Académique Documents
Professionnel Documents
Culture Documents
Role of blood transfusion services Important for planning a national blood programme
provide equitable access to safe blood/blood
Needs based programme - to satisfy the needs of a
products for all patients who need it
country's health care system, equitably and timely
adjust supply to actual needs (routine and emergency)
Shortages No global standard for estimating countries' needs for
various reasons (lack of donors or well organized blood/blood products, and estimates have to be made
donor programme, safety measures,) for each country and each region
periodic or continuous Plan blood collection and donor recruitment
crucial for patients when no alternative is available systematically, to avoid an excess or a shortage
1
Variables affecting demand and supply Demand and Supply
2
BTS related Parameters (1 of 2) BTS related Parameters (2 of 2)
Development and effectiveness of BTS to provide Degree of component preparation tailored to real need
safe blood/blood products to support regular and and resources of a country
specific transfusion needs What % of blood should be separated into
Number of blood centres and level of coordination components?
% of blood separated into components Future needs, including the feasibility of using recovered
plasma for fractionation
shelf-life of blood/blood components
Future need for apheresis and / or autologous programme
90 18 0.27
Size of hospital (s) and number of patients Time-Expiring at
NBS
Time-Expiring at
NBS
2.23
80 16
Complete Donations
No. and kind of procedures, deliveries, anaemia pts 70
Not Validated
14 2.02
Complete Donations
Not Validated
Incomplete Bled
Donations
Clinical competence and experience of staff 60 12 Incomplete Bled
Donations
Attendees Not Bled
50 10
Training for hospital and blood bank staff Issued Red Cell
8
Attendees Not Bled
40
10 2
Different types of components needed
0 0
Michael Bowden 2006 Michael Bowden 2006
Complete donations not validated = testing losses (i.e. repeat reactives for microbiological markers,
abnormal test results in grouping) plus processing losses.
These figures do not include time-expiry/wastage in hospitals which was of the order of 2.2%in the
relevant period.
3
Donations/1000 population
80.0 Low HDI Medium HDI High HDI Method 1
Average 38.1
Number of donations / 1000 population
Blood Usage
Method 2
120 countries report that a total of 51,400 hospitals
perform blood transfusions, serving a population of Method 2: based on acute hospital beds
around 3.6 billion
Suitable for countries with modern hospital services
Only 25 % hospitals performing transfusions in
Calculate 6.7 units of blood per acute hospital bed
developing countries and 33% hospitals in transitional
countries have a transfusion committee to monitor per year (WHO, 1971)
transfusion practices; as compared to 88% hospitals in
developed countries
4
Population Based Model Method 3
project the trend in requirements in terms 10 000 000 x 2% = 200 000 units of blood per
of population trends year or approximately 3850 per week
paint a picture of the national situation A minimum of 100 000 donors will be needed if
each donor gives blood at least twice per year
5
Overview
The Global Burden of Disease
A brief introduction to the Global Burden of
approach to comparable
Disease project
international statistics
Issues in preparing comparable cross-national
statistics
Gretchen Stevens 1. Selecting indicators and metrics
Health Statistics and Informatics Department
2. Correcting for bias in available data
3. Estimating and communicating
uncertainty
Health Statistics and Informatics 3 February 2010 Health Statistics and Informatics
Common metric or summary measure Internal consistency used as a tool to improve validity
1
Three types of health statistics What is meant by comparable statistics?
Key elements:
Unadjusted statistics: derived directly from primary data
collection Quantities of interest are estimated at the
population level
Adjusted statistics: corrected for known biases
Intervention
Improved 1. Selecting indicators and metrics
Infrastructure; Coverage of health outcomes
ICT access & interventions & equity
services
Governance
Indicator
Financing
Information Efficiency
3. Estimating and communicating uncertainty
Data Population-based surveys
Administrative sources Facility assessments Coverage, health status, equity, risk protection, responsiveness
collection Financial tracking system; NHA
Databases and records: HR,
infrastructure, medicines etc.
Clinical reporting systems
Service readiness, quality, coverage, health status
Policy data
Civil registration
2
Bias in height and weight reported
Self-reported and corrected obesity
over the telephone
NHANES a national health examination survey
measures height and weight of a national sample
3
Framework
Summary M&E of health systems strengthening
Inputs & processes Outputs Outcomes Impact
Choice of exposure metric may need to be Improved
flexible to meaningful and/or accommodate data Infrastructure;
ICT
Intervention
access &
Coverage of
interventions
health outcomes
& equity
availability services
Governance
Indicator
Financing
Health readiness Social and financial
domains
There is often a trade-off between data workforce
Intervention
Prevalence risk
behaviours &
risk protection
quality and population-based data Supply chain quality, safety factors Responsiveness
Information Efficiency
Civil registration
Assessing and communicating uncertainty is a Analysis Data quality assessment; Estimates and projections; In-depth studies; Use of research results;
continuing challenge & Assessment of progress and performance of health systems; evaluation
synthesis
Communication
Health Statistics and Informatics & use
Health Targeted and comprehensive reporting; Regular country review processes; Global reporting
Statistics and Informatics
evaluation
Governance
Indicator
Financing
Information Efficiency
Researchers can use data and experiences from
multiple settings to correct for biases in country
data or to make estimates when they are not
available
4
World Health Organization 12 April, 2010
2 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010
In areas of "unstable" malaria, the rates of inoculation fluctuate Emergency and epidemic preparedness and response
greatly over seasons and years. Entomological inoculation rates
are usually < 5 per year and often < 1 per year. This retards the
acquisition of immunity. Intermittent preventive treatment in infancy (IPTi)
all age groups (adults and children alike), are at high risk of progression to
severe malaria if untreated.
3 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010 4 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010
5 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010 6 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010
1
World Health Organization 12 April, 2010
Hemoglobin less than 5g/dl (PCV less than 15%) It affects more than half of all pregnant women and
children less than five years old
Features of anaemic heart failure (even if PCV is >15%)
Each year in children < 5 years
In the presence of P.falciparum parasiteamia
1.4 - 5.7 million cases
190,000 - 974,000 deaths
Case fatality rate of severe anaemia (13.4 - 17.2%)
Highest mortality in infants
7 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010 8 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010
Antimalarial treatment
In children with less severe anaemia (i.e. packed cell volume 1318%, Hb 46 Treatment
g/dl), transfusion should be considered for high-risk patients with any one of the
following clinical features: transfuse fresh blood, clotting factors or platelets as required.
respiratory distress (acidosis);
impaired consciousness;
hyperparasitaemia (>20%).
The sicker the child the more rapidly the transfusion needs to be given.
11 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010 12 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010
2
World Health Organization 12 April, 2010
13 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010 14 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010
Comparison of trend patterns of inpatient malaria cases and deaths, by year, all ages, 2000/1-2006/7. Eritrea,
Rwanda, Sao Tome and Principe, Zambia, and Zanzibar.
12000 Eritrea 140 Rwanda
25000 450
Inpatient cases
Inpatient deaths 120 400
10000
20000 350
100
8000 300
80 15000
Deaths
Impact of the scale up malaria
Cases
250
Deaths
Cases
6000
60 200
10000
4000
5000 100
2000 20
50
0 0 0 0
2000 2001 2002 2003 2004 2005 2006 2000 2001 2002 2003 2004 2005 2006 2007
7,000
350
12,000 8000 300
250,000 6,000
10,000 200
250
200,000 5,000 6000
8,000 150 200
4,000
150,000
6,000 4000 150
100 3,000
4,000 100,000 100
2,000
50 2000
2,000 50,000 1,000 50
12 April 2010
15 | 0 0 0 0 0
2 000 2 001 20 02 200 3 2004 2005 2006 2 007
0
2001 2002 2003 2004 2005 2006 2001 2002 2003 2004 2005 2006
Figure 2a. Malaria and non-malaria in- and out-patient cases, children <5 years old, January to Inpatient and outpatient indicators decline markedly, to low levels in 2006 and
October 2001-2007, Rwanda. LLIN = long-lasting insecticidial nets, ACT = artemisinin-based 2007, MRC research hospital and clinic, Fajara, Gambia
combination therapy medicines.
LLIN,
10000 ACT 14000 9000
70000 Inpatient Inpatient
s malaria malaria
sea
9000 8000
12000
60000
8000
cd cases deaths
em 7000
ess
ess
firn
74%
se 7000 10000 ac6000
50000 ac 100%
asc oc tn
tn
y-r iet
eti
ntie 6000
8000 ot ap5000 40000 ap
ta 5000 rao -in t-u
-pin
bla oa
riala4000
ir
ntie
30000
6000
riala 4000 ta am ala
aM3000
p- n-o3000 m
-n Outpatient
4000
uto 2000
N 20000
No
2000 ari slide
2000 ala 10000 Rainfall
1000 M 1000 positivity
0 0 0 0
rate (SPR) 73%
2001 2002 2003 2004 2005 2006 2007 2001 2002 2003 2004 2005 2006 2007
Year Year
Malaria out-patient laboratory-confirmed cases Non-malaria out-patient cases
Malaria in-patient cases Non-malaria in-patient cases
12 April 2010 12 April 2010
Source: Ceesay SJ et al. Changes in malaria indices between 1999 and 2007 in The Gambia: a retrospective analysis. Lancet 2008; 372:1545-54.
3
World Health Organization 12 April, 2010
Combined Approved Interventions and the Impact Hemoglobin rises in 2005-2007 and blood transfusions in children
decrease to near zero in 2007, Sibanor, Gambia
Positivity
rate
Prevalence
rate
12 April 2010
19 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010
Source: Ceesay SJ et al. Changes in malaria indices between 1999 and 2007 in The Gambia: a retrospective analysis. Lancet 2008; 372:1545-54.
Conclusions
21 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010 22 | Requirements of blood for management of malaria. Expert Consultation, Geneva, 03 Feb 2010
4
World Health Organization 12 April, 2010
Outline
WHO Experts' Consultation on Estimation of Blood Requirements WHO Experts' Consultation on Estimation of Blood Requirements
1| Geneva Feb 3-5, 2010 2| Geneva Feb 3-5, 2010
WHO Experts' Consultation on Estimation of Blood Requirements WHO Experts' Consultation on Estimation of Blood Requirements
3| Geneva Feb 3-5, 2010 4| Geneva Feb 3-5, 2010
Outline
1
World Health Organization 12 April, 2010
Data sets 8 11 10 5
We need to
Maternal deaths 4508 16089 11777 2823
have a
Lancet 367: 1066-1074, 2006
(13.3-43.6) (5.9-48.5)
strategic
(1.1-46.9) (4.7-34.6)
WHO Experts' Consultation on Estimation of Blood Requirements WHO Experts' Consultation on Estimation of Blood Requirements
7| Geneva Feb 3-5, 2010 8| Geneva Feb 3-5, 2010
Country Year Maternal deaths MMR Haemorrhage Number per 1000 deliveries
DR Congo 1997 143 510 16%
Antepartum haemorrhage 7.26
Egypt 2000 585 84 30%
Postpartum haemorrhage 12.5
Senegal 2002 87 690 22%
Puerperal sepsis 8.0
Tanzania 1988 76 529 23%
WHO Experts' Consultation on Estimation of Blood Requirements WHO Experts' Consultation on Estimation of Blood Requirements
9| Geneva Feb 3-5, 2010 10 | Geneva Feb 3-5, 2010
WHO Global Surveys on Maternal and WHO Global Survey on Maternal and
Perinatal Health Perinatal Health
Facility based survey conducted between 2004 and 2008 Blood transfused in 1.58% of births
24 countries in Latin America, Africa and Asia Spontaneous vaginal delivery 1940/205303 (0.94)
Analysed mode of delivery, maternal and perinatal Operative vaginal delivery 198/7287 (2.72)
outcomes
Antepartum CS - no indications 14/1826 (0.77)
Varying caesarean delivery rates between and within Intrapartum CS - no indications 26/1063 (2.45)
regions and countries
Antepartum CS with indications 887/26876 (3.3)
2
World Health Organization 12 April, 2010
15 13.2
10.7
Guatemala 1998-
Bangladesh 199
Bangladesh 199
Bolivia 1998
Tanzania 1996
Zambia 1996
Jordan 1997
Turkey 1998
Indonesia 1997
Indonesia 1994
Chad 1996-97
Egypt 1995
Yemen 1997
Philippines 1998
Brazil 1996
Colombia 1995
Republic 1996
Guatemala 1995
Nicaragua 1998
Peru 1996
Dominican
9-2000
6-97
99
Sub-Saharan Africa North Africa/West South & Southeast Asia Latin America & Caribbean
Asia/Europe
Source: Macro International Inc, 2010. MEASURE DHS STATcompiler. http://www.measuredhs.com, February 2 2010.
WHO Experts' Consultation on Estimation of Blood Requirements WHO Experts' Consultation on Estimation of Blood Requirements
13 | Geneva Feb 3-5, 2010 14 | Geneva Feb 3-5, 2010
Outline Challenges
When are blood and blood components used in maternity Limited data
care? Amount
Blood or blood components
How often are blood and blood components required?
Estimated need versus actual transfusion requirements
What are the challenges in estimating requirements?
Other issues
Epidemiology Malaria, helminthiasis, HIV
Recognising the need for blood transfusion
Intervention rates
Access to care
WHO Experts' Consultation on Estimation of Blood Requirements WHO Experts' Consultation on Estimation of Blood Requirements
15 | Geneva Feb 3-5, 2010 16 | Geneva Feb 3-5, 2010
Anaemia in among pregnant women Proportion of pregnant women age 15-49 with anaemia. Anaemia
includes mild anaemia (haemoglobin count d/dl 10.0-10.9), moderate anaemia (haemoglobin count d/dl 7.0-9.9), and severe anaemic
(haemoglobin count d/dl below 7.0)
Gaps in skilled care In Bangladesh, only 18% of women
deliver with skilled professionals.
Wealthy women had 11 times higher
In China, women in the least affluent
access to skilled care than their poor
90 areas are twice as likely to deliver
counterparts.
80 without a trained health worker as
Mild anemia (%) Moderate anemia (%) Severe anemia (%)
% of preg nant w om en w ho are anae m ic
Ca mbodia 2005
Ca meroon 2004
Mali 2006
G uinea 2005
U ganda 2006
Niger 2006
G hana 2003
India 20 05-06
M adagas c ar 20 03-04
Nepal 2006
M oldov a 2005
J ordan 2007
Egy pt 2005
Ethiopia 2005
Armenia 2005
Boliv ia 2003
L es otho 2004
Malawi 2004
Az e rbaijan 2006
R wanda 2005
Swaz iland 200 6-07
41 - 60% Data source: proportion of births attended by a skilled health worker 2008 updates, WHO
The name as shown and the designations used in this map do not imply official endorsement off
61 - 80% acceptance by the United Nations.
81 -100 %
WHO Experts' Consultation on Estimation of Blood Requirements WHO Experts'
No data Consultation on Estimation of Blood Requirements
available
17 | Geneva Feb 3-5, 2010 18 | Geneva Feb 3-5, 2010
3
World Health Organization 12 April, 2010
2.5
2
1.4
% of births
1.5 1.3
1
1 0.8 0.8 0.7
0.6 0.5
0.4 0.3 0.4 0.4
0.5
0.1 0.1 0.1
0
Elsewhere
Richest
Health
Urban
Richer
Middle
Poorest
Poorer
6+
1
2 to 3
4 to 5
<20
20-34
35-49
Rural
facility
Place of Residence Wealth quintile Birth order Mother's age at
In Indonesia, women in urban areas are Less than 5 % delivery birth
three times more likely to have access to C- 5-15 %
section than their rural counterparts.
More than 15 %
No data available
Source: Macro International Inc, 2010. MEASURE DHS STATcompiler. http://www.measuredhs.com, February 2 2010.
Data source: Demographic and Health Survey
The name as shown and the designations used in this map do not imply official
WHO Experts' Consultation on Estimation of Blood Requirements
endorsement off acceptance by the United Nations. WHO Experts' Consultation on Estimation of Blood Requirements
19 | Geneva Feb 3-5, 2010 20 | Geneva Feb 3-5, 2010
4
Requirements of blood
and blood components for trauma care
To know blood requirements
Pablo Perel
How frequent is trauma?
Interpersonal Violence 16 14 19 12
War 20 15 16 8
Legend*
No data
120 - 131.1
95.0 - 119.9
70.0 - 94.9
The boundaries and names shown and the designations used on this map do not imply the expression of any 45.0 - 69.9
IfIf current
current trends
trends continue,
continue, road
road traffic
traffic and
opinion whatsoever on the part of the World Health Organization concerning the legal status of any country,
and
territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on
maps repre sent approximate border lines for which there may not yet be full agreement.
WHO 2002. All rights re served
1
Ten most common causes of death in young people (10-24)
To know blood requirements
Reference: Patton GC, et al. Global patterns of mortality in young people: a systematic analysis of
population health data. Lancet. 2009 Sep 12;374(9693):881-92.
Registry
Germany 2,475 54% 17.1%
(DGU)
Exsanguination CNS injury
45% 41% US Trauma Centre 5,645 8% 3%
4% 10%
Other Organ failure - Maegele, M Changes in transfusion practice in multiple injury between 1993 and 2006: a retrospective analysis
on 5389 patients from the German Trauma Registry. Transfusion Medicine. 19(3):117-124, June 2009.
- Como JJ et al Blood transfusion rates in the care of acute trauma. Transfusion. 2004 Jun;44(6):809-13.
Reference: Sauaia A et al. Epidemiology of trauma deaths: a reassessment. J Trauma 1995;38:185-193 - Soffer, D et al. Usage of Blood Products in Multiple-Casualty Incidents: The Experience of a Level I Trauma
Center in Israel. Archives of Surgery. 143(10):983-989, October 2008.
2
Red cell transfusions
Transfusion threshold Mortality in patients who declined blood transfusions
30 days mortality
Carson JL et al. Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion Transfusion. 2002
Jul;42(7):812-8.
Reference: Hill S Transfusion thresholds and other strategies for guiding allogeneic red blood cell
transfusion. Cochrane Database Syst Rev. 2002;(2): 14
3
Frequency
Frequency
Point at which benefits of Point at which benefits of
transfusion exceeds harms transfusion exceeds harms
blood loss
Cochrane reviews of blood sparing red blood cell transfusion. CDSR 2000 Issue 1.
Favours Favours
treatment control
4
Effects of TXA Effects of TXA
0 0.4 0.8 1.2 1.6 2.0 0 0.4 0.8 1.2 1.6 2.0
Blood units Antifibrinolytic better Antifibrinolytic worse
5
Results I Results II
Number of patients per country Characteristics of patients included
N %
Male 15,932 83.75
Gender
Female 3,091 16.25
<25 5,320 27.97
25-34 5,720 30.07
Age categories
35-44 3,573 18.78
>44 4,410 23.18
<1 1,791 9.41
Hours since injury 1 to 3 10,963 57.63
>3 6,269 32.95
6
Results IX Tranexamic acid and blood loss
Outcomes and units transfused by region
according to subgroup Traumatic bleeding (CRASH-2 trial completed)
Systolic Blood Pressure Systolic Blood Pressure
Postpartum bleeding (WOMAN trial in progress)
AFRICA EUROPE
>89 76-89 <76 >89 76-89 <76 GI bleeding (in preparation)
Mortality 16 31 43 Mortality 7 14 42
Mean no of units 2.5 2.7 2.9 Mean no of units 8.8 11.4 12.4
SOUTH EAST ASIA AMERICAS If tranexamic acid also reduces blood loss in these conditions
Mortality 13 17 35 Mortality 9 19 32 then could have a substantial impact on global demand for
Mean no of units 4.1 4.8 7.2 Mean no of units 6.0 8.0 10.6
blood.
WESTERN PACIFIC EASTERN MEDITERRANEAN
Mortality 8 24 0 Mortality 4 9 24
Mean no of units 6.6 16.3 31.0 Mean no of units 3.1 4.7 4.0
www.crash2.lshtm.ac.uk www.woman.lshtm.ac.uk
7
World Health Organization 12 April 2010
Anaemia
Anaemia Anaemia
Microcytic Normocytic Macrocytic Microcytic Normocytic Macrocytic
Low High Low High Yes No Low High Low High Yes No
iron thalasse sidero aplastic haemolytic vitamin folic acid hepatic haemolytic iron thalasse sidero aplastic haemolytic vitamin folic acid hepatic haemolytic
deficiency mia anaemia disease B12 deficiency mia anaemia disease B12
blastic anaemia disease anaemia blastic anaemia disease anaemia
Leukaemia transfusion anaemia Leukaemia transfusion anaemia
anaemia reaction anaemia reaction
120
Nutrient Effect on
100 w/o anaemia
Thiamine DNA synthesis Anaemia
80
Folic acid DNA and RNA synthesis
(%)
60
Vitamin B12 DNA and RNA synthesis
Vitamin E Lysis of membranes 40
Vitamin C Iron mobilization 20
Copper Ceruloplasmin: ferric to ferrous iron
0
Pyridoxine Hb synthesis: alcoholism 5 10 15 20 30 40 50 60 70 80
Iron Hb synthesis Prevalence of anaemia (%)
Source: WHO/ UNICEF / UNU. Iron deficiency anaemia: Assessment, prevention and
control, a guide for programme managers. Geneva ,WHO, 2001.
5| 6|
1
World Health Organization 12 April 2010
293 million children under 5 are anaemic Iron deficiency: health implications
Total body iron: 3-5 g
Adequate growth and development
! !
Immunity
!
!
Normal (<5.0%)
Reproductive performance
Mild (5.0-19.9%)
Moderate (20.0-39.9%) Source: WHO/CDC. Worldwide prevalence of anaemia 1993- Raising of other metals levels
Severe (40.0%) 2005. WHO Global Database on Anaemia. Geneva, World Health
No Data Organization, 2008.
7| 8|
9| 10 |
Altitude Smoking
In addition to a diet with low iron/poor bioavailability
Haemoglobin
Increase in Hb (mg/L)
Non smoker 0
Smoker + 0.3
-1 packet/day + 0.3
1-2 packets/day + 0.5
2 packets/day + 0.7
11 | 12 |
2
World Health Organization 12 April 2010
13 | 14 |
Source: WHO/ UNICEF / UNU. Iron deficiency anaemia: Assessment, prevention and
Source: Stoltzfus y Dreyfuss, 1998
control, a guide for programme managers. Geneva ,WHO, 2001.
15 | 16 |
Yes
Therapeutic supplementation
Nutrition counselling
Adapted: Casanueva et al, 2008
17 | 18 |
3
World Health Organization 12 April 2010
Anaemia
WHO-VMNIS
Microcytic Normocytic Macrocytic
Sideroblasts Reticulocytes
iron thalasse sidero aplastic haemolytic vitamin folic acid hepatic haemolytic
deficiency mia anaemia disease B12
blastic anaemia disease anaemia
Leukaemia transfusion anaemia
anaemia reaction
19 | 20 |
Acknowledgements
Financial and/or technical support for the Micronutrients Unit
21 |
4
Estimating National Blood Requirements
what should we measure?
1. Needs/demand for blood in the existing
health system
Estimating National Blood
2. Capacity and gaps of health system to
Requirements in Africa deliver services
Lawrence H. Marum, MD, FAAP, MPH Should a national blood service focus on estimating
Centers for Disease Control and
and meeting needs within existing health system
Prevention - Zambia OR expanding the number and distribution of
facilities with capacity for transfusion?
2.7
per 1000 Population
Rwanda 3.5
3.3
5.4
Zambia 3.7
3. Surgical services Guyana
5.7
5.4
7.5
4. Trauma Namibia
Botswana 6.5
9.1
8.8
11.8
0 2 4 6 8 10 12 14 16 18
HIV treatment associated anaemia Units of Whole Blood Collected per 1000 Population
1
Proportion of paediatric University Teaching Hospital:
transfusions - Zambia changing uses of blood
40 1864 beds
35 Uses 27% of national
30 blood supply
25 #1 08
#1 09
Maternity 30%
Maternity
20
#2 08 Paediatric
Medical
Paediatric 17%
15 #2 09 Surgical
10
Other Medical 21%
5 Surgical 14%
0 Other: outpatient and
Level 1 Level 2 Level 3 special services 14%
J ul
J ul
J ul
Oct
Oct
Oct
Oct
J an
J an
J an
J an
A pr
A pr
A pr
A pr
2
Macha Hospital - Non Children's Macha Hospital - Children's Ward
Ward Blood Transfusions Blood Transfusions
200 200
150 150
100 100
50 50
0 0
Jul
Jul
Jul
Jul
Jul
Jul
Jul
Jul
Apr
Apr
Apr
Apr
Apr
Apr
Apr
Apr
O ct
O ct
O ct
O ct
O ct
O ct
O ct
O ct
Jan
Jan
Jan
Jan
Jan
Jan
Jan
Jan
2000 2001 2002 2003 2000 2001 2002 2003
250
2002 1294 336
200 2003 1418 393
150
2004 423 155
100
2005 123 60
50
0
2006 565 225
JAN
APR
JAN
APR
JAN
APR
JAN
APR
JAN
APR
JAN
APR
JAN
APR
OCT
OCT
OCT
OCT
OCT
JUL
OCT*
JULY
JULY
JULY
JULY
JULY
JULY
Ju l
Ju l
Ju l
Ju l
Ju l
Ju l
Ju l
Ju l
Sept
O ct
O ct
O ct
O ct
O ct
O ct
O ct
O ct
O ct
Ju n e
Ja n
Ja n
Ja n
Ja n
Ja n
Ja n
Ja n
Ja n
Ja n
Apr
Apr
Apr
Apr
Apr
Apr
Apr
Apr
Apr
Apr
DJ ae nc
3
Emergency Obstetric Services Conclusions
1230 ANC facilities; 937 offer PMTCT Changing blood needs
Reduced paediatric transfusion w/ malaria control
132 transfusing facilities
Expansion of emergency obstetric services
Lack of trained nurse/clinical officers Increased chronic disease treatment (ARVs)
Only 60% of national health posts filled M&E needs
Rural retention schemes; retired nurses Comprehensive data on use of blood; vein to vein linkages
Prescriber information for monitoring and supervising
Expansion of C-section capacity to level 1 SmartDonor and SmartCare: national electronic records
hospitals and larger health centres many Address national transfusion coverage in Health System
that do not have transfusion capability Strengthening efforts how quickly can we safely expand?
4
Background : national health care
Canada
WHO Experts Group Consultation on Estimation Population:
33,968,200
of Blood requirements
Territory:
9,984,670 km
Carolina Sarappa
Hospitals:
Business Analyst
99
Hma-Qubec
Model:
Blood banks in
03-05 February 2010
hospitals
Indications %
50
Surgery: Elective 25 45.5
Units/1000 population/year
40
Urgent 12 33.0
28.5
30
Obstetrics 1
20
Trauma 7
10
Hematological
43
disease & transplant 0
USA
France
QUEBEC
Others 12
Total 100
1
Demand Forecasting: Key Criteria to
Types of Forecasting Techniques
Consider
1. Informal: intuitive depending on individual experience and abilities 1. Item to be forecasted : RED BLOOD CELLS
Horizon:
Long term (5-10 yrs)
Short term (1-2 yrs)
Very short term (< 1yr)
Short-term forecasting
(1 to 2 years)
2
Quantitative techniques Results obtained
Nave method
Dt = Dt-1 + c
Forecast
Forecasting method % error
Where c is determined by historical data and /or expert judgement (12 months)
One of the simplest methods to use
Simple linear trend 219,406 Reference
For Hma-Qubec, this method works well since the demand is relatively stable.
Exponential smoothing 270,844 + 23.4 %
Exponential smoothing
Holt-Winters 231,376 + 5.5 %
This method is a special form of the weighted average and focuses on the most recent period.
Dt = aDt-1 + (1 - a)Dt-1 Holt-Winters
228,085 + 4.0 %
(Seasonality month)
Where a (the smoothing constant) is determined by trial and error
Holt-Winters
228,090 + 4.0 %
Fairly complex statistical methods are involved (Seasonality quarter)
The results indicate that the following variables have the most important effect on the
It is based on a chronological series related to the quantity of red blood cells
demand for red blood cells:
improvement of surgical and medical practices
distributed to hospitals for a 349 week period
medical and technological advancement from 11/22/1999 to 07/31/2007
substitute products and alternative treatments
education of hospital personnel
protocols of transfusion
For the following 18 week period, the absolute percentage errors range from 0.31%
expiration targets for blood products
to 10.61%
the mean error is 4.90% per week or 0.70% per day.
However, the findings appear almost impossible integrate into a regression model,
historical data remained the best indicator of the future demand for the purpose of
this study.
Demand Forecasting
ARIMA model Red Blood Cells Shipped to Hospitals
Observed 9.00%
5500
Forecasted
8%
240 000
5000
Distribution of Packed Red Cells
6.00% 6%
230 000 4%
227 581
223 723
221 659 221 256 2%
4000
223 100
220 000 0.84%
220 215
0%
3500
211 901
210 000 -1.83% -1.94% -2%
3000
-4%
200 000
-5.27%
-6%
0 100 200 300 400 -6.48%
Week
190 000 -8%
2001-2002 2002-2003 2003-2004 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009
3
So how DO we forecast? Monitoring daily inventory
14
12
Long-term forecasting (5 10 years)
Forecast based on the population
pyramid
10
Drawbacks:
Does not consider the usage per
DRG
8
Does not take into account
medical and scientific advances
4
Apr-06 Sep-06 Feb-07 Jul-07 Dec-07 May-08
4
DIFFERENT MODELS OF BLOOD ESTIMATION
A BLOOD CENTRE PERSPECTIVE
Summary
2. Long-term forecasting (5-10 yrs): for strategic planning, demographics and DRGs
are critical elements.
3. BUT: Very short term forecasting (daily, weekly and monthly): the most important
one since only this forecasting prevents shortage of blood and thus gives the best
service to the patients in need of blood.
5
Assessment of Needs for Blood Introduction
Products Pilot study of a model
The blood needs for a population could be
based on clinician experience defined as the sum of the needs for all patients
Elizabeth Vinelli, Rashid Salmi, Brian McClelland, Marco Pinel, with all diseases.
Rosa Kafati, Guillermo Guivobich, Juana Lozano, Ana del Pozo,
Christian Hertlein Since there are countless combinations of
disease, stage, co morbidity and intervention
that can put a patient at risk of needing a
Presented on behalf of the project group by Brian McClelland WHO
February 3, 2009
transfusion.
It is difficult to define the information required
and extract it from conventional registers of
clinical data.
Hypotheses 2
Hypotheses 1
The majority of blood needs are related to compensation of acute
or chronic anemia; therefore, if red cell needs were met, this
For a given period and given category of should be sufficient to meet the needs for platelets and plasma
since these can be separated from whole blood
disease, blood needs will be a function of:
Experienced specialist clinicians should be able to assign the
The number of individuals having the disease main groups of patients at risk of transfusion (GPRT) into broad
clinical categories in relation to transfusion needs
during the period
These are the categories that will have a major impact on the total
The proportion of them which develop a need for blood, either because they include
pathophysiological condition requiring many patients requiring a modest amount of blood, or because
they include a
transfusion smaller number of patients each requiring a large amount of
blood
Quantity of blood needed for each category
Disease groups other than the main GPRT should have a small
impact on blood needs .
1
Information sought from clinicians
List of Groups of patients needing blood
Formal consensus methods have been shown to
be helpful in developing initial estimates of Number/ of individuals in each group
patient populations in the absence of accurate during the defined period
clinical and epidemiological data. Proportion of these having a
pathophysiological condition requiring
blood
Quantity of blood needed for each
pathophysiological condition tha requires
blod
2
Comparison with observational data
- blood request forms Data collected from patient charts
1376 blood request forms from the main reference hospital were
available for review, in 1335 there was a reason for the request
Demographic data: age, gender
68% of the reasons for transfusion matched one of the GPRT Hospital Stay: events, length of stay
Anemia: Hb and Hct at admission and before
The remaining 433 blood request forms fell into two categories: transfusion
unspecified anemia and others.
Presence of acute bleeding
100 transfusion requests were matched to discharge diagnosis. Only Number of patients for whom blood requested
patients who had been transfused were included in this sample. In Number of red cell units requested by the physician
67% of charts the discharge diagnosis coincided with one of the
GPRT. Anemia, diabetes and solid tumors accounted for most of the Number of patients transfused
remaining diagnosis. Number of red cell units transfused
Clinicians were able to select 67-68% of all the clinical conditions for
which patients were transfused during 2004.
Stage 1 result:
Limitations of chart review GPNB defined by Nominal Group
Burns
Neonates with pathology
Many charts were unavailable Gynaecologic and obstetric complications
Deceased patients could not be included Trauma
Orthopedic surgery
as their charts were not sccessible Cardiovascular surgery
Upper GI haemorrhage
Transfusions were poorly documented in Hematological and Hemato-oncological diseases
the charts Non-hematological cancers
Portion requiring
ICD Code transfusion:
Group Concensus Units requested Units transfused
1 Gastric Carcinoma C16 0.80 0.57 0.37
2 Cervical Carcinoma C53 0.72 0.86 0.64
3 Leukemias C91-
C91-C95 0.89 0.73 0.73
GPRT defined by the complete 4
5
Aplastic Anemia
Cardiovascular Surgery
D61 0.77
0.73
0.76 0.74
0.90 0.42
concensus process 6
7
Esophageal Varices
Peptic/ Doudenal Ulcer
I85
K25--K29
K25
0.96
0.45
0.86
0.72
0.76
0.62
8 Chronic Renal Insufficiency N18 0.90 0.65 0.44
9 Abnormal Uterine Bleeding N93.8-
N93.8-93.9 0.19 0.84 0.34
10 Incomplete Abortion 03--06
O 03 0.28 0.94 0.16
11 Postpartum Hemorrhage O 72 0.51 0.86 0.24
12 Premature babies P07 0.11 0.28 0.26
13 Prematurity and Sepsis P36 0.15 0.28 0.23
14 Fracture of the pelvis S 32.1-
32.1-32.8 0.54 0.60 0.38
15 Fracture of the femur S72 0.44 0.60 0.18
16 Myomas D25 0.17 1.00 0.34
17 Gun-
Gun-shot wound Y.24 0.65 0.80 0.22
18 Stabbings Y.28 0.42 0.51 0.19
3
CLINICAL ICD CONSENSUS REQUESTED OBSERVED
Participat Prevalence Prop Px Estimat Need
No. CONDITION CODE UNITS REQUIRED UNITS TRANSFUSIONS
No. CONDICION Clinicians 2004 Need Blood Units/Px
Units/ Px/Yr
Px /Yr
1 Gastric Carcinoma C16 3 4 3
1 Gastric Carcinoma 10 7.16E--05
7.16E 0.80 3
2 Cervical Carcinoma C53 3 5 4
2 Cervical Carcinoma 12 1.20E-
1.20E-04 0.72 3
3 Leukemias C91-
C91-C95 4 6 3
3 Leukemias 12 8.07E--05
8.07E 0.89 4
4 Aplastic Anemia D61 7 8 4
4 Aplastic Anemia 9 3.40E-
3.40E-05 0.77 7
5 Cardiovascular Surgery 4 3 3
5 Cardiovascular Surgery 3 4.50E-
4.50E-05 0.73 4
6 Esophageal Varices I85 4 6 5
6 Esophageal Varices 8 3.34E--05
3.34E 0.96 4
7 Peptic/ Doudenal Ulcer K25--K29
K25 3 4 3
7 Peptic/ Doudenal Ulcer 10 1.89E-
1.89E-04 0.45 3
8 Chronic Renal Insufficiency N18 2 5 3
8 Chronic Renal Insufficiency 3 1.95E--04
1.95E 0.90 2
9 Abnormal Uterine Bleeding N93.8--93.9
N93.8 2 3 2
9 Abnormal Uterine Bleeding 10 2.22E-
2.22E-04 0.19 2
10 Incomplete Abortion O 03-
03-06 2 2 2
10 Incomplete Abortion 6 1.11E-
1.11E-03 0.28 2
11 Postpartum Hemorrhage O 72 3 2 2
11 Postpartum Hemorrhage 11 2.03E--04
2.03E 0.51 3
12 Premature babies P07 0.30 ,10 0.097
12 Premature babies 14 2.65E-
2.65E-04 0.11 .3
13 Prematurity and Sepsis P36 0.30 .13 0.13
13 Prematurity and Sepsis 13 2.55E--04
2.55E 0.15 .3
14 Fracture of the pelvis S 32.1-
32.1-32.8 2 4 3
14 Fracture of the pelvis 19 2.96E-
2.96E-05 0.54 2
15 Fracture of the femur S72 2 3 2
15 Fracture of the femur 22 2.01E--04
2.01E 0.44 2
16 Myomas D25 2 3 2
16 Myomas 6 1.92E-
1.92E-04 0.17 2
17 Gun-
Gun-shot wound Y.24 3 3 2
17 Gun-
Gun-shot wound 13 1.80E-
1.80E-04 0.65 3
18 Stabbings Y.28 2 3 2
18 Stabbings 12 2.26E--04
2.26E 0.42 2
4
Analysis Results: comparison of observed data with clinicians
Intraclass correlation coefficient was used to calculate the level of agreement concensus
between the clinician based need estimate versus the calculated need based CLINICAL ICD PREVALENCE MODEL REQUESTED OBSERVED
on units requested or units transfused. CONDITION CODE 2004 ESTIMATE UNITS * TRANSFUSIONS*
Gastric Carcinoma C16 7.10E-05 1169 1099 544
ICC calculated against units requested was 0.750 Cervical Carcinoma C53 1.19E-04 1769 3310 2097
Leukemias C91-C95 8.00E-05 1954 2207 1204
Aplastic Anemia D61 3.37E-05 1245 1325 679
ICC calculated against units transfused was 0.834 Cardiovascular Surgery 4.46E-05 894 826 381
Esophageal Varices I85 3.31E-05 872 1179 868
Peptic/ Doudenal Ulcer K25-K29 1.87E-04 1732 3889 2386
Overall ICC between clinician based estimates and Chronic Renal Insufficiency N18 1.93E-04 2381 4100 1756
hospital records data was 0.951 Abnormal Uterine Bleeding N93.8-93.9 2.20E-04 574 4049 1027
Incomplete Abortion O 03-06 1.10E-03 4230 14200 2417
Postpartum Hemorrhage O 72 2.01E-04 2108 2370 661
The intraclass correlation coefficient ranges from 0 and Premature babies P07 2.63E-04 60 51 45
Residual variability (1 - intraclass correlation coefficient) Myomas D25 1.90E-04 443 3414 886
Gun-shot wound Y.24 1.79E-04 2393 3269 540
is due to true variation between clinicians and Stabbings Y.28 2.24E-04 1292 2640 580
measurement error. TOTAL NEEDS 24612 50509 16846
Strengths Weaknesses
Clinicians were able to define a group of clinical Labour intensive, time consuming,costly
conditions to which 67-68% of all transfused patients Depends on the willingness of clinicians to participate,
could be assigned and on the adequacy of their knowledge of blood
Their estimates of the red cell transfusion requirements utilisation in their own specialties
showed reasonable comparability to those obtained from Clinicians could not estimate prevalence of the
hospital records. conditions identified, so there is dependence on an
Requires the investigators and blood services to consult additional data source
clinicians about the transfusion requirement for their Validation against other data sources depends on the
patients existence, availability and quality of hospital records and
Should engage clinicians to think about blood on availability of human resources to extract data from
requirements about the quality of data that could help to them
assess need, and the adequacy of the data currently Method does not take account of access to health care
available. Additional data on this would be essential to calculate
Anecdotal evidence from the project team that these blood requirements in any country where an important
approaches have been welcomed. proportion of the population lacks access to facilities in
This would seem to be supported by the high levels of which the availability of safe blood transfusion could
clinician participation in the present project benefit the outcomes of GPRT
Conclusions
Clinicians were able to define a group of clinical
conditions to which 67-68% of all transfused patients
could be assigned
Their estimates of the red cell transfusion requirements
showed reasonable comparability to those obtained from
hospital records.
Neither source of data can adequately identify the
adequacy or otherwise of the current supply levels.
To estimate the blood requirements for a given
population at a given time, data such as those
obtained in this study should be combined with
information on access to hospital care
5
Objectives
WHO Expert Consultation on Review parameters in health system and
clinical care which influence requirement of
estimation of blood blood and blood components
requirements Review of existing mechanisms/
methodologies and models of blood
estimation based on regional/country
experience
Day 1
Assess the feasibility and accordingly define
the steps in developing a simple model to
estimate blood needs
Gretchen Stevens
Neelam Dhingra
Global burden of disease database
New estimates due 2011
Overview of current situation Important principles in preparing cross-national
Little progress in the area of predicting blood statistics
requirements Selecting health indicator and metrics
Essential for planning Framework for monitoring health systems
Historical perspective Facility assessments
Various non-evidence based estimations Population-based surveys
Advanced healthcare systems Clinical reporting systems
Donations- 5% of population Correcting for bias in available data
3% of population regular blood donors Estimating and communicating uncertainty
Previous approaches Input uncertainty
Blood usage with different denominators Poor quality data
Per 1000 population
Model uncertainty
Per acute hospital bed
Parameter uncertainty
1
Pablo Perel
Luz Maria De Regil
Frequency of trauma
Low resolution data on mortality and DALYs (but no/little data on
incidence and morbidity) Global burden of disease database has data on
Increasing in importance anaemia but
Frequency of bleeding in trauma Variable Hb cut offs and definitions
Bleeding probably important cause of death Adjustments required for altitude (1g/dL per 1000m),
Reported transfusion rates differ widely smoking and gestation
Evidence base for transfusion of blood/products in Targeting of public health interventions depends on
trauma prevalence of anaemia in Groups at Risk
Weak/contradictory VMNIS (Vitamin and Mineral Nutritional Information
Interventions to reduce transfusions System
Well conducted clinical trials (e.g. CRASH-2) required Estimates of micronutrient deficiencies at national and
Clinical trials such as CRASH-2 may provide better regional levels
and higher resolution data on frequency of trauma Helminth infections?
and frequency of bleeding in trauma (WOMAN- PPH) Haemoglobinopathies?
2
Ideal: need Ideal: need
No Morbidity/Mortality
Donor selection / motivation Y Potential Donors Access 100%
(management) X units for transfusion, such that no patient experiences (at
no time) morbidity/mortality due to shortages in RBCs, X is
Donor deferral driving number of potential donors (Y)
Patient need
Donor screening (testing) -Define spatial and temporal specific drivers for transfusion, McClelland
- Malaria (ATLAS, Marum, Olumese, WHO)
Processing of blood products - Trauma (Perel)
- Nutrition (De Regil)
- Maternal Health (Mathai)
- etc
Inventory
- Define methodology (McClelland, Rao, GBD)
Patients X units for transfusion, such that no patient - Perfect transfusion practices
experiences (at no time) morbidity/mortality - Optimal use of alternatives (drugs, colloids, salvage, EACA etc)
due to shortages in RBCs
In fact: X is driving Y - No uncertainty and bias
Use: The amount of blood actually transfused (excludes Use: The amount of blood actually transfused (excludes
unmet demand) unmet demand)
Need: The amount of blood that would be used if all those Need: The amount of blood that would be used if all those
who needed a bood transfusion were recognised and had who needed a bood transfusion were recognised and had
blood appropriately prescribed i.e. includes unmet demand blood appropriately prescribed i.e. includes unmet demand
and excludes inappropriate transfusions and excludes inappropriate transfusions
1
If you have to forecast,
forecast often.
Edgar R. Fiedler,
The Three Rs of Economic Forecasting:
Irrational, Irrelevant and Irreverent
3 4
Production
438,400 Testing 732
Donor Inventory Hospital
Customers R&D Customers Supply Demand
Education
916,000 WB units 4,525 employees 600,000 patient Supply Chain Management Enablers
41,000 17,000 volunteers transfusions a year Donor Recruitment Event Planning Production Planning Inventory Mgmt Customer Mgmt
Donor Retention Locations and Hours Discard Mgmt Inventory Protocol Product Disposition
plateletpheresis units 41 permanent Cost to recipient is
Donor Contact Appointment Booking Recall Mgmt Product Delivery Product Utilization
55,000 plasmapheresis collection sites fully covered under Donor Segmentation Donor Influx & Flow Order Fill Demand Estimates
units 12 manufacturing provincial / territorial Corporate Partners Staff & Volunteer Mgmt Integrated Systems
All units are freely centres government health
donated 3 blood-testing plans Demand Forecasts
2.16 WB donations per centres
donor The collection, manufacturing and delivery of blood products is a complex business,
supported by a host of enablers. Demand forecasts can provide the lead time necessary
to ensure that adequate supply is available to meet expected customer demand. It allows
CBS to maximize service delivery and stakeholder value.
5 6
1
What's behind the demand for blood? How is demand trending?
Total RBC Demand - 52 Week Moving Average O Neg RBC Demand - 52 Week Moving Average
840,000
100,000
830,000
820,000 95,000
810,000
800,000 90,000
790,000
85,000
780,000
770,000
80,000
760,000
750,000 75,000
7
7
05 -27
05 -27
7
06 -27
06 -27
06 -27
7
06 -27
7
07 -27
07 -27
07 27
07 -27
7
7
08 -27
-0 7
7
08 -27
7
09 -27
7
7
7
10 -27
3-2
6-2
9-2
2-2
3-2
6-2
9-2
2-2
3-2
6-2
9-2
2-2
3-2
6-2
9-2
2-2
3-2
6-2
9-2
2-2
20 3-2
20 -09-2
200 -05-2
20 -07-2
20 -11-2
20 -09-2
-2
20 -01-2
20 -05-2
200 7-2
20 1-2
20 -03-2
-2
20 -07-2
200 -09-2
1-2
20 -05-
20 -05
20 -07
20 -11
20 1
20 -03
20 -09
20 -01
20 -03
20 -07
200 -11
20 -03
20 -09
20 -01
200 -05
20 -11
-0
-0
5-0
-1
-0
-0
-0
-1
-0
-0
-0
-1
-0
-0
-0
-1
-0
-0
-0
-1
-0
-0
-1
-0
05
05
05
06
06
06
06
07
07
07
07
08
08
08
08
09
09
09
09
05
05
05
6
06
07
07
8
08
08
09
09
9
09
200
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
The longer-term underlying growth in total RBC demand has been in the order of 2% per
year, but this growth has not always been consistent. Note the slow down in the latter
half of FY0708, the rapid growth throughout FY0809 and the current decline in FY09/10.
Even O Neg growth has eased off in FY09/10 - slowing, but not declining. The
Average units of blood/blood products required per recipient = 4.6 units proportion of total RBC issues which are O Neg has grown from 10% at the start of
FY2004/05 to 11.3% this fiscal YTD
7 8
1,500 100
1,500 100
1,200 80
1,200 80
900 60
900 60
600 40
600 40
300 20
300 20
0 0
0 0 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ 2005 2013 2020 2030 Units Transfused per 1,000 FY0506 Blended
Supply management
Bloods competitive Concentration of hospital customer demand...
brand and profile
The Pareto Principle (80/20 rule) is alive and well at Canadian
Blood Services
11 12
2
Hospital shipments by day Smoothed hospital shipments by day
# of RBC Units Issued to Hospitals per Day # of RBC Units Issued to Hospitals per Day (7 Day Moving Average)
4,500 19,000
4,000 18,000
3,500 17,000
3,000 16,000
2,500 15,000
2,000 14,000
1,500 13,000
1,000 12,000
500 11,000
0 10,000
1
07 /27
07 /23
8
07 /14
07 /09
4
07 /30
07 /26
07 /21
7
08 /12
08 /07
0
08 /25
1
08 /16
08 /12
7
08 /02
08 /28
08 /24
9
09 /15
09 /10
5
09 /03
09 /29
4
09 /20
09 /15
09 /11
6
09 /01
09 /27
3
09 /18
4
20 /04/0
20 /06/1
20 /09/0
20 /12/1
20 /03/0
/3
20 /05/2
20 /08/0
20 /11/1
20 /02/0
20 /04/2
20 8/0
20 /10/2
2/1
1
07 /27
3
07 /18
4
07 /09
07 /04
0
07 /26
1
08 /17
2
08 /07
08 /04
08 /30
5
08 /21
6
08 /12
7
08 /02
8
08 /24
9
09 /15
0
09 /05
3
09 /29
4
09 /20
5
09 /11
6
09 /01
7
09 /23
4
20 /04/0
20 /05/2
20 /07/1
20 /09/3
20 /11/2
20 /01/1
20 4/2
20 /06/1
20 /08/0
20 /09/2
20 /11/1
20 1/1
20 /03/0
20 /04/2
20 /06/1
20 /08/0
20 9/2
20 /11/1
2/1
20 /04
20 /05
20 /07
20 /08
20 /09
20 /10
20 /11
20 /01
20 /02
20 /03
20 /04
20 /06
20 /07
20 /09
20 /09
20 /10
20 /12
20 /01
20 3
20 /03
20 5
20 /06
20 /07
20 /09
20 /09
20 /11
/0
/0
/0
/1
20 /04
20 /06
20 /08
20 /09
20 /10
20 /12
20 /02
20 3
20 /03
20 /05
20 /07
20 /09
20 /10
20 /12
20 /02
20 /03
20 /05
20 /07
20 /09
20 /10
/0
/0
/0
/0
/1
07
07
07
07
08
08
08
08
08
08
09
09
09
09
07
07
07
07
07
07
08
08
08
08
08
08
09
09
09
09
09
09
09
20
20
13 14
2.0%
100%
90%
1.0%
80%
Total B-
60% Total A-
-1.0%
Total O-
50%
Total AB+
40% Total B+
-2.0%
Total A+
30% Total O+
-3.0%
20%
10%
-4.0%
0% O+ A+ B+ AB+ O- A- B- AB- Blood
08 r
09 r
20 ay
07 v
20 ec
20 ay
08 v
09 c
20 ay
09 v
ec
07 l
20 ep
20 /Feb
08 l
20 ep
20 eb
09 l
20 ep
20 un
20 an
20 un
20 /Jan
20 un
07 t
08 t
09 t
07 r
08 r
09 r
20 ug
20 ug
20 ug
Group Rh
20 /Ju
20 /Ju
20 /Ma
20 /Ju
20 /Oc
20 /Oc
c
20 /Ap
20 /Ap
20 /Ap
20 /No
20 o
20 e
20 /No
/M
/O
/D
/N
/D
/D
/F
/M
/S
/M
/S
/M
/S
/J
/J
/J
/J
/A
/A
/A
07
08
09
07
07
07
08
08
08
08
08
09
09
09
09
07
08
09
20
20
20
Not all blood groups are in equal demand. Not all blood types grow at the same rate.
Almost 70% of all demand is concentrated in O Pos and A Pos. Demand for B+ and AB+ is declining; growth rates for Neg Rh are
higher than for Pos.
15 16
Bottom Up Forecast:
Contacts
available (how many transfusions; what types of
RBC, Platelets & Plasma procedures; etc.)
Feeds detailed Budget distribution,
Ju
JuneJune
& Nov Collection & Production tactics Nov/Dec Clinical driver data available has not been particularly
Utilizes six months current year data
effective at forecasting variations in customer demand
(still need to forecast the clinical drivers)
Blend of Top-down (statistics based) and Bottom-up (customer
canvass based) forecasting techniques.
17 18
3
Model selection process Volatility of demand ...
12 Month Moving RBC Issue Yr/Yr Growth Rates Monthly RBC Issue Yr/Yr Growth Rates
4.0% 14.0%
10.0%
2.0% 4.0%
-4.0%
ct
ct
ct
ct
ct
ct
ct
ct
pr
ul
pr
ul
pr
ul
pr
ul
pr
ul
pr
ul
pr
ul
n
an
an
an
an
n
Ju
pr
ct
ct
ul
Ap
l
(R-squared = .83) outperformed
an
Ju
Ja
Ja
Ja
Ja
Ap
/O
/O
/O
/O
/O
/O
/O
/J
/J
/J
/J
/J
/J
/J
/A
/A
/A
/A
/A
/A
/A
Ja
O
/O
/J
/J
/J
/J
/J
/A
06/
/J
08/
08/
05
08
09
05
06
08
09
05/
07/
07/
08/
09/
05
06
09
05
06
08
09
07/
05
06
09
05
06
08
09
07/
07
07
08
09
05
06/
07
07
06
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
weekly model
Higher level model produced best fit
so ABO Rh distributions were made
using a Top Down Multiple Level Annualized year over year growth rates ranged from
model
3.8% in March 2009 to 0.2% in December 2009.
ABO Rh forecasts were further
distributed by Region Underlying trend is in the neighbourhood of 2% per
year, but exponential smoothing models will weight
recent data more heavily than past data.
19 20
Forecast model performance ... Inventory - the buffer between supply & demand
Daily Red Blood Cell Inventory Levels
20,000
35,000
19,000
32,500
18,000
30,000
17,000
27,500
16,000
25,000
15,000
22,500
14,000
20,000
13,000
17,500
12,000
15,000
11,000
12,500
10,000
10,000
1
1
-0
-0
8-0
0-0
-0
-0
-0
6-0
-0
0-0
-0
-0
-0
-0
-0
0-0
2-0
-0
04
06
12
02
04
08
12
02
04
06
08
02
7-0
7-1
8-0
8-1
9-1
9-1
7,500
7-
7-
7-
8-
8-
8-
8-
9-
9-
9-
9-
0-
0
1
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
5,000
Actual Budget View
1
01
01
01
01
01
01
01
01
1
-0
-0
0-0
-0
4-0
-0
4-0
-0
-0
1-0
-0
4-0
-0
-0
-0
1-0
7-
0-
7-
0-
1-
7-
0-
1-
04
07
01
01
07
10
04
04
07
10
-1
-0
-0
-1
-0
-0
-0
-1
-0
-0
-0
-1
-0
-0
-
-
04
04
04
05
05
05
05
06
06
06
06
07
07
07
07
08
08
08
08
09
09
09
09
10
The exponential smoothing model does a reasonable job of predicting future
Volatility in demand & supply can lead to unavoidable imbalances between the two.
demand - at least at an aggregate level of detail. The budget view remains
Inventory acts as a buffer to offset these imbalances, shrinking when demand outpaces
fixed for each fiscal period, but quarterly forecast updates are reviewed.
supply and growing when the opposite occurs. A minimum of 5 days of inventory on
hand for each ABO Rh type is recommended.
21 22
Demand forecasting - just the beginning ... When detailed demand data isn't available ...
Extraneous: RBC Units Issued per 1,000 population by fiscal period
Technology
Weather (Number)
Regulation
Trauma Q2 2009/10 Issued CAGR per
Labour Action 2004/05 2005/06 2006/07 2007/08 2008/09
Annualized CAGR 1,000 pop
Canada (Excl Quebec) 31.2 31.4 31.7 31.7 32.7 32.3 1.8% 0.7%
CBS Strategies/ Demand Forecast Comparison of Newfoundland and Labrador 37.7 37.7 36.9 37.3 35.9 33.5 -2.7% -2.4%
Goals/Tactics Actual Results to Prince Edward Island 25.5 28.2 26.5 28.2 30.9 26.8 1.4% 1.0%
Target Nova Scotia 35.3 34.8 35.9 33.3 33.7 32.8 -1.4% -1.5%
New Brunswick 30.7 31.3 32.8 32.4 33.4 32.4 1.0% 1.1%
Quebec 29.2 29.1 29.2 29.6 29.9 29.8 1.1% 0.4%
Ontario 31.4 31.3 31.2 30.9 32.3 32.3 1.5% 0.6%
Aging Population Hospital Expansion/ Manitoba 36.9 36.7 38.0 38.5 37.4 36.9 0.8% 0.0%
Contraction Saskatchewan 36.0 36.6 37.3 37.8 38.5 38.6 2.1% 1.4%
Alberta 30.4 31.7 32.1 31.6 32.2 31.0 3.0% 0.4%
Analysis of
British Columbia 27.2 28.1 28.8 30.5 31.0 31.0 3.8% 2.6%
Key Drivers Yukon Territory 26.4 25.8 30.1 26.1 27.9 26.3 1.5% -0.1%
Recommended Northwest Territories 21.6 19.2 17.4 17.2 17.3 19.1 -2.4% -2.4%
Actions Cause & Effect
Nunavut 10.1 9.7 9.2 8.4 9.6 9.4 -0.1% -1.6%
Formal Results
Review
Population statistics and forecasts are usually readily available. Relating hospital
demand to population growth will explain some, but not all of the growth in
Demand forecasting is just the beginning. Performance during the year must demand. Refining population estimates to weighted cohorts (e.g. by age band)
be closely monitored, analyzed and reviewed and lead to the development would likely yield improved demand forecasts. Provisioning for non-population
of appropriate corrective actions or adjusted goals and strategies. related overlays (e.g. increased health care funding) could also be considered.
23 24
4
Thank you! Questions?
Tony.Steed@blood.ca
25
5
Background Hong Kong
Area: 1,103 square km
Population: 7 million
Estimating blood demand Chinese 95%
people/ km2
Overall density: 6,300 people/
methodology practiced in HK Total health expenditure: 5.1% of GDP
Public health expenditure:
expenditure:
WHO Experts
Experts Consultation on 2.6% (2005/
(2005/06) (US$4.13 billion)
Estimation of Blood Requirements
Requirements Birth rate: 11.3 live births per 1000 population
03-
03-05 February 2010, WHO, HQ, Infant mortality rate: 1.8 per 1000 live births
Geneva
Life expectancy: male 79.3 yr, female 85.5 yr
Che-
Che-Kit Lin
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
1
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
2
Inventory in BTS and HBBs BTS WB/RBC inventory levels
BTS aims to maintain inventory of WB/RBC 5 Level Description Group O+ Group A+ Group B+ Group AB+
days of supply
I Desirable 1400 800 800 Not applicable
Stock holding of WB+RBC (all blood groups) at BTS as patient can
- 8.89 days (yr
(yr 2008 annual average) II Safe 1100 - 600 - 799 600 - 799 receive RBC of
any ABO group
Each HBB holds 1399
holds about 3-
3-5 days of hospital
III Action 600 - 400 - 599 400 - 599
consumption 1099
Inventory level in HBB is set out in the Blood IV Alarm 350 - 599 200 - 399 200 - 399
Supply Agreement
Agreement which is reviewed annually V Dangerous < 350 < 200 < 200
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
< III < II < II Further reduce stock supply and handle difference by case requests.
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
Client Satisfaction
250000 120 Blood Utilization Statistics
A n n u a l T a r g e r ( U n it )
200000 100
P ercentage
80
150000 Annual Target
60 Achievement (%)
100000
40 Client Satisfaction (%)
50000 20
0 0
P l a te le t
P l a te le t
P l a te le t
P l a te le t
P l a te le t
P l a te le t
P l a te le t
P l a te le t
P l a te le t
R e d c e ll
R e d C e ll
R e d C e ll
R e d C e ll
R e d C e ll
R e d C e ll
R e d C e ll
R e d C e ll
R e d C e ll
P la sm a
P la sm a
P la sm a
P la sm a
P la sm a
P la sm a
P la sm a
P la sm a
P la sm a
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
3
Red Cells Utilization by Specialties in Public Hospitals
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
Platelet Utilization by Specialties in Public Hospitals FFP Utilization by specialties in Public Hospitals
Year 2004 2005 2006 2007 2008 Year 2004 2005 2006 2007 2008
M&G 46531 47504 53322 57346 57378 M&G 21393 21686 23316 22082 19906
Surgery 12665 14922 14577 15102 14120 Surgery 15020 15751 17069 17102 16849
Paediatrics 9374 10848 10940 11393 8403 Neurosurgery 1443 1504 1970 1829 2577
Oncology 8204 6913 6806 7914 7526 Orthopaedics 1731 1636 1651 1771 2252
Chest 2109 3072 2776 2852 2639 Chest 2164 2711 2277 2183 2157
Neurosurgery 1288 1680 1494 2139 2473 Paediatrics 2426 2209 1999 1888 1747
Orthopaedics 1519 1466 1582 1818 1939 ICU 5497 1960 961 1251 1618
O&G 1479 1317 1278 1384 1385 O&G 1003 932 936 1060 1178
ICU 4338 1960 605 929 1162 Oncology 1091 1413 1338 990 1121
A&E 245 373 404 338 310 A&E 333 373 479 405 441
Other 6922 6066 948 7893 10197 Other 742 1389 628 167 1609
Total 94674 96121 100191 109108 107532 Total 52843 51564 52764 51256 51455
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
WB+RC issued 159564 161660 160152 170625 172722 Platelet issued 88483 90641 94852 103197 100891
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
4
Benchmarking Blood Utilization in Public Production planning
Hospitals
Estimate annual blood requirement
A territory-
territory-wide peer-
peer-to-
to-peer review of blood Review quarterly
quarterly demand of blood components
utilization and expiration by hospitals and various of different blood groups,
groups, blood collection, blood
clinical specialties. inventory and wastage and plan short term
BTS provides report every six months. adjustments.
Hospital Transfusion Committee has the responsibility
to review its hospital
hospitals performance and implements
Monthly communication with HBB on matters
improvement measures accordingly. that potentially affect short-
short-term demand
Weekly stochastic forecasting based on historical
demand and communication with HBB to plan
daily production of components
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
Hospitals
Hospitals Forecast of WB/RC Demand BTS Calculation of hospital WB/RC Demand
5
BTS Calculation of WB/RBC Demand BTS Calculation of WB/RBC Demand
for 2010-
2010-2011 for 2010-
2010-2011
= [WB/RBC issued in 2009 x population growth /
WB/RBC issued to clients in the period of
November 2008 to October 2009: 200,027 units Blood stock replenishment satisfaction in 2009]
+ Clients
Clients estimated potential increase/decrease
Average satisfaction rate of WB/RBC stock
replenishment during the period of November in WB/RBC demand for 10- 10-11
2008 to October 2009: 99.66%
Clients
Clients estimated potential increase/decrease in = (200,027 x 1.004 / 0.9966) + 20
annual WB/RBC demand = 20 units
HK population growth: 0.4%
= 201,532 units
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
Since hospitals
hospitals forecast is greater than the BTS Average WB/RBC expiry rate in the previous
calculation,
calculation, it will be taken as the baseline three years, i.e. 2006-
2006-2008 = 0.013%
demand for further calculation to determine the
annual WB/RBC demand for 2010/2011.
2010/2011.
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
6
Long Term Forecast
Forecast Effect of the Silver Tsunami
Tsunami
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong
Admission Kong
14515 Red Cross
15079 Blood14999
Transfusion
15790Service, Hospital16879
15801 Authority
Conclusion
Involving hospitals in forecasting short term demand
seemed to be an effective approach
To achieve maximum use of the precious gifts of life
from blood donors and to ensure all demands are met
timely,
timely, it is important to understand the complex
interrelations of supply and demand, factors that
impact upon them and have all parts and parties of
supply chain working together
Blood utilization is increasing
Aging of population will have significant impact on the
demand for blood supply
Hong Kong Red Cross Blood Transfusion Service, Hospital Authority Hong Kong Red Cross Blood Transfusion Service, Hospital Authority
7
Needs Assessment:
How can we use this data
Epidemiology of Transfusion in
Scotland in UK or similar setting
Who gets transfused and why?
in resource restricted setting
Evolution
2000: STEP Introduction of tailored information system software
to enable the easy collection and analysis of transfusion data for prompt
Scottish Transfusion Epidemiology Project feedback to clinicians and Hospital Transfusion Committees. This would
involve the construction of a merged record that is a by-product of routine
clinical practice (held on the existing hospital patient administration system)
and data extracts from the local hospital laboratory system (and in some cases
operating theatre).
2005: STED
Scottish Transfusion
Epidemiology database
WHO Needs assessment Feb 5 WHO Needs assessment Feb 6
2010 2010
1
Why
Progressively uncovered problems in
data quality
2008 NHSS-AFB terminology and definitions for data items
NHS Scotland opacity of Progesa data
heterogeneity of hospital blood bank IT systems
Account for Blood heterogeneity of setting up [same system used in
different ways]
human resource for regular data extraction and QA
Etc etc
Predict requirements
Disseminate
2
Associating transfusion record with clinical
Structure of linked data Date rule
episodes Clinical rule
Patient had 6 admissions,28 procedure codes
Blood bank transfusion records Inpatient episode records 15 diagnosis codes and 4 transfusion episodes
January
RBC,Plt, 4 Procedure and 6 diagnosis fields
Patient Id RBC
Cyro,FFP
RBC,Plt,
Cyro,FFP RBC
December
RBC
Transfusion Records
Date of Transfusion
Non Health Service On line report on red
RBC Used Data sets cell use for surgical
Platelets used procedures
FFP used General Register Office
Death Records
Cryo used
Census Data
Other Health
Service data
sets Inpatient and Day
Patient case Records (SMR1)
Maternity
Date of admission
Neonatal
Date of discharge
Outpatients Cancer Registry
Procedures
Ward Watcher
(ICU) Diagnosis
Incidence Date Consultant responsible for
care
SCI Morphology/Stage/
Hospital of Treatment
referrals A&E Tumour size
PIS Hospital WHO Needs assessment Feb
Diagnosis 15 WHO Needs assessment Feb 16
Prescribing 2010 2010
3 associated with
intensified blood
Substantial reduction over period 2.5
saving initiatives
2003-2006 including cell salvage
2
2003 2006
3
Red cell use in aortic aneurysm repair Red cell use in primary total hip replacement
Elective repair of aortic aneurysm Primary total hip replacement
7 1.4
1
5
4
variation variation in 0.8
practice between health Tayside increase is an
boards continues but 0.6 artefact of an identified
3
reduced anomaly with the source
2
0.4 data for 2006 and should
be ignored.
0.2
1
0
0
Fife
Tayside
Fife
Tayside
Greater Glasgow
Greater Glasgow
Ayrshire & Arran
Gram pian
Highland
Lanarkshire
Lothian
Gram pian
Highland
Lanarkshire
Lothian
Borders
Western Isles
Borders
Western Isles
Ayrshire & Arran
H ighland
Lothian
Tayside
Fife
H ighland
Lothian
Tayside
Grampian
Lanarkshire
Grampian
Lanarkshire
Greater Glasgow
Greater Glasgow
Example of STED report: red cell use in a medical condition lymphoid leukaemia
Utilises ~18% of total red cell use per year (~35,000 units)* Incidence Prevalence
Red cell use data
Annual
mortality
* STED Data for 2006 WHO Needs assessment Feb 21 WHO Needs assessment Feb 22
2010 2010
4
Which clinical conditions do we still
have to label as other?
Demographics
patients who have multiple admissions
with several diagnoses
+75%
5,000,000 Total Scotland 80
Population
4,000,000 Male 60
+39%
3,000,000 Female
40
2,000,000
20
1,000,000
0
0
-20 11%
-12% -
02
04
06
08
10
12
14
16
18
-15% -18%
20
20
20
20
20
20
20
20
20
-40
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
>=85
5
Population Change in Europe
RBC Projections for Scotland (excluding Forth Valley), 2006-2018
Figure 9 Projected Percentage Population Change in Selected European Countries, 2004-2031
230,000 30
RBC projection
20
220,000 (2005 HB rates
applied to
population 10
Percentage change
210,000 estimates)
0
RBC projection
200,000
(age/sex rates -10
applied to
190,000 age/sex -20
population
estimates)
-30
180,000
E stonia
E U25
E U15
Cyprus
Austria
England
Hungary
Italy
Portugal
P oland
Finland
Spain
Bulgaria
Latvia
Romania
Lithuania
Czech Republic
E U new members
Slovakia
Germany
Slovenia
Denm ark
Netherlands
France
Wales
M alta
Belgium
Ireland
Luxem bourg
Greece
Northern Ireland
Sweden
UK
Scotland
170,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Source: GAD (UK and constituent countries) and Euros tat. Note: Euros tat als o produce an alternative UK projection not shown here.
Orkney Islands
17.9
Shetland Islands
21.6
32.6 Borders
35.7
Ayrshire & Arran
33.8
In patient/day case records per 1000 population RBC units transfused per 1,000 Inpatient/Daycase
records
RBC units tx per 1,000
Inpa tie nt/da ycase records
Inpatie nt/Da ycase re cords
per 1000 popn
He alth Board 2003 2005
Hea lth Boa rd 2003 2005 Argyll & Clyde 194.0 149.4
Argyll & Clyde 205.3 214.5 Ayrshire & Arran 141.1 138.2
Ayrshire & Arra n 236.5 247.5 Borde rs 169.9 161.6
Borde rs 196.2 217.4 Dumfrie s & Ga llow a y 143.8 146.6
Dumfrie s & Gallow a y 206.8 214.5 Fife 185.5 187.7
Fife 196.5 204.4 Grampia n 179.3 172.6
Gra mpia n 213.8 212.9 Grea te r Gla sgow 171.9 155.3
Gre ater Glasgow 340.4 349.5 Highla nd 127.4 114.9
Highla nd 261.5 269.4 La na rkshire 147.9 135.5
Lanarkshire 238.0 238.3 Lothia n 213.8 189.5
Lothia n 226.5 236.8 Orkne y 130.1 125.4
Orkne y 162.4 175.4 Shetla nd 113.2 18.6
She tla nd 163.6 192.7 Ta yside 200.2 183.3
Tayside 240.8 242.5 We ste rn Isle s 199.1 146.0
Scotla nd Ex cl FV 177.4 161.5
We ste rn Isles 249.6 229.5
Scotla nd Excl FV 244.8 251.5
WHO Needs assessment Feb 35 WHO Needs assessment Feb 36
2010 2010
6
Scottish Index of Multiple Deprivation 2006
" Deprivation takes many different forms in every known society. People
can be said to be deprived if they lack the types of diet, clothing, housing,
household facilities and fuel and environmental, educational, working and
social conditions, activities and facilities which are customary, or at least
widely encouraged and approved, in the societies to which they belong.
Townsend, P (1987) Deprivation, Journal of Social Policy 16 (1) pp 125-146
37 indicators
Income, Employment, Crime, Education, Health (including standardised
mortality ratios), Housing, Geographic access to services
SIMD 2006 divides Scotland into 6,505 data zones with median
population size of 769. These are ranked from 1 most deprived to 6,505
least deprived
Greater Glasgow
ALD by SIMD quintile From now on
Alcoholic Liver Disease in Greater Glasgow, 2005
No Patients RBC Units RBC per NHS Scotland Account for blood: data
Tx with ALD Transfused in patient Tx warehouse development with automated
SIMD Quintile in 2005 2005 (2005) harvest of standardised data from hospital
1 (Least depived) 12 57 4.8
2 10 113 11.3 blood bank systems.
3 18 118 6.6
4 39 242 6.2
5 (Most deprived) 173 1,264 7.3 Finally it is adequately funded
Greater Glasgow 252 1,794 7.1
No Patients Transfused who have a history of Alcoholic Liver Disease and
were transfused in 2005
7
Needs Assessment: Needs Assessment:
How can we use this data - in UK or How can we use this data - in resource
similar setting restricted setting
8
Aggregated Blood Report from
AABB (ARC and ABC facilities)
National Blood Collection and Utilization US Blood Centers Estimated Days of Supply
and 16.0
January 29, 2010
14.2 O+
Blood Availability and Safety Information System 14.0
O-
Estimated Days
12.0
(BASIS) 10.0
A+
A-
8.0 6.7 6.8 6.9 7.2
B+
6.0 4.6
3.1 4.0 B-
4.0
Jerry A. Holmberg, Ph.D,
Ph.D, MT(ASCP)SBB 2.0
AB +
307,450
100,000
O- 3.1 10,332 19,721 30,053
80,000
60,000 Fixed estimate In hospital A+ 6.8 108,336 95,788 204,124
40,000 based on assumption of
constant 6 day supply, i.e., A- 4.6 13,056 16,904 29,960
20,000 281,731
0
B+ 6.9 29,331 25,356 54,687
O+ O- A+ A- B+ B- AB + AB - B- 4.0 3,724 5,635 9,359
Blood Type
AB+ 14.2 19,949 8,452 28,401
AB-
AB- 7.2 3,364 2,817 6,181
Total 307,450 281,731 589,181
1
BASIS Report BASIS Hospital Red Cell Supply
(All Group/Types)
Represents approximately 95 Sentinel Hospitals reporting consistently Represents approximately 95 Sentinel Hospitals reporting consistently
Represents approximately 95 Sentinel Hospitals reporting consistently Represents approximately 95 Sentinel Hospitals reporting consistently
Represents approximately 95 Sentinel Hospitals reporting consistently Represents approximately 95 Sentinel Hospitals reporting consistently
2
National Blood Collection and
Utilization Survey Overview
Introduction
Methods
Key Findings
Biovigilance
Hospital Costs of Blood
Collection and Processing
Experience
Transfusion Experience
Cellular Therapy Products
Historical Perspectives
Current Issues in Transfusion and
Transplantation
www.hhs.gov/bloodsafety
3
Red Blood Cell Transfusions WB and RBC Recipients
Estimated Transfusions by Blood Centers and Hospitals
Type of 2006 2004 Per Cent 3.0 units per recipient (unweighted
(unweighted))
RBC Difference
Transfusion
Blood Hospital Total Total
()
8,275,000 allogeneic units (incl
(incl directed)
Center
2,740,000 recipients
Allogeneic 716,000 13,262,000 13,978.000 13,728,000 1.8%
(not 2004: 2.7 units per recipient
directed)
Autologous 7,000 182,000 189,000* 271,000 - 30.3%* Extrapolation of ratio of
transfused/recipient
Directed 0 126,000 126,000 132,000 - 4.6%
Pediatric 5,000 352,000 357,000* 59,000 504.8%*
Estimated 5 M recipient
6.6% decrease in transfusion recipients
Total 729,000 13,921,000 14,650,000 14,191,000 3.2% (compared to 2004)
Significant Difference (*) from 2004 to 2006
95% Confidence Intervals calculated
4
Current Issues in Transfusion Trends in WB and RBC Collections
Blood inventory shortages for non-
non-surgical procedures 18.0
16.0
2006 2004
14.0
13.5% (231/1707) reported at 16% (257/1604) reported at
Millions of Units
least one day shortage least one day shortage 12.0
Mean number of days was 22 Mean number of days was 19.27 10.0
8.0 Total
Six (6) hospitals reported 365 Eight (8) hospitals reported 365
Allogeneic
days the blood needs were not days the blood needs were not 6.0
Autologous
met. met.
4.0
Number of days regular or
2.0
standing order was incomplete
0.0
44,910 total days (estimated?)
1989 1992 1994 1997 199 2001 2004 2006
On any given day, 123 Survey Year
hospital did not have their
standing order met.
15
Millions of Units
14 70.0
60.0
13
2006: 48.9
50.0
12
40.0
11
30.0 Transfusions 95% Cl/1000 pop. (all ages)
10 Collections 95%CI/1000 pop. (ages 18-64)
20.0
1989 1992 1994 1997 1999 2001 2004 2006 1980 1982 1984 1986 1987 1989 1992 1994 1997 1999 2001 2004 2006
Survey Year
Survey Year
5
Blood Systems
American Red Cross
United Blood Services
2007 2007
870,000 collects that serve 500 hospitals in 18 states 6,332,000 collections that served over 2500 hospitals
1/3 of continental US throughout US
Estimation of blood needs Roll up of individual hospital utilization data on the most recent
recent
12 months
Roll up of individual hospital distribution for most recent 60
Application of Sales and Operation Planning (SNOP) to create
months (5 yrs) distribution is assumed ~ to transfusions
a 12 month projection
(return policy)
Application of statistical software package (Decision Pro) Based on distribution, assumption that distribution ~ transfusion
transfusion
Annual survey of hospitals to determine new changes in
Unfilled orders are tracked solely for customer satisfaction
services that might change utilization
Forward looking estimates do not currently take into
consideration planned changes in hospital services (e.g. Since 2009, review of unemployment statistics which seem to
track blood utilization figures due to loss of health insurance
cardiac surgery)
coverage
C:T ratio is not used as BSI collects no transfusion data
Information obtained via phone interview by Karen Lipton Information obtained via phone interview by Karen Lipton
6
2006 Blood collections per 1000 population
Estimating Blood Requirements National Blood Services only
Ethiopia
Nigeria
Haiti
Tanzania
Mozambique
Kenya
Uganda
Rwanda
Cote d'Ivoire
Zambia
Guyana
Geneva, Switzerland 0 2 4 6 8 10 12 14 16 18
February 4, 2010 Units collected / 1000 population
Family/Replacement
70000
donors
60000 Voluntary non-
50000 remunerated donors
40000 Regular donors
30000
20000
10000
0
1
Coverage
2006 Blood collections per 1000 population
All collections (Red
(Red =
= Hospital
Hospital collected/tested)
collected/tested)
Ethiopia
Nigeria
Haiti
Tanzania
Mozambique
Kenya
Uganda
Rwanda
Cote d'Ivoire
Zambia
Guyana
Namibia
Botswana
South Africa
0 2 4 6 8 10 12 14 16 18
Units collected / 1000 population
Data Sources
Rapid assessment
Surveys
Ministry Data
2
Stepwise approach-
approach-infrastructure Stepwise approach
approachclinical issues
Organization Composition
Hospital based? Whole blood
Regional? Pediatric units
National? Components
Incorporate Ministry, Private, NGO, Faith based? RBCs,
RBCs, FFP, platelets
Usage vs demand Clinical guidelines
Family replacement vs Volunteer Physician familiarity
familiaritypractice
Transition
Transitionutilization increase due to previous Training on new component options
unmet demand Laboratory
Data management capability--
capability--inventory
--inventory Baseline values
Manual/paper Monitoring
Electronic
Processing
Collection Utilization
3
Objectives
Country and National Blood Transfusion
Blood Supply and Demand: Service background
Georgetown, Guyana Investigation background
November, 2007 Case definitions
Methods
Results
Sridhar Basavaraju, MD Shortage calculations
Medical Officer
Centers for Disease Control and Prevention Lessons learned
Atlanta, USA
Study Background
December, 2007: NBTS review suggests 60%
of all blood orders unmet
GPHC-NBTS opinion differences
Reports of delayed surgeries Case Definitions
Inappropriate requests
Blood returned unused
Field investigation to determine:
Was enough blood collected?
Was there a true shortage of blood?
Case Definition Case Definition
Unit: An individual blood product WB, PRC, Order: A unit is requested by GPHC by
FFP, PLT, Cryo submitting a written blood request form.
Issued: Unit given by NBTS to ward for the Rejected: The order by GPHC ward is refused
purpose of transfusion by the NBTS due to a problem with
Filled: Unit is prepared by NBTS and ready to information provided to NBTS
be issued. A unit must be filled before it is Unused: Issued unit is not transfused into a
issued. Not all filled units are issued patient by ward.
Methods
Methods Methods
Audit of NBTS data for November 2007 Blood Request Form Files
3 Logbooks in NBTS Issued
Book 1: Book of Cross matched issued blood Filled and not picked up by ward
Book 2: Book of daily requests Rejected orders
Book 3: Book of returned units Orders no longer required
Comparison between logbooks and Blood
Request Form files
GPHC NBTS
Units Issued to GPHC November, 2007 Packed 1130 Packed 431
Red Cell Red Cell
Packed Red Cell 431 Whole 41 Whole 22
Whole Blood 22 Blood Blood
Platelets 2 Platelets 0
Platelets 0
Fresh 133 Fresh 59
Fresh Frozen Plasma 59 Frozen Frozen
Plasma Plasma
Cryoprecipitate 59 Cryo.
Cryo. 22 Cryo.
Cryo. 59
Total 571 Total 1328 Total 571
Overview of Issued and Non-issued units
Request
cancelled: 482
Ensure Safe Blood in Africa Population in need of Safe Blood epidemiology of disease conditions
that require Safe Blood transfusion
Current access of this group to health services and potentially to Safe
Blood when needed
Obtaining available cost for Safe Blood strategy, particularly in the
presence of multiple funding sources..
Pamela Rao - Forecasting scale-up costs for national programs in the
Associate Director, Global Health and Development Strategies
absence of data almost impossible..
Social & Scientific Systems, Inc.
Hence, a model-based approach.
Working Group 2SSS and AABB
..and it became 2-7-10 24/7 job !!
1
Factors Considered in Choosing Sample Countries BTS Composite Indicator
Strength of blood program, country-specific health HDI (life expectancy, literacy, GDP)
system performance indicator, Human Development
Index (HDI) Health System Performance Indicator (WHR 2000)
Nigeria
Kenya
Cote dIvoire
Mozambique
Representation of 4 Organizational Models for BTS Sample Countries for Varied Analysis
Hospital-based: Each hospital runs its own services with or Kenya Medium E. Africa Regionalized
without coordination at national level
Mozambique Weak S. Africa Mixed
Mixed: Combination of hospital-based and some regional and
national coordination (incomplete coverage)
Nigeria Weak W. Africa Hospital-based
2
Providing a Model to Estimate the Level of Resources for Safe Blood Sources to Identify the Target Groups
Conditions Requiring Blood Transfusion in Rank Order Target Groups Requiring Safe Blood in Africa
Cte
1. Identifying priority target group requiring Safe Blood dIvoire Kenya Mozambique Nigeria
2. Estimating the size of priority target groups 1
Children <5 65.5% 60.0% 79.6% 69.2%
Pregnant
45.9% 46.7% 52.3% 51.7%
women
2
Women 40.0% 40.0% 40.0% 40.0%
Source:
1
UNICEF. State of the Children 2006
2
IFPRI- Harvest plus
3
WHO/NHD/01.3. Iron deficiency anemia: Assessment, prevention, and control
3
Estimating the Target Group Size Likely to Be Transfused Size of the Target GroupPopulation-Based Estimates
Severe Anemia Rates as proportion of those anemic
Cte
Anemia in children < 5 years 10% dIvoire Kenya Mozambique Nigeria
Low birth weight (based on annual Low birth weight 112,370 132,200 115,350 745,220
number of live births)
20%
Shock/trauma/
Shock/trauma/burns/elective 295,373 746,300 500,300 2,862,678
15% burns/surgery
surgery
Women 1,615,600 2,963,200 1,816,400 11,362,800
Anemia in women (15-64 years)
less live births, year 2004
3%
Men 1,446,000 2,739,000 1,491,000 10,473,000
Proportion of Total Demand for Safe Blood Justifications des Demandes de Produits Sanguins par Types
Among Target Groups de Services: Priodes Fvrier-Juillet 2004 et 2005
4
Triangulating Target Group Data With Providing a Model to Estimate Level of
Available Country-Specific Data on dd Resources for Safe Blood
Proportions of PTGs requiring transfusions
Cte 1. Identifying target groups
Kenya Mozambique Nigeria
dIvoire
2. Estimating size of target groups in Africa
Children <5 45.47% 45.16% 47.33% 46.19%
Pregnant women 16.15% 16.70% 16.12% 17.64% 3. Estimating total PTG that may require blood
transfusion (i.e., proportion of the target
Low birth weight 5.98% 3.58% 4.62% 4.78% group with access to health care services)
Shock/trauma/
11.79% 15.14% 15.04% 13.76%
burns/surgery
Total population
16.94 32.98 19.11 125.74
of country (in millions)
Cte
Cte Kenya Mozambique Nigeria
Kenya Mozambique Nigeria dIvoire
dIvoire
Children <5 75,163 165,674 111,748 441,079
Children <5* 44.00% 49.60% 47.30% 30.60%
Pregnant women 40,929 72,233 46,332 290,610
Pregnant women* 67.45% 58.50% 57.60% 52.80%
Low birth weight 15,159 13,114 10,912 45,607
Low birth weight* 67.45% 49.60% 47.30% 30.60%
Shock/trauma/burn
9,304 17,687 14,409 85,880
s/surgery
Shock/trauma
21.00% 15.80% 19.20% 20.00%
burns/surgery** Women 10,178 14,046 10,462 68,177
Women** 21.00% 15.80% 19.20% 20.00%
Men 6,073 8,655 5,725 41,892
Men** 21.00% 15.80% 19.20% 20.00%
Total PTG 156,806 291,409 199,588 973,245
Total population
16.94 32.98 19.11 125.74
of country (in millions)
* Composite Indicator
** Hospital Utilization Indicator
5
Providing a Model to Estimate Level of
ResultsMagnitude of the Problem Resources for Safe Blood
Average Number of Blood Units Per Case Total Number of Blood Units Required for PTG in a year
Cte
Number of dIvoire
Kenya Mozambique Nigeria
Target group blood units
Children <5 37,581 82,837 55,874 220,540
Children <5 0.5
Pregnant women 102,321 180,582 115,830 726,526
Pregnant women 2.5 Low birth weight 7,579 6,557 5,456 22,804
Shock/trauma/
Low birth weight 0.5 27,913 53,062 43,226 257,641
burns/surgery
Magnitude of the Problem Base Year 2004 Providing a Model to Estimate Level of
Resources for Safe Blood
6
Growth Rates Adjusted Growth Factor
Preliminary Base Growth Factor was calculated by assuming It has been observed that factors other than per capita
that the growth factor for all countries for Sub-Saharan Africa
(SSA) would range from a minimum of 0.1 to a maximum of income influence performance of health systems and
0.2. potential expansion of BTS.
The minimum growth factor of 0.1 was assigned to the
average per capita income of SSA countries with lower per
To adjust the base growth factors for other factors, we
capita (per <$750) the maximum to per capita income >
$4,000. estimated regression equations expressing the coverage for
DPT as a function of GNI per capita and calculated the ratio
Growth factors for all countries between the lowest income
and highest income groups were calculated by linear of observed coverage to predicted coverage. This ratio as a
interpolation between 0.1 and 0.2 based on their per capita proportion was used to adjust the base growth factor.
income relative to the average per capita income of the lowest
group to the average of the highest group.
7
Cost of 1 unit of whole blood (recurrent) - CI
Blood Transfusion Costs
Capital costs Capital costs Capital costs Capital costs Storage & Cold chain, Distribution
+ + + +
fixed cost - QA, informatics, administration, logistics,
Recurrent costs Recurrent costs Recurrent costs Recurrent costs
incineration, maintenance buildings and equipment
Personnel salaries.
Total recurrent cost per unit of safe blood (21500
CFA = $ 40
Assumptions Scenario 2
Results Table Scenario 1
8
Level Resources needed for 4 countries (2006-2010)
Results Table Scenario 2
$12
$11
$10
$9
(in millions)
$8 Cote d'Ivoire
US Dollar
$7 Kenya
$6
$5 Nigeria
$4 Mozambique
$3
$2
$1
$0
2006 2007 2008 2009 2010
Year
9
Points for discussion
Points for Discussion and Recommendations
Increase in HIV among adult population will decrease the potential supply
There is a desperate need for complete and accurate data for better of safe blood and increase the dd for blood due to increase in clinical
planning, budgeting, and forecasting resources required to ensure malaria among HIV positive (Mozambique) and anemia resulting from ART
Safe Blood in African countries. (Botswana)
10
Demand: The
Need: An estimation of the amount of blood to amount of blood that
meet the transfusions requirements of the would be transfused
population according to current guidelines, best if all prescriptions for
blood were met.
practices and policies.
Demand may be
appropriate or
inappropriate
practices
Need
Population Need
Tools for Estimation of Blood
Needs
Unmet Demand
Unpresecriped needs
Development Index
Use
Appropriate
Use: The actual amount of
blood currently transfused
(use may be appropriate or Inappropriate
inappropriate.
BTS Tools
He eng osp
St S/H ity
alt the ital
m
BT pac
r
hS n
te
Ca
ys
ys
ed t S
tem
Ne rren
SE
s
/U
Cu
De ply
nd
p
ma
Su
Population Needs
1
Process Forward
2
Objective: Need
The amount of blood that would be used if
To provide resources that will assist all those patients who could benefit* from
authorities to estimate the current and transfusion were recognised and if blood
was prescribed according to appropriate
future blood transfusion needs for patients guidelines.
treated in their health systems.
*All those patients who could benefit implies 100% access to health
services but where access to the health system is restricted to a
part of the population, need is in effect limited to those who have
access.
1
Identification
of target populations 2 Size of the target populations
Incidence, Prevalence
From existing sources in country or countries
with similar demography etc
Sources of epidemiological data
Primary data collection Burden of disease data
Professional concensus Review the RAO model in detail
Published or grey literature
Burden of disease databases
New systematic reviews may be needed
Data on blood use for target Data sets and definitions for describing
populations hospital blood use
Is supply sufficient?
From existing sources in country or countries Georgetown model,
with similar demography etc
Primary data collection Which conditions receive how much blood?
Professional concensus Zambia model
Published literature
How many patients per time period?
2
Maternity
Data Items
Deliveries/year
Number with APH, PPH
Proportion with MH that bleed in hospital or reach
hospital alive and potentially resuscitatable OR
Number of MH patients who each hospital
Proportion who need transfusion
Units of blood used per patient with MH who is
transfused
Number of patients having C section
Proportion needing blood
Quantities of blood needed