh frozen plasma) 869 Inactivating plasma in blood centres (costs related to service) 754 Inactivating platelets in blood centres (costs related to service) 351
Source: applications submitted to Estonian Health Insurance Fund (Octaplas – submitted 2011, inactivating in blood centres – submitted in 2008) and evaluation of Estonian Health Insurance Fund to applications, Estonian Health Insurance Fund data
The total cost of inactivated products depends on the used amounts in the future: the costs of inactivated plasma products could decrease and cost of inactivated platelets increase.
According to the calculations of Estonian Health Insurance Fund, both Octaplas and plasma inactivated in blood centres would be cost-effective, but the latter would provide more cost-effectiveness.
The precondition for starting to use inactivated products would be a total transition to inactivated products i.e. it is unethical to use inactivated (i.e. with a higher quality) products only in some hospitals and for only some patients. An exception could be children as a special target group, but in the case of inactivating in blood centres, the amounts would be unreasonably small for purchasing equipment.
5. Fractionation of plasma leftovers and purchasing plasma products
Currently there are a lot of fresh frozen plasma transfusions in Estonia compared to other developed countries and therefore the proportion of plasma going to fractionation is relatively small compared to the transfused plasma. Fractionation contracts of blood centres are different and the prerequisite of plasma sales could become the purchase of Octaplas at some point. A situation could also occur, where some health care institutions receive plasma products cheaper and other must buy them with a higher price.
If the use of fresh frozen plasma would be more optimal in Estonia, more plasma could be sent to fractionation and the resulting income would be larger. But the question of how to treat the allocation of revenue from plasma leftover needs further discussion. Increasing the utilisation of plasma leftovers is possible with good cooperation between blood centres and by centralizing the quality management of the blood service.