Emerging Technologies in Transfusion Medicine
http://www.100md.com
《新英格兰医药杂志》
Efforts to reduce the risk of transfusion-transmitted human immunodeficiency virus (HIV), hepatitis C virus (HCV), and other infectious agents in the United States have resulted in major changes in the ways in which blood donors are screened and their blood tested before transfusion. Nevertheless, the core methods that are used in hospitals and blood centers to provide blood for transfusions have not changed appreciably in decades. Most hospital transfusion services type and cross-match blood by manual methods in test tubes and interpret the end points of antibody–antigen tests subjectively, by visual inspection. Most community blood centers "pack" red cells by centrifugation and separate plasma and platelets by decanting the supernatants by visual inspection.
(Figure)
Antique Blood-Transfusion Apparatus.
By permission of the Wellcome Library, London.
The editors of Emerging Technologies in Transfusion Medicine, Christopher Stowell and Walter Dzik, invited experts to describe 11 new forms of technology that could transform and improve the diagnostic and therapeutic aspects of blood transfusion. Among the promising diagnostic techniques are new approaches to the testing of blood for prions and bacteria, phage displays for the improvement of blood-typing reagents, and molecular methods to resolve serologic problems by genotyping. Emerging therapeutic agents and methods include recombinant products (rituximab, activated coagulation factor VII, and activated protein C), inactivation of pathogens in blood components, and a new generation of therapeutic agents to carry oxygen (i.e., "blood substitutes").
These presentations are technically expert and highly recommended as a glimpse into what the technology of blood transfusion might be like in the future. However, an epilogue concerning the practical aspects of implementing these new and potentially pricey techniques could have added an important perspective. Budget-conscious hospitals have struggled in recent years to cover the costs of new diagnostic tests for transfusion-transmitted viruses (e.g., HIV, HCV, and human T-lymphotropic virus), leukocyte reduction of blood components, and bacterial cultures of platelet components. Unquestionably, these recent advances improve the quality and safety of blood transfusions. However, their implementation has been controversial because of a lack of additional funding to pay for them.
Historically, blood centers introduced new testing methods and passed the increased costs on to hospitals by raising the price of blood components. But upward adjustments in reimbursements to hospitals from the Centers for Medicare and Medicaid Services (CMS) and other third-party payers, if any, lag behind the increased prices to hospitals by at least two years. Thus, the cost of recent improvements in technology and safety for blood transfusion has been borne primarily by this nation's hospitals. In Washington, D.C., the introduction of leukocyte reduction added $15 to the cost to hospitals for 1 unit of red cells. Bacterial testing added $22 to the cost for 1 unit of apheresis platelets, but there has been no new money added to the system to compensate hospitals for providing these improved services.
According to the 2002 annual survey of the American Hospital Association, 57 percent of hospitals lose money on patient care and 55 percent lose money on patients who are covered by Medicare. In this environment, there are real barriers to implementing any of the promising emerging techniques outlined in this interesting book. Two things must happen for these new forms of technology to emerge as a reality in clinical practice. First, a process is needed to evaluate and select the emerging methods that meet defined standards for efficacy, safety, and cost effectiveness. Similar processes and institutions in other fields of medicine already exist in the United States. More critically, "new money" is needed to pay for new services.
In April, the Advisory Committee on Blood Safety and Availability of the Department of Health and Human Services recommended that the secretary "address funding needs at all levels of the blood system to support product safety, quality, availability, and access through targeting additive resources and appropriate reform of the CMS reimbursement system for blood and blood products." Emerging Technologies in Transfusion Medicine is a blueprint for the future efficacy and safety of transfusion. But without "additive resources," these promising forms of technology will remain "emerging" and unlikely to become a reality in the foreseeable future.
S. Gerald Sandler, M.D.
Georgetown University Hospital
Washington, DC 20007
sandlerg@gunet.georgetown.edu(Edited by Christopher Sto)
(Figure)
Antique Blood-Transfusion Apparatus.
By permission of the Wellcome Library, London.
The editors of Emerging Technologies in Transfusion Medicine, Christopher Stowell and Walter Dzik, invited experts to describe 11 new forms of technology that could transform and improve the diagnostic and therapeutic aspects of blood transfusion. Among the promising diagnostic techniques are new approaches to the testing of blood for prions and bacteria, phage displays for the improvement of blood-typing reagents, and molecular methods to resolve serologic problems by genotyping. Emerging therapeutic agents and methods include recombinant products (rituximab, activated coagulation factor VII, and activated protein C), inactivation of pathogens in blood components, and a new generation of therapeutic agents to carry oxygen (i.e., "blood substitutes").
These presentations are technically expert and highly recommended as a glimpse into what the technology of blood transfusion might be like in the future. However, an epilogue concerning the practical aspects of implementing these new and potentially pricey techniques could have added an important perspective. Budget-conscious hospitals have struggled in recent years to cover the costs of new diagnostic tests for transfusion-transmitted viruses (e.g., HIV, HCV, and human T-lymphotropic virus), leukocyte reduction of blood components, and bacterial cultures of platelet components. Unquestionably, these recent advances improve the quality and safety of blood transfusions. However, their implementation has been controversial because of a lack of additional funding to pay for them.
Historically, blood centers introduced new testing methods and passed the increased costs on to hospitals by raising the price of blood components. But upward adjustments in reimbursements to hospitals from the Centers for Medicare and Medicaid Services (CMS) and other third-party payers, if any, lag behind the increased prices to hospitals by at least two years. Thus, the cost of recent improvements in technology and safety for blood transfusion has been borne primarily by this nation's hospitals. In Washington, D.C., the introduction of leukocyte reduction added $15 to the cost to hospitals for 1 unit of red cells. Bacterial testing added $22 to the cost for 1 unit of apheresis platelets, but there has been no new money added to the system to compensate hospitals for providing these improved services.
According to the 2002 annual survey of the American Hospital Association, 57 percent of hospitals lose money on patient care and 55 percent lose money on patients who are covered by Medicare. In this environment, there are real barriers to implementing any of the promising emerging techniques outlined in this interesting book. Two things must happen for these new forms of technology to emerge as a reality in clinical practice. First, a process is needed to evaluate and select the emerging methods that meet defined standards for efficacy, safety, and cost effectiveness. Similar processes and institutions in other fields of medicine already exist in the United States. More critically, "new money" is needed to pay for new services.
In April, the Advisory Committee on Blood Safety and Availability of the Department of Health and Human Services recommended that the secretary "address funding needs at all levels of the blood system to support product safety, quality, availability, and access through targeting additive resources and appropriate reform of the CMS reimbursement system for blood and blood products." Emerging Technologies in Transfusion Medicine is a blueprint for the future efficacy and safety of transfusion. But without "additive resources," these promising forms of technology will remain "emerging" and unlikely to become a reality in the foreseeable future.
S. Gerald Sandler, M.D.
Georgetown University Hospital
Washington, DC 20007
sandlerg@gunet.georgetown.edu(Edited by Christopher Sto)