What is it all about?

T his Transfusion Supplement contains two articles reporting National Blood Collection and Utilization (NCBUS) data showing dramatic declines in blood utilization between 2013 and 2015 and extensive supplementary information regarding the 2013 and 2015 surveys. In an additional article, investigators apply these data to a model predicting costs associated with Zika blood test implementation. The authors deserve kudos and our appreciation for designing the survey, which quantifies blood and blood components collected, processed, tested, and distributed by US blood centers and the amounts transfused at hospitals, including costs and reactions associated with transfusion. Blood centers and hospitals receiving survey requests responded at rates far higher than those achieved with previous NBCUS data requests, perhaps reflecting survey design improvements and the perceived importance of these data. The current report provides an essential continuum of utilization data collected in various formats since the 1970s. Dr. Klein discussed this eloquently in a September 2016 TRANSFUSION editorial, which remains relevant amid the rapidly changing transfusion medicine environment. That editorial provided a provocative analysis of data in the simultaneously published 2013 survey reports from the NBCUS and the AABB. Between 2013 and 2015, red blood cell collections decreased 11.6%, and transfusions decreased 13.9%. Overall, red blood cell collections decreased 27.2%, and red blood cell utilization declined 16.1% from their peaks in 2008 (17,286,000 units collected and 15,014,000 transfused) and 2015 (12,591,000 units collected and 11,349,000 transfused). Surgical setting red blood cell transfusion utilization fell 41.5% between 2013 and 2015. Red blood cell transfusions per 1000 US population declined from 48 or 49 during 2001 through 2008 to 44 in 2011, 41.7 in 2013, and 35.3 in 2015. Overall platelet usage decreased 13.1% between 2013 and 2015, and plasma transfusions declined 24.8%. Unpublished data show transfusions declining another 2.2% between 2015 and 2016, a rate of decline approximately one-half that observed during each of the two previous years, possibly suggesting an approaching plateau (personal communication, Blood Centers of America, April 2017). NBCUS reported changes in blood donor demographics, with a shift toward younger and older donors accounting for 13.4% and 12.4%, respectively, of the 6,812,000 individuals donating in 2015 (compared with 9,203,000 individuals in 2013). The number of first-time donors declined to 2,223,000 from 2,840,000 in 2011. The longterm consequences of these changes and others in US population demographics raise a cautionary flag about blood supply adequacy if transfusion needs increase as the US population ages. In conjunction with fewer distributed products, blood center revenues declined further as median prices paid by hospitals for leukocyte-reduced (LR) red blood cells decreased by $10 per unit between 2013 and 2015 to $211 compared with $204 for non-LR red blood cells. Apheresis platelet and plasma unit prices declined $16 and $5 or $6 to $524 and $52 to $54, respectively. These changes presumably reflect increased competition among blood centers for market share rather than expense reductions or overall efficiencies, because anecdotal reports indicate that most blood centers had negative financial margins in 2015 and 216. The NCBUS data possibly provide some insight into hospital-based price sensitivity. In the absence of a regulatory mandate, only 71.3% of red blood cells are leukocyte-reduced (of note, some blood collection agency officials believe this is an under-estimate). Using the $7 median price differential between LR and non-LR units and the 71.3% estimate, US blood costs would increase by $31.5 million with universal LR. In contrast, price adjustments for Zika blood testing, currently included in blood center charges, added more than $100 million to US blood costs, as predicted in the Supplement Zika article and presentations at a November 2016 US Food and Drug Administration (FDA) Blood Products Advisory Committee meeting. Notably, other safety advances, such as pathogen reduction for platelets, linger in the absence of an FDA mandate. These lethargic safety-innovation implementation discrepancies suggest a stochastic rather than a systematic decisionmaking process. The Risk-based Decision Making (RBDM) process presents a pathway. RBDM, as developed by the Alliance of Blood Operators, provides a unique framework for optimizing blood services’ blood safety decision making. It recognizes that resources are scarce and assesses risk in relation to their effect and impact. RBDM fosters transparency and involves stakeholders, blood safety risk, operational risk, jurisdictional issues, health economics and outcomes, risk tolerability, and social concern and responsibility. Data-derived scenario planning, as represented in the Supplement Zika article, complements the RBDM process; precision improves when available data exist. doi:10.1111/trf.14177