by Brian Witte, PhD
The health of the United States depends on blood and technology. Blood and blood products play a key and irreplaceable role in medicine: 5 million people per year receive transfusions of red blood cells, clotting factors or plasma products[i]. Traditionally, the technological aspects of blood has long focused on improving the safety, collection, and storage of blood.
As the recently released RAND Corporation report[ii] makes clear, the result has been a remarkably consistent record of safety in the modern era. Transfusion-related infections and adverse reactions are at an all-time low, even as new blood-borne pathogens continue to emerge.
The Zika virus outbreak that occurred during the summer of 2016 offers an excellent case in point. Within months of the virus becoming a threat, and before its spread was confirmed within the U.S., there were multiple tests available to detect the virus.
The system is not perfect, and several experts voiced concerns that the response to Zika was too slow and too cautious. Finding the right balance between speed and accuracy is always a concern, and is a topic worth revisiting in a future post. From the perspective of winter 2017, however, we can see that there were no confirmed cases of transfusion-mediated Zika transmission in the U.S.[iii] Despite the spread of Zika and a host of other diseases new to the continental U.S., the U.S. blood supply is safer than ever.i
The Cost of Safety
The high quality of the U.S. blood supply comes at a cost. The RAND report cites increasing expense for blood testing and processing as some of the factors that are, paradoxically, acting to destabilize our nation’s blood supply.
Rising costs are not occurring in a vacuum. Even as vigilance becomes more stringent, the current trend suggests that the overall demand for blood continues to fall, while the donor pool appears to be shrinking and aging. Fewer donors means that blood centers must devote more resources to recruitment even as overall revenue, and revenue per unit, are falling.
The factors behind these trends are addressed in Chapter 4 of the Rand Report. The net effect, however, is increased stress on the blood centers that collect, process and distribute most of the blood products in the U.S.
As blood centers become more strained, their resilience can become compromised in the face of increasingly common public health emergencies. In particular, organizations that are already operating at close to tolerance may have difficulty in responding to surge demand around a terrorist event, natural disaster, or rapidly emerging epidemic.
As serious as these concerns are, Dr. Zbigniew M. Szczepiorkowski, president of the AABB, believes that “[t]he RAND report fails to capture the urgency of the challenges facing the United States’ fragile blood system”[iv].
The Way Forward
The blood industry landscape has changed dramatically, and the pace of change is only accelerating. There is no going back. How, then, to move forward?
In Chapter 10, the RAND Report makes seven recommendations for ensuring a stable blood supply for the U.S. These recommendations cover a range of topics, including a mix of regulatory reform, government-led initiatives, and necessary technological innovation.
Many of the technology and policy suggestions focus on two areas: information collection and supply chain issues. Better data collection allows more accurate forecasting of trends in supply and demand. Strong data sets can also help us analyze the impact of innovations as blood centers and hospitals adapt. Understanding which initiatives are working, and which are not, is possible only with good data. Supply chain issues, on the other hand, focus on improving the efficiency of blood collection and distribution, as well as the ability to meet short-term surges in demand.
The data collection suggestions made by RAND focus on reporting overall units produced and transfused, as well as implementing a centralized hemovigilance system. These ideas are conceptually simple, and the benefits are clear.
The challenge is largely technological. Using current technology to report and compile this data would be a massive undertaking. With few standards on data collection and a host of mutually incompatible blood bank information systems, data must be collated for each blood center and health care provider.
In the present climate of fiscal austerity and hostility to regulation, progress on the policy side may be slow in addressing these issues. The technological fix, however, is comparatively straightforward. With a modern system of transacting blood supplies critical information on production, movement, and use of blood products would be as simple as a database query.
Whether such a system could be implemented remains to be seen due to misaligned incentives among organizational stakeholders. There is clear movement in that direction, however, and a broad consensus that such information is both useful and necessary.[v]
The supply chain issues facing the blood banking community are perhaps less obviously a technological challenge. The significance of the supply chain issues raised in the RAND Report are echoed in a recent article[vi] by Professor Anna Nagurney, a distinguished researcher in Operations Management.
If both sets of supply chain-related suggestions could be distilled, it might be that blood distribution needs to enter the era of flexible supply and demand. Before the early 2000’s, hospitals were tightly connected to their local blood center in a symbiotic relationship. Demand could be counted on to rise year-over-year as the population grew and utilization increased.
In the new era, overall demand is shrinking even as increasing instability means that some areas see a temporary surge while others see dramatic downturns. In a world where production and demand are geographically constrained, every blood center would need to both retain significant surge capacity while also being able to dramatically reduce normal operating expenses.
The supply chain innovation approach, by contrast, focuses on maintaining network flexibility. Such a program, as suggested by both Professor Nagurney and the RAND Report, would necessarily depend on a means of coordinating blood product supply and demand. Geographical regions temporarily producing more units than their local health care providers could use would be able to redistribute surplus units to areas experiencing shortages.
For meeting surge demand, due to natural disaster, epidemic, or mass casualty events, the system would be able to rapidly move large quantities of units using existing transportation networks. Contrast this to the existing model of disaster relief in which large depots of essential resources are maintained against emergency, and are then moved en mass when needed.
The key element of this suggestion is that the transfers be both rapid and frictionless. As the Zika epidemic in Puerto Rico[vii] demonstrated, large volumes of emergency blood supplies can be mobilized at need. Doing so, however, required direct intervention of HHS to coordinate and the ability of a single large provider to source the needed supplies. A distributed system using existing networks, by contrast, would put less strain on any individual component of the system while simultaneously inoculating against single-point failures.
As the RAND Report notes, Bloodbuy is one of the organizations at the forefront of developing such a system. With an automated network to connect geographically distinct regions, we are helping to build the data collection infrastructure and blood distribution network of the future. Blood centers, transfusion centers, logistics experts, and public policy agencies will all be part of the solution. The stakes are nothing less than ensuring the stability of the U.S. blood supply.
[i] Blood Safety Basics. (2013, January 31). Retrieved January 26, 2017, from https://www.cdc.gov/bloodsafety/basics.html
[ii] Mulcahy, Andrew W. Toward a sustainable blood supply in the United States: an analysis of the current system and alternatives for the future. Santa Monica, CA: RAND Health, 2016.
[iii] Zika and Blood Transfusion. (2016, November 18). Retrieved January 26, 2017, from https://www.cdc.gov/zika/transmission/blood-transfusion.html
[iv] Szczepiorkowski, Z. M. (2016). Advisory Committee on Blood and Tissue Safety and Availability November 28-29, 2016. Retrieved January 26, 2017, from http://www.aabb.org/advocacy/statements/Documents/statement161128.pdf AABB Public Comment
[v] Klein, H. G. (2016), Blood collection and use in the United States: you can't manage what you can't measure. EDITORIAL, 56: 2157–2159. doi:10.1111/trf.13724
[vi] Nagurney, A. (2017, January 8). Uncertainty in blood supply chains creating challenges for industry. The Conversation. Retrieved January 26, 2017, from http://theconversation.com/uncertainty-in-blood-supply-chains-creating-challenges-for-industry-70316
[vii] HHS ships blood products to Puerto Rico in response to Zika outbreak. (2016, March 07). Retrieved January 26, 2017, from https://www.hhs.gov/about/news/2016/03/07/hhs-ships-blood-products-puerto-rico-response-zika-outbreak.html
[viii] Dunglison, R. (1856). Human Physiology (8th ed., Vol. I). Retrieved January 26, 2017, from https://archive.org/details/humanphysiology00dung p. 354