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Cost-effectiveness of preoperative autologous donation in coronary artery bypass grafting
J D Birkmeyer1, J P AuBuchon, B Littenberg
1Department of Family and Community Medicine, Dartmouth Medical School, Hanover, New Hampshire.
Insights
Preoperative autologous blood donation (PAD) before coronary artery bypass grafting (CABG) is not cost-effective. The risks associated with PAD for CABG patients may outweigh the benefits of reduced allogeneic transfusions.
Area of Science:
- Cardiovascular Surgery
- Transfusion Medicine
- Health Economics
Background:
- Preoperative autologous blood donation (PAD) is common for major noncardiac surgeries due to safety concerns with allogeneic blood.
- The cost-effectiveness and benefits of PAD specifically for elective coronary artery bypass grafting (CABG) remain unclear.
Purpose of the Study:
- To determine the cost-effectiveness of PAD in CABG, measured as cost per year of life saved.
- To compare the health benefits of reducing allogeneic transfusions against the risks of autologous blood donation in patients with coronary artery disease.
Main Methods:
- Decision analysis was employed to model the costs and outcomes of PAD in CABG.
- Data from a prospective study across 18 institutions on transfusion practices and blood costs in CABG were utilized.
Main Results:
- PAD for CABG costs between $508,000 and $909,000 per quality-adjusted year of life saved.
- Cost-effectiveness improves when PAD is targeted to younger patients at high-transfusion-rate centers ($518,000 per year of life saved).
- Even a minimal fatality risk from PAD (>1 in 101,000 donations) eliminates any life expectancy gains.
Conclusions:
- At current costs, PAD for CABG is not cost-effective, offering minimal health benefits at a high societal expense.
- For individual patients undergoing CABG, the risks of PAD likely exceed the benefits of avoiding allogeneic transfusions.
Abstract:
Concern about the safety of the allogeneic blood supply has made preoperative autologous blood donation (PAD) routine before major noncardiac operations. However, the costs and benefits of PAD in elective coronary artery bypass grafting (CABG) are not well established. We used decision analysis to (1) calculate the cost-effectiveness of PAD in CABG, expressed as cost per year of life saved, and (2) compare the health benefits of reducing allogeneic transfusions with the potential risks of autologous blood donation by patients with coronary artery disease. A prospective study of 18 institutions provided data on transfusion practice and blood product costs in CABG. On average, PAD in CABG costs $508,000 to $909,000 per quality-adjusted year of life saved, depending on the number of units donated. Preoperative autologous blood donation is more cost-effective (as low as $518,000 per year of life saved) when targeted to younger patients undergoing CABG at centers with high transfusion rates. The cost-effectiveness of PAD is strongly dependent on estimates of posttransfusion hepatitis incidence, but less so on plausible estimates of the current risk of human immunodeficiency virus transmission. Although the actual risk of PAD is uncertain, even a small fatality risk (> 1 per 101,000 donations) associated with blood donation by patients awaiting CABG negates all life expectancy benefits of PAD. At current costs, PAD by patients awaiting CABG is not cost-effective, producing small health benefits at high societal cost. For the individual patient, the risk of donating blood before CABG may well outweigh the benefits associated with fewer allogeneic transfusions.