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• W2004376629 abstract "Annual income twenty pounds, annual expenditures nineteen nineteen and six, result happiness. Annual income twenty pounds, annual expenditures twenty pound ought and six, result misery. Mr Micawber in David Copperfield Maintenance of an adequate national blood supply has been a longstanding aim of the federal government, second only to assuring the safety of that supply. Over the past three decades, the Department of Health, Education and Welfare and its successor, the Department of Health and Human Services (DHHS), have sponsored through the National Heart, Lung and Blood Institute (NHLBI) numerous surveys and studies of blood collections, inventories and transfusions for the purpose of assessing the adequacy of supply. As early as 1973, the Department of Health, Education and Welfare issued National Blood Policy setting forth four principal goals and 10 points of Federal policy.1, 2 Two of the goals involved ensuring an adequate supply accessible to all. Among the 10 points was the development of data collection and processing systems to compile statistics for evaluating and planning national blood needs on a continuing basis. In 1975, with federal prompting, the three major blood services organizations and an assortment of other agencies and organizations coalesced to form a nongovernment agency, the American Blood Commission, for the purpose of implementing National Blood Policy. The American Blood Commission, in turn, created the National Blood Data Center, which developed, tested, and operated the first national blood information system in the period between 1977 and 1982 with the support of NHLBI. Summary data collected by this system for 1979 and 1980 were published in 1983 in The Nation's Blood Resource.3 Beginning in the early 1980s with the advent of the HIV epidemic and demise of the American Blood Commission, primary attention of federal agencies and blood services organizations shifted from matters of adequacy to means of ensuring the safety of supply. Throughout the 1980s and early 1990s, safety issues dominated federally sponsored blood studies. It was not until the late 1990s that maintenance of an adequate supply again became a concern of DHHS, largely as a result of new restrictions on donor eligibility and recent substantial declines in annual margins of allogeneic RBC collections over transfusions.4 To monitor this situation, in January 2000 DHHS (through NHLBI) sponsored development by the National Blood Data Resource Center (NBDRC) of a monthly reporting system of blood supply activities by a nationally representative sample of 25 US blood centers. In 2001, representatives of the Office of the Assistant Secretary of Health, DHHS supplanted the NBDRC system with a monitoring system based on daily reports from a set of 26 sentinel hospitals and three full-service blood centers. Results from the first year of operation of this latest DHHS system are reported elsewhere in this issue of TRANSFUSION.5 A primary objective of past federally sponsored surveys, special studies, and monitoring systems has been to avoid or minimize blood shortages. Evaluation of the success of these efforts depends on how the terms adequacy and shortage are defined and measured. While there appears to be general agreement that a failure to fulfil a legitimate order for blood required for surgical or medical purposes in timely manner constitutes a specific blood shortage, differences exist as to how exactly shortages or threats of shortages are to be measured in the aggregate and the extent to which the occurrence of specific shortages is acceptable within an otherwise adequate blood supply. For example, in Table 1 of the article by Nightingale et al.5 in this issue of TRANSFUSION, the authors list a series of questions regarding events that define an actual shortage (delayed or canceled surgery) or threat of shortage (adversely altered order) from a transfusion service perspective. While extensive, the list does not include postponement of a medical need for blood as evidence of a shortage. The list does illustrate well a multiplicity of events that can be used to define an actual shortage or threat of shortage in hospital. For blood centers, however, such a list likely would be different. For example, some center managers consider failure to fulfil every ABO/Rh item on every hospital order as evidence of a center shortage. Others define a shortage or threat of a shortage by established measures of the extent to which existing center inventories breach preset inventory control limits stated in terms of number of days supply of ABO/Rh blood types on hand. Similar differences exist among parties endeavoring to assess the adequacy of the nation's blood supply. Some perceive an inadequate supply whenever there is postponement or cancellation of a single surgery or medical treatment. Others find the occurrence of “local and temporary” shortages quite acceptable. Examples of these differing positions occurred recently in hearings before the House Energy and Commerce Subcommittee on Oversight and Investigations, on September 10, 2002. Concerned by an aging donor population, continuing increases in transfusion demands in the face of smaller margins of collections over transfusions, and periodic reports of individual and seasonal shortages, representatives from the three major blood services organizations, the American Red Cross, the American Association of Blood Banks, and America's Blood Centers, testified as to the existence and seriousness of the current threat of blood shortages.6 In contrast, Janet Heinrich, Director, Health Care – Public Health Issues of the General Accounting Office (GAO), informed the Subcommittee that the GAO in its study of the situation found “Although local and temporary blood shortages occur from time to time, America's blood supply is generally adequate.”7 Differences in operational and historic perspectives, as well as tolerance for periodic shortages, accounted for the difference between testimonies. Blood services representatives were expressing the future uncertainties of blood service managers faced with daily blood demands from hospitals under conditions of falling margins and cyclic shortfalls in supply. The GAO, on the other hand, used a historic perspective based on the certainty of aggregate past events, including the knowledge that previous smaller margins had met most past transfusion demands despite “local and temporary shortages”. In planning a system for monitoring the national blood supply, the obvious question is: what purpose is the system to serve? Is it to disclose the current state of the national blood supply in some continuous representative manner, or is it to detect and/or predict in “real time” the existence of or threat of shortages? The system developed by NBDRC is an example of a system designed to fulfil the first purpose. The DHHS system, described by Nightingale et al.5 in this issue of TRANSFUSION, is one designed to meet the second. While both systems monitor the blood supply, they do so in different ways with particular advantages and limitations. The NBDRC system, now operated independently, provides monthly information on the state of allogeneic center supply, a basis for monthly estimation of national RBC and PLT collections, distributions and other center-related blood supply activities, and a historic database of monthly time series data potentially useful in forecasting future supply activities. The system is restricted, however, by its inability to secure comprehensive ABO/Rh RBC activity data from all participating centers, lack of direct information on center backorders and other evidence of center and hospital shortages, and is limited to monthly reporting. The system is attuned more to monthly estimation and reporting of blood center activities on a national scale than to rapid reporting of instances of current shortfalls in supply. The DHHS system was designed to determine in “real time” whether the current blood supply is sufficient to meet demand and to determine whether fluctuation in days supply could be used to predict actual blood shortages. The system endeavors to determine adequacy of supply through daily reporting of transfusion service activities in a sample set of mainly large urban hospitals and three full service blood centers. The system collects daily information on the existence of blood shortages and threats of shortages among the sample set of transfusion services along with data on median days supply of ABO/Rh-typed RBCs and whole blood or apheresed PLTs on hand, and produces graphs of aggregate daily blood service activities and summaries of frequencies of weekly shortages, actual or threatened. Its principal limitations are lack of a nationally representative sample, use of daily data, and dependence on conditions in large urban hospitals. Daily data, aside from having the potential for identifying within-week cycles of hospital blood activities about which little can be done, is more confusing than informative. Actions taken as a result of daily information can just as well be taken based on weekly summations and the random noise inherent in daily data makes the data difficult to use in predicting future events. In addition, large urban hospitals have not been the source of most in-hospital actual blood shortages. In 2001, over 56 percent of all canceled surgeries and 68 percent of days of unmet medical needs for blood occurred in medium- and small-size hospitals of less than 5000 surgeries per year.8 Recent events leading to creation of the new Department of Homeland Security evidence the strong likelihood of continued federal monitoring of the national blood supply. If so, what might be the principal characteristics of an effective federal monitoring system? Neither of the two current systems fulfil all requirements for such a system; however, a merging of the positive attributes of the two systems, together with some additions, could accomplish this end. In order to be authoritative, findings from the system should be based on a representative sample of US blood establishments. The system should produce its findings in a timely manner, without excessive, costly reporting requirements, and include a database that permits the discernment of trends and prediction of cyclic variations in the national blood supply. Like present systems, an effective national monitoring system should capture data on allogeneic whole blood, RBC, and PLT collections, imports, exports, distributions, outdates, and periodic inventories, and should transmit it in timely fashion via the internet. RBC data should be categorized by ABO/Rh type and platelet data by whole blood or apheresis derivation. Reporting establishments should be blood centers; reporting should be done weekly; and reports should include information on actual shortages in hospitals and threatened shortages in centers measured in terms of the extent to which mean days supplies of ABO/Rh-typed RBC or whole blood or apheresis-derived PLT inventories vary from established inventory control limits. Blood centers rather than hospitals are the preferred reporting establishments, because blood centers account for 93 percent of all national collections; are few in number and nationally distributed, making possible a reasonably small, cost-effective representative sample; maintain the buffering inventories that modulate variations in hospital blood supplies; allocate limited supplies amongst competing hospital demands; and produce surplus collections of blood for export to deficit regions and institutions. Because actual in-hospital blood shortages, measured by postponed or canceled surgeries and unmet medical needs, occur very infrequently, such occurrences should be reported to each center by the hospitals it serves for inclusion with information on center shortages in each weekly report. Weekly reporting seems optimal: it avoids the noise and excessive detail of daily reporting, reduces data processing and analytic efforts and costs while providing requisite information in sufficient time to permit prompt remedial action if and when required, and makes possible creation of a database with a sufficient number of data points to permit time series identification and prediction of short-term repetitive cycles in collections and inventories and longer term trends. These proposed requirements for a hypothetical national monitoring system may appear simple, but they are likely to be difficult to implement. Many present blood center information systems are incapable of producing the required information in a timely manner. For example, 10 of the 25 centers included in the present NBDRC reporting system are unable to provide ABO/Rh-typed RBC activity data monthly. By and large most present center information systems have been designed to fulfil regulatory, not operational, requirements. Consequently, if DHHS wishes to continue monitoring the adequacy of the national blood supply in a representative, effective, and timely manner, it must first undertake the substantial task of selecting and developing a sample set of blood centers representative of the US as a whole that have information systems capable of producing the requisite weekly data. In some instances DHHS may have to subsidize blood center information system development in order to fulfil its monitoring requirements. For the present such a blood sample monitoring system should be sufficient for DHHS purposes. In time, however, DHHS may find it desirable or even necessary to enlarge the system to encompass all blood centers in the US. Only when such a system has been developed and is fully operational will federal monitoring of the national blood supply be an effective, authoritative instrument for assessing the present and future adequacy of the national blood supply." @default.
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• W2004376629 title "Monitoring the nation's blood supply" @default.
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