the analysis of cost-effectiveness of the optimal system of …...matra project2 was conducted by...

The analysis of cost-effectiveness of the optimal system of the

blood service

University of Tartu

Tallinn 2012

http://www.sm.ee/

The analysis of cost-effectiveness of the optimal system of the blood service 2

Research ordered by Ministry of Social Affairs.

Research done by University of Tartu.

Authors of the research: Janika Alloja, University of Tartu

Kerly Espenberg, University of Tartu

Raul-Allan Kiivet, University of Tartu

Authors of the research thank everybody who participated in the making of this report, including by

assisting the project team in collecting data, found time for sharing experience in interviews and

contributed in the development of solutions.


TABLE OF CONTENTS

Table of contents ............................................................................................................................................. 3 Short summary ................................................................................................................................................ 5 1. Introduction ........................................................................................................................................... 6

1.1. Focus of the report and research questions ................................................................................... 7 1.2. Methodology .................................................................................................................................. 8 1.3. Terms used in the report .............................................................................................................. 10 1.4. Main components of blood and vein-to-vein chain ..................................................................... 12

2. Overview of blood services and developments ................................................................................... 15 2.1. Different blood services in developed countries .......................................................................... 15

2.1.1. Blood service in the UK ........................................................................................................ 17 2.1.2. Blood service in Finland........................................................................................................ 17 2.1.3. Blood service in Sweden....................................................................................................... 18

2.2. Trends in collecting, testing, processing and using blood products in Europe ............................ 19 3. Blood service in Estonia ....................................................................................................................... 22

3.1. Structure of Estonian blood service.............................................................................................. 22 3.1.1. System of Estonian blood centres ........................................................................................ 23 3.1.2. System of hospital blood banks ........................................................................................... 25

3.2. Information system of blood service ............................................................................................ 26 4. Donation in Estonia today and in the future ............................................................................................. 28

4.1. Trends in donation ........................................................................................................................ 28 4.2. Age-specific structure and residence of donors ........................................................................... 30 4.3. Collecting donor blood ................................................................................................................. 32 4.4. Forecast of the number of donors ................................................................................................ 34 4.5. Evaluation to donation ................................................................................................................. 35

5. Use of blood products in Estonia .............................................................................................................. 37 5.1. Trends in the use of blood products in Estonia and the users of blood products ........................ 38 5.2. Practice of blood product use ...................................................................................................... 41 5.3. Efficiency of using donor blood .................................................................................................... 44 5.4. Sufficiency and availability of blood products .............................................................................. 46 5.5. Estimation of the use of blood products for 10-15 years ............................................................. 47 5.6. Evaluation to the use of blood products ...................................................................................... 49

6. Quality of blood products .................................................................................................................... 51 6.1. Content of the quality and quality requirements for blood products in Estonia ......................... 51 6.2. Content and organization of supervision by the State Agency of Medicines ............................... 54 6.3. Self-control and training ............................................................................................................... 56 6.4. Safety of blood products and haemovigilance in Estonia ............................................................ 56 6.5. Evaluation to blood product quality ............................................................................................. 59

7. Economic efficiency of blood service ................................................................................................... 61 7.1. Costs and structure of costs of the blood service ........................................................................ 61 7.2. Income of blood centres ............................................................................................................... 64 7.3. Productivity and unit price in blood centres ................................................................................ 65 7.4. Evaluation of economic efficiency ................................................................................................ 68

8. General evaluation and recommendations ......................................................................................... 70 8.1. Critical needs ................................................................................................................................ 71 8.2. Recommendations ........................................................................................................................ 73 8.3. Scenarios describing blood service division of responsibilities .................................................... 76


8.3.1. Scenario 1: maintaining current division of responsibilities ................................................ 77 8.3.2. Scenario 2: consolidating processing and testing ................................................................ 78 8.3.3. Scenario 3: centralized (national) blood service with two blood centres ............................ 80 8.3.4. Scenario 4: centralized (national) blood service with one blood centre ............................. 82 8.3.5. Sensitivity analysis of the financial impacts of the scenarios ............................................... 84

Conclusion ..................................................................................................................................................... 86 Sources .......................................................................................................................................................... 90 Annexes ......................................................................................................................................................... 96


SHORT SUMMARY

The focus of the research is the current situation, future outlooks and economic efficiency of Estonian

blood service. In this analysis, cost-effectiveness marks a situation, where the same costs can provide

more or better quality blood products, or products of same amount and same quality with less costs. The

blood system is observed as a whole: from donation, processing and distribution to transfusion. The

report is based on scientific literature, previous researches, expert interviews and analysis of statistic

data. The research was conducted by University of Tartu and ordered by the Ministry of Social Affairs.

The task of the blood service is to ensure the constant supply of safe blood products to healthcare

institutions. As of 2012, there are four blood centres and 27 hospital blood banks in Estonia, which are all

structural units of hospitals under private law and their division of responsibilities and cooperation is

ensured by legislation and mutual agreements. In Estonia, blood service is financed from the budget of

Estonian Health Insurance Fund through the prices set for blood products, in 2011 the whole cost of

Estonian blood service was 5.8 million Euros.

In a general evaluation to the situation of the blood service today, it can be stated that Estonian blood

service is based on a relatively stable base of donors, in which a well functioning everyday blood product

supply chain has developed and the safety of blood products is ensured. There is also a clear division of

responsibilities and liability in order to ensure to function of everyday orders. The work of blood centres is

efficient from the aspect of using donor blood and resources.

Considering future developments and the limited resources in Estonia, the critical needs vitally important

to implement are brought out in the report from the aspect of optimizing the further development and

cost-effectiveness, and also recommendations, which should be considered.

The three critical needs to ensure consistent blood supply are:

- Moving from first-time and young donors to regular donors;

- Developing a uniform blood service information system, which is important for optimizing costs,

cooperation and safety;

- Re-organizing the financing of blood service to help ensure the quality and safety.

Three recommendations to support the development of blood service are:

- Centralizing and systematically forwarding of the information necessary for donors;

- Establishing central coordination, management and planning;

- Deciding on the use of inactivated blood products on a national level.

Three scenarios are brought out regarding the future of Estonian blood service, which differ on the levels

of cooperation and consolidation. Compared to the current system, the changes would lead to an increase

in cost-effectiveness by centralizing the processing and testing of blood products and implementing a

unified information system for the blood service, which involves both donation and hospital blood banks.

The supplementary cost-effectiveness is achieved through minimizing the future investment needs, with

the prerequisites of agreements between hospitals and changes in financing blood products.


1. INTRODUCTION

The principle, that every country should be self-sufficient by using voluntary free donation, was set by the

European Commission already in 1989 (European Commission Directive 98/381/EC). The Directive

emphasizes the critical importance of the safety of blood transfusion. Therefore, the state must ensure a

sufficient amount of safe blood products relying on its own donors.

As blood is a biological product, that can be collected from donors only in a limited amount and cannot be

kept as a supply, the efficiency of using blood is very important. This aspect becomes even more topical,

since the demand for blood increases and supply of blood decreases due to the aging population and the

requirements of qualifications for donors become stricter. In the context of limited resources increasingly

more attention is paid on the cost of processing and economic analysis together with the efficiency of the

use of blood products.

The general concept in the economic analysis is ensuring efficiency, but the latter term is used very

differently1. Efficiency can be evaluated by comparing inputs and achieved health effects, which is done in

cost-effectiveness analysis and used when comparing different health interventions. Alternatively,

efficiency can be considered as the analysis of inputs and outputs through productivity and unit cost

analysis. Analysis of planning the locations of blood centres and logistics is also closely related to

efficiency (e.g. Sahina et al 2007, Sarul 2009, Nagurney et al 2012), also analysis of inventory

management, matching demand and supply of blood products, analysis of waste minimization (e.g.

Katsaliaki 2008), and analysis of productivity and scale effect (e.g. Bell et al 2008, Pereira 2006, Pitocco

2005, Veihola 2008).

The system of Estonian blood service has been evaluated in three documents in the last 10-15 years,

which all focus on pointing out problems and offering solutions, but unlike the research at hand, they

have not been focused on the aspect of economic efficiency.

In the Transfusiology development plan (2001) it was stated after analysing the work of blood

centres, that Estonian blood service is excessively fragmented. The processing capacities of

smaller centres exceed the district’s needs and fragmented blood processing limits the optimal

use of donor blood. In the area of blood safety, it is brought out that blood testing is also

fragmented causing difficulties in developing unified requirements and it is harder for smaller

centres to ensure good processing practices and maintain quality. Depreciated facilities and

equipment as well as complicated logistics also make it difficult for all centres to have good

processing practices. Centralizing the blood service was seen as a solution for these problems,

which would be based on two blood centres handling the processing and testing and one

additional centre for donor management and storage.

1 In English literature the terms effectiveness, efficiency, technical efficiency etc are sometimes used in different meanings,

hence the need to carefully observe what is measured in every specific case.


Matra project2 was conducted by Dutch experts in 2003 and mainly focused on three areas:

developing a unified quality management system, developing a unified blood information system

and raising awareness of the population and donors. The structure of the blood service was

slightly mentioned as well, by stating that only North Estonia blood centre works with a sufficient

processing capacity from the aspect of efficiency. The authors recommend considering one

national blood supply organization in Tallinn, which would handle all the processing and testing

and would have a supportive centre in Tartu for donor management, storing and distributing

blood products and training.

State program of developing blood donation and blood product self-sufficiency for 2013-2015

brings out the most important problems in the area of donation and blood product supplying and

offers measures for solving those problems. The highlighted problems are:

1. Insufficient level of blood donation, caused by the lack of awareness of the population

and acknowledgment of the necessity of donation;

2. Lack of preparedness for nation-wide crisis situations;

3. The need for further development of blood product safety, which blood centres do not

have resources for;

4. Complications of self-supplying with plasma products;

5. Depreciated facilities of PERH Blood Centre;

6. Inefficiency of small blood centres;

7. Shortfalls in developing the blood information system due to the lack of extra resources

in blood centres.

Until now, the costs of blood centres have not been aggregated and analysed, and this report is going to

fill that gap.

1.1. Focus of the report and research questions

The aim of the analysis is to offer the most optimal nation-wide model for developing blood donation and

self-supplying with blood products in Estonia from the aspect of cost-effectiveness, which would be based

on the current system and take possible future developments into consideration.

Objective information about the Estonian blood service will be gathered in order to evaluate the current

situation of the blood service and point out the problematic areas. The evaluation is based on the main

goal of the state blood service – to offer a sufficient amount of safe blood product. The sufficiency of

blood products depends on two main factors – the number of donors and the use of blood products. As

blood products have a short shelf life, it is not possible to keep them in store for a long time hence the

strategic supplies are based on the existence of donors. The larger the number of donors in a country and

the more often they donate, the better it is ensured to have a supply of different blood types and blood

products. The transfusion of blood products is also important – the more optimal the use of blood

products for transfusions, the more optimal is the use of donated blood. The safety of blood products

depends on the epidemiologic situation of the country and the quality of blood processing and testing.

2 The aim of the Matra program was to support the implementation of legislation of the non-economic sector in European

Union candidate states and creating lasting contacts between institutions of Netherlands and Estonia. The project Development of the Capacity of the Estonian Blood centres was a part of the program.


The mentioned areas are closely related to efficiency of resource use. Therefore, the Estonian blood

service will be evaluated through the following four areas.

1. Blood donation

• Are there enough donors (also compared to other countries)?

• How will the number of donors change in the near future?

• What are the problems of the current system from the aspect of blood donation?

2. Use of blood products

• Who are the users of blood products and what is the practice of using blood products (also

compared to other countries)?

• How will the use of blood products change in the near future?

• Is the use of donor blood efficient (also compared to other countries)?

• What are the problems of the current system from the aspect of ensuring sufficient supply

according to the need for blood products?

3. Safety of blood products

• What affects the quality of blood products?

• Are blood products safe?

• What are the problems of the current system from the aspect of blood safety?

4. Economic efficiency of the blood service

• How efficiently do blood centres use their resources (also compared to other countries)?

• Does the economic efficiency of blood processing depend on the capacity of processing?

• What are the problems of the current system from the aspect of economic efficiency?

The evaluation of Estonian blood service is mainly based on the performance and work process of blood

centres, but where possible and necessary, matters regarding hospital blood banks will also be handled.

Based on the evaluation and the main problems highlighted during the analysis, the last chapter will

propose activities which should or could be undertaken for developing the blood service. In addition,

different scenarios describing the tasks for blood centres with an impact analysis has been brought out.

In this report, blood service cost-effectiveness means a situation where 1) more products and/or products

with better quality can be provided with the same costs or 2) the same amount and same quality products

can be provided with less costs.

1.2. Methodology

To gather necessary information for evaluating Estonian blood service and making suggestions, the

relevant scientific and specialized literature, previous evaluations and other documents concerning

Estonian blood service were consulted, experts were interviewed and other relevant data about

important indicators in blood centres and on state level were gathered. Wherever possible, statistics

about foreign countries was also obtained for comparison.

In the analysis of scientific literature, attention was given to articles which focused on measuring and

evaluating the efficiency of blood centres and blood service, forecasting the use of blood products in


other countries and describing global developments. Additionally, information about blood services in

other countries was searched, in cases of countries with centralized blood systems, valuable information

was obtained from annual reports (e.g. Finland, Canada, the UK, Australia, New Zealand).

In order to learn about the developments in Estonian blood service previous overviews (e.g.

Transfusiology development plan and the state program of developing blood donation and self-supplying

with blood products) and the legislation regulating the work of Estonian blood service were used. Main

sources of information were interviews with various experts; 15 different experts were interviewed during

the research. Heads of blood centres, head and specialist of the department of biologicals of the State

Agency of Medicines, manager of treatment financing service of Estonian Health Insurance Fund were

repeatedly consulted. Estonian Anaesthesiologists Association and Estonian Haematologists Association

were asked for expert opinions about the forecast of the future use of blood products. Project manager of

the Estonian blood service information system from Gennet Inc. was consulted to get acquainted to the

information system of Estonian blood service. Representatives from hospital blood banks from three

hospitals were interviewed about the work of hospital blood banks. Experts from the blood services of the

UK, Finland and Sweden were contacted for information about blood services in their countries.

In addition to the information from the interviews, different numeric data was gathered for an objective

overview of the blood service. Data about staff, donors, blood donations, mobile collections, processing

capacities etc was asked from blood centres. In addition, detailed financial reports from 2010-2011, list of

equipment and a list of issued products of 2011 were received. Blood centres also enabled access to their

information systems for statistics of donors by age and residence. Statistics on state level was received

from two sources. Firstly, from the database of health statistics and research of the National Institute for

Health Development (TAI), where various indicators from annual reports of blood centres and also the

information submitted by hospitals about the use of blood products and cases of transfusion reactions are

aggregated. Secondly, aggregated data about compensated blood products in 2002-2011 and detailed

data from 2008-2011 by hospitals from Estonian Health Insurance Fund. Estonian Health Insurance Fund

also provided an overview of the model of product prices, which includes information about the costs

calculated in the product prices. Main information sources describing blood supply in foreign countries

were the European Directorate for the Quality of Medicines & Healthcare (EDQM) annual reports about

blood collection, processing and testing in European countries.

Several analyses were performed based on the collected data:

Analysis of donors by age and residence and the forecast of the number of donors based on the

population projections;

Analysis of trends in the use of blood products and comparison two datasets – the statistics of

compensated products by the Estonian Health Insurance Fund and the statistics of the use of

blood products by the TAI submitted by hospitals;

Analysis of users of blood products by healthcare providers, types of providers and counties

based on the data from Estonian Health Insurance Fund;

Analysis of practices of blood product use by larger hospitals, comparison with other countries;

Analysis of efficiency of donor blood use, during which all the losses from collecting donor blood

to transfusion in every stage of the process were calculated, comparison with other countries;

Gathering financial reports of blood centres for comparing and grouping costs, comparison with

other countries;


Calculation and analysis of productivity and unit price by blood centres, comparison with other

countries;

Comparing equipment in blood centres and calculating the proportion of equipment, which has

exceeded optimal period of use;

Calculating sales revenue of blood centres based on the product prices and number of issued

blood products, comparison of results with the sum compensated by Estonian Health Insurance

Fund;

Grouping the costs of blood centres by stages of the production chain, according to the price

model of Estonian Health Insurance Fund;

Assessing financial impacts of scenarios describing possible division of responsibilities in blood

service.

1.3. Terms used in the report

Aphaeresis – a procedure, during which one or several components of blood are separated from the

whole blood and the residual components of the blood are transfused back to the donor during or at the

end of the procedure (European Commission Directive 2004/33/EC).

Aphaeresis platelets concentrate – blood product containing the platelets of one donor suspended in

blood plasma or additive solution and anti-coagulation solution obtained by aphaeresis (Procedure of

using blood preparations at Tartu University Hospital).

Blood centre – an independent healthcare provider or a hospital department, with the tasks to collect

blood and produce, examine, store and issue blood components with the aim to guarantee the availability

of blood components to healthcare providers.

Blood component – a therapeutic constituent of blood e.g. erythrocyte, platelet, plasma (European

Parliament and Council Directive 2002/98/EC).

Blood plasma – a non-cellular component of blood transporting blood cells, nutrients and residues and

participates in coagulation.

Blood product – a therapeutic product derived from human blood, which contains one or several

components of blood (European Parliament and Council Directive 2002/98/EC). The Blood Act uses the

term blood preparation which is medication produced from blood and packaged and marked accordingly,

containing one or several components of blood. Blood preparations are whole blood, blood components

and plasma derivatives.

Blood service – the system of blood centres and hospital blood banks in a state.

Buffy coat – blood component prepared by centrifugation of a unit of whole blood, which contains a

considerable proportion of leucocytes and platelets (European Commission Directive 2004/33/EC).

Buffy-coat (BC) platelets concentrate – concentrated suspension of blood platelets obtained by

processing whole blood units and pooling the derived platelets (European Commission Directive

2004/33/EC). According to the number of pooled units, 1BC, 2BC, 3BC, 4BC and 5BC platelets

concentrates are recognized.


Cross-matching – an activity during which the donor blood compatibility for a recipient is analysed and

the suitable donor blood is identified for a recipient.

Cryoprecipitate – blood product prepared by concentrating fresh frozen plasma and containing important

plasma proteins participating in the coagulation process (Procedure of using blood preparations at Tartu

University Hospital).

Donation i.e. giving blood – one-time blood donation.

Donor – a person with active legal capacity, who is 18–65-years of age and donates blood for the purpose

of treatment of other persons to a handler of blood (Blood Act).

Erythrocyte i.e. red blood cell – cellular component of blood carrying oxygen to the tissues and organs of

a body.

Erythrocyte suspension – blood product containing erythrocytes suspended in anti-coagulation and

nutrition solution (Procedure of using blood preparations at Tartu University Hospital).

Filtration – procedure where leucocytes are removed from the blood product by a leucocyte removal

filter.

Fractionation – industrial process where different components are separated from blood plasma to

prepare plasma derivatives.

Fresh frozen plasma – blood product separated from whole blood by centrifugation or collected by

aphaeresis and frozen.

Haemovigilance – the procedures of reporting and identifying the causes of serious adverse events

occurring during collection, testing, processing, storage and distrubution and serious adverse reactions

occurring during or after blood transfusion (Blood Act).

Hospital blood bank – structural unit of a hospital with the tasks to order and storage blood components

and distribute them within the hospital, perform immunohematological testing and coordinate and advise

the use of blood component transfusions for treatments.

Immunohematological testing – tests where the ABO and Rh(D) type, K-antigen and irregular antibodies

are identified and/or the crossmatch of recipient and donor blood is performed.

Irradiation – procedure where the ability of lymphocytes to proliferate in blood products can be inhibited

with ionized radiation (Procedure of using blood preparations at Tartu University Hospital)

NAT-test (nucleic acid test) – molecular biology test for directly identifying pathogens’ DNA or RNA in

blood, which enables to identify viruses with shorter window period compared to serological tests, which

indentify antibodies in blood.

Pathogen inactivation/reduction – procedure with blood products where nucleic acid replication is

disabled and therefore viral infections and bacteria are inactivated in blood products.

Plasma product i.e. plasma derivative – medication industrially produced from the blood plasma of

several donors and includes a certain component of blood plasma, e.g. albumin (Blood Act).


Platelet i.e. thrombocyte – cellular component of blood which participates in coagulation process.

Recipient – a person on whom a blood transfusion is performed (Blood Act).

Reconstituted blood – blood product prepared by pooling erythrocytes and fresh frozen plasma

(Procedure of using blood preparations at Tartu University Hospital).

Retrospect procedure – an act initiated to identify the causes of serious adverse events or side effects

that happened during the process of handling blood in order to identify a recipient to whom a potentially

infectious blood component was transfused, or a donor, whose donated blood was the source of the

blood component transfused to the patient (Haemovigilance and blood component recall conditions and

procedures).

Serious adverse event – untoward occurrence associated with the collection, testing, processing, storage

and distribution of blood and blood components, which might lead to death or life-threatening, disabling

or incapacitating conditions for patients, or which results in, or prolongs, hospitalization or morbidity

(European Parliament and Council Directive 2002/98/EC).

Serious adverse reaction – unintended reaction on a donor or a recipient associated with the collection or

transfusion of blood or blood component, which is fatal, life-threatening, disabling, incapacitating, or

results in, or prolongs, hospitalisation or morbidity (European Parliament and Council Directive

2002/98/EC). The term transfusion reaction is also used to describe a serious adverse reaction on a

recipient.

TRALI (transfusion related acute lung injury) – lung injury occurring during or after blood transfusion,

which can be fatal.

Transfusion therapy or blood transfusion – medical procedure where the recipient is transfused whole

blood or blood components (Blood Act).

Virus testing – tests, where donor blood is examined for pathogens, e.g. pathogens for HIV, hepatitis and

syphilis.

Washed red cells – process of removing plasma or storage medium from cellular products by

centrifugation, decanting of the supernatant liquid from the cells and addition of an isotonic suspension

fluid, which in turn is generally removed and replaced following further centrifugation of the suspension.

The centrifugation, decanting, replacing process may be repeated several times. (European Commission

Directive 2004/33/EC).

Whole blood – blood taken from a donor containing all blood component (term is also used for single

blood donation in European Commission Directive 2004/33/EC). Also unprocessed donor blood in anti-

coagulation and nutrition solution (Procedure of using blood preparations at Tartu University Hospital).

1.4. Main components of blood and vein-to-vein chain

In modern medicine, blood products instead of whole blood are used for transfusion, in order to save

donor blood and avoid the use of blood products not necessary for the treatment of a specific patient.


Blood products are made by separating blood components from whole blood - every component has a

different function.

Erythrocytes help to transfer oxygen into blood. Erythrocyte suspension is produced from

erythrocytes, which is used to treat anaemia and in cases of extensive blood loss due to trauma

or surgeries.

Platelets help blood coagulate. Platelet concentrate is produced from platelets, which is used for

treatments of blood diseases (including leukaemia) and other diseases which interfere with blood

coagulation.

Plasma is used to treat coagulation disorders. Fresh frozen plasma and cryoprecipitate are

produced from plasma. Plasma products (e.g. albumin, immunoglobulins, coagulation factors) are

prepared from pouring together plasma from several donors. Plasma products are used for

several diseases, e.g. immune deficiency, neurological-, infectious- and autoimmune diseases,

heart failure, asthma, repeated miscarriages, bleedings and haemophilia.

The process from collecting donor blood to transfusion of blood products can be divided into five stages –

1) collecting blood from donors, 2) producing blood products, 3) testing, 4) storing and distributing to

hospitals and 5) transfusion. The first four stages are performed in blood centres, the fifth in hospitals

(q.v. Figure 1).

Figure 1. Scheme of the process of blood movement

COLLECTING

Blood can be collected as whole blood donations and via aphaeresis. During whole blood donations, the

donor is taken 450 millilitres of blood, which is called a whole blood dose. With aphaeresis, one or several

components of blood are separated and the rest of the blood is transfused back to the donor during or

after the procedure. This enables to collect a larger quantity of a specific component, for example 1-3

doses of platelets concentrates during aphaeresis, or several components at once, like one dose of

platelets and two doses of plasma.

Collecting

Processing

Blood centre

Testing

Storing and

distribution

Donors

Loss - defects

- infections - expiration

Hospitals

Transfusion


TESTING

Blood testing begins in the phase of collection, where the donor is taken an extra 20 millilitres of blood.

This is used for immunohematological testing of the donor blood (identifying the blood type and

antibodies) and identifying viral infections. Infections can be identified only after the so-called window-

period, which differs by infections.

PROCESSING

The collected whole blood is separated into blood components during processing. For this, the dose of

whole blood is put in centrifuge, which separates the components into layers by their weight. Then the

layers of plasma, erythrocytes and the layer of platelets and leucocytes are separated in the separator. As

for the latter, the amounts of 3-4 doses of the same blood type are pooled together and the leucocytes

are separated by centrifuge producing a platelets concentrate.

In addition to separating blood components from whole blood, different procedures can be performed to

clean erythrocytes and platelets in certain manners.

washing – erythrocytes are washed three times with a physiological solution, which removes a

large amount of leucocytes and platelets in addition to plasma proteins;

filtration – an erythrocyte suspension is poured through a special filter to remove the leucocytes;

irradiation – for further removal of leucocytes, the blood product is irradiated with ionized

radiation, which disables the lymphocyte ability to proliferate while not harming the erythrocytes

and platelets.

Plasma is processed into more than 20 different blood products through cleaning, concentrating and

removing different components i.e. fractionation.

STORING

Blood components are stored in different temperatures. Plasma is stored in a fast-freezer after

separation, where it has to be frozen into -30 degrees in an hour and it can then be stored up to 3 years.

Erythrocytes are stored at +2 to +6 degrees and the cells are suitable for transfusion for 35 days. Platelets

need room temperature and constant gentle shaking for survival. Platelets concentrate can be stored for

5-7 days.

TRANSFUSION

Blood centres issue blood products according to orders to hospital blood banks, where blood products are

stored and issued for transfusions. The recipient’s blood type is identified and matching i.e. analysis for

the compatibility of the donor’s and recipient’s blood is performed for the transfusion. The recipient is

transfused blood which matches their type or is 0-negative. If antibodies are identified in the recipient’s

blood during matching, the blood is sent to the blood centre for typing the antibodies and finding specific

donor blood.


2. OVERVIEW OF BLOOD SERVICES AND DEVELOPMENTS

The following chapter gives an overview of different systems of blood services and focuses in detail on the

blood services in three countries – Finland, the UK and Sweden. The countries are chosen by the different

types of their blood services (accordingly: coordinated by the Red Cross, state system and a decentralized

system). The current matters of blood products and blood processing, which could influence future

developments, are brought out in the end of the chapter.

2.1. Different blood services in developed countries

Different countries have introduced different blood service systems, some of them centralized i.e. under

unified management, others decentralized (q.v. Table 1). In decentralized systems, several organizations

collect and process blood, e.g. hospitals in Norway and Sweden. In centralized systems the blood service

system is coordinated by the Red Cross or the state. In most cases the systems are non-profitable,

however some countries also have profit-oriented centres. For example, The National Plasma Centres in

the USA compensates donors for donating plasma. According to the data on the organization’s website,

there are over 500 profit-oriented plasma collection centres with 1.5-2 million paid donors in the USA.

Table 1. Blood service systems of the world

Centralized

National

Centralized

NPO (e.g. Red Cross)

Decentralized

Hospitals

Mixed systems

France

The UK

New Zealand

Ireland

Latvia

Finland

Netherlands

Australia

Switzerland

Canada

Austria

Germany

Norway

Sweden

Estonia

Denmark

USA (Red Cross + America’s blood

centres (network of indep. non-profit

community blood centres)

Lithuania (National blood centre + two

hospital-based blood centres + one

profit-based blood centre)

Source: European Blood Alliance, Veihola 2008, websites of blood centres

Centralized blood systems are more common in Europe and other developed countries and according to

the South and East European Network, European countries move towards centralized blood service

systems due to the increasing requirements for the safety and quality of blood products and the

increasing costs of blood processing (SEEHN, WHO, Current Status and Future…, 2011). For example, such

developments have occurred in the UK during the last twenty years (q.v. chapter 2.1.1).

Both centralized and decentralized blood systems have strengths and weaknesses. The strengths of

centralized systems are: possibility to concentrate more sophisticated activities into fewer blood centres,

which enables to achieve better quality and decrease costs; more optimal use of human and financial

resources; better blood supply management between different regions; easier planning and adjustment

of blood demand; easier standardization of blood centre activities (Moftah 2004). The World Health

Organization (WHO) also brings out the advantages of centralized systems being unified planning and

coordination and cost-effectiveness, but problems with logistics were mentioned. In decentralized


systems the problems could occur with ensuring the unity of services, cost-effectiveness and quality

management (WHO, Strategies for Safe Blood Transfusion, 2000).

In addition to the level of centralization of management, another aspect giving information about a

country’s blood service is the number of blood centres. Generally countries with a larger population and

area have more blood centres, but not always. For example, Finland has blood centres in 17 regions, but

in Switzerland blood is processed in about 50 blood centres.

Table 2. Number of blood centres and hospital blood banks in European countries, 2010

No. of blood establishments in a country No. of hospital blood banks in a country

Austria 16 blood establishments, 14 plasmapheresis centres 150

Belgium 6 112

Bulgaria 5 regional centres, 28 hospital-based smaller blood collection departments

56

Cyprus 1 6

Czech Republic 79 56

Denmark 13 blood centres, 59 donation sites 61

Finland 1 blood establishment with 17 sites 54

France 17 regional establishments for processing and testing, collection in 158 places and distribution in 152

705

Germany 84 blood establishments with 140 processing sites, 5 private organizations focused on plasma collection for fractionation

approximately 800

Greece 14 81

Ireland 5 55

Italy 326 Blood Transfusion Services with tasks of both blood centres and blood banks

326 Blood Transfusion Services with tasks of both blood centres and blood banks

Liechtenstein 2 1

Lithuania 4 102

Luxembourg 1 9

Malta 1 4

Netherlands 1 approximately 115

Norway 36 Some

Poland 23 533

Portugal 26 …

Romania 41 blood establishments, one blood establishment of the Ministry of Defence

345

Slovakia 44 unknown as are not registered

Slovenia 3 blood establishments, one with 2 departments in different locations. Other 7 blood establishments are becoming part of one existing centre.

3

Spain 25 341

Sweden 32 transfusion centres in 82 locations with tasks of both blood centres and blood banks

82

Switzerland 54 licenses for blood establishments, which perform collection and/or processing activities, 50 licenses for establishments which perform serology testing

approximately 100

The UK 14 390

Source: European Commission, Summary Table of Responses…. (2010)


2.1.1. Blood service in the UK3

Blood service in the UK (National Health Service ─ Blood and Transplant, NHSBT) is a part of the national

healthcare system, whose tasks are to ensure a supply of blood, organs and tissues and to improve the

quality of blood and transplant services, productivity and economic efficiency. NHS organ donor registry,

the British bone marrow registry and NHS cord blood bank are also located at the NHSBT.

The blood service system consists of blood establishments, smaller blood collection clinics and mobile

blood collection units. There are 15 blood establishments which work as distribution centres. Only three

of them perform blood testing (microbiological and NAT-tests) and five perform blood processing. About

half of NHSBT staff work in mobile blood collection units.

2 million doses of whole blood and 200 000 doses of aphaeresis platelets were collected from 1.4 million

blood donors in 2011/12. 1.83 million doses of erythrocytes and 0.27 million doses of platelets were

produced.

NHSBT receives its main income from the sales of blood products and services to hospitals. The prices of

services and products are set annually via national commissioning process, based on the volume

assumptions for the services and products provided for the year ahead and the prices are calculated so

they would cover the operating costs. In addition, NHSBT receives income via central financing from the

government, which is used to cover mostly the costs of special services and organ donor services. The

latter also covers capital investments (e.g. purchase of equipment). In 2011/2012 NHSBT income was 431

million pounds, from which 72% came from sales revenue, the operating surplus was 4.3 million pounds.

6.5 million pounds (1.5% of the income) was set for capital investments.

The blood system of the UK has been strongly centralized during the last twenty years. In the beginning of

1990s, 14 independent regional blood systems were reorganized and National Blood Authority was

created. Until 2000, the system was divided into three competing zones. In 2000 another reorganization

took place, where the zones where lost. In 2005 NHSBT was created. The new organization began

consolidating processing and testing, as a result of which the number of processing and testing sites was

planned to be decreased from twelve to eleven in 2007 to five and three by the end of 2011. The number

of testing sites is planned to be decreased from three to two by March 2013. The main reason of

consolidation was the need to raise the economic efficiency and quality in order to decrease the prices of

blood products. In the period of 2008/09 – 2011/12 the price of erythrocytes decreased from 140 pounds

to 125, saving 30 million pounds. (NHSBT website, The National Audit Office Audit Report 2000, NHSBT

Commercial Review 2011, NHSBT Strategic Plan 2012─2017, NHSBT Annual Review 2011/2012, Sandle

(2011))

2.1.2. Blood service in Finland

Finnish Red Cross blood service (FRCBS, Punainen Risti Veripalvelu) is the centralized non-profit unit of

Finnish Red Cross. The main goals of FRCBS are to provide blood products to health care sector and to

coordinate blood donation. FRBCS also offers the following services to hospitals: red cell serology testing;

3 NHSBT, i.e. the blood service of England and North Wales is under observation. In addition to the mentioned organization,

there are also independent Northern Ireland Blood Transfusion Service, Welsh Blood Service and Scottish National Blood Transfusion Service in the UK.


testing of organ, tissue, and stem cell transplants; testing and supplying with coagulation factors and

platelets; management of Bone Marrow Donor Registry and Cord Blood Bank. FRCBS also works actively

with R&D activities and consultations.

The Finnish blood service is divided into 17 districts. The main operating site is located in Helsinki blood

centre, where most of the laboratory analyses are performed. Additionally, there are four regional centres

in the Finnish blood service (Kuopio, Oulu, Tampere and Turku) and 12 local donor centres. All sites collect

donor blood, which gives approximately 60% of the collected donor blood, 40% of the donor blood is

collected from mobile units and donor days held all over Finland. Blood testing, processing and

distribution are centralized. Blood testing is concentrated into one centre. Blood processing is performed

in two centres (Helsinki and Oulu, processing was stopped in Tampere) since 2010. Distribution of blood

products is also done from two centres; under special conditions hospitals can also offer blood products

to each other.

263 000 doses of blood (48.7 doses per thousand people4) was donated in Finland in 2011 and 5000 doses

of plasma and 500 doses of platelets were collected via aphaeresis. 240 000 doses of erythrocytes, 42 000

doses of platelets and 50 000 doses of fresh frozen plasma were produced from the blood (accordingly

44.4 doses, 7.8 doses and 9.3 doses per 1000 people) and transfused to 55 000 patients. Plasma products

(including Octaplas) are bought in outside the country, in addition to Octapharma, a contract was also

made with Baxter in 2011. During three years, the amount of erythrocytes sold to hospitals has decreased

(from 251 000 in 2009 to 240 500 in 2011) and the amount of platelets has increased (from 39 900 to

41 700 doses).

Finnish blood service is not profit-oriented and their main income comes from the sales of blood products

and services to hospitals, which is used to cover the operating costs and investments. FRCBS yearly

income was 69 million Euros in 2011, 66% of which was received from the sales of blood products, 12%

from the sales of unprocessed plasma and 9% came from laboratory tests. The largest costs were related

to staff (48%) and materials and subcontracting (25%). The loss of 2011 was 2.3 million Euros, but the

surplus of 2010 was 1.8 million Euros. The blood service does not receive financial aid from its roof-

organization nor from the Finnish government. (FRCBS website, FRCBS Annual Report 2010 and 2011)

2.1.3. Blood service in Sweden

The Swedish blood system consists of blood centres managed by county councils.

Sweden has 30 blood organizations (Blodcentralsorganisation), consisting of blood centres, donor centres

and mobile blood collection units. Blood centres are mostly located at hospitals (81 hospitals), but blood

is collected in separate stationary donor sites (e.g. shopping centres) and mobile units, with the total of 24

and 14 in 2011. Mobile collection units visit cities, counties and larger organizations. The internal division

of responsibilities is decided by the blood organizations themselves. For example, at larger counties the

blood centre at a university hospital is usually set as a regional blood centre, which is responsible for

other blood centres located at smaller hospitals (e.g. unified quality systems, logistics of blood products

etc). In several counties the regional centres are responsible of blood testing, processing or provision of

specific blood products. 4 The information about Finnish population in 2011 found in the website of Statistics Finland is used for stating the collected

blood and produced blood components per 1000 people (5 401 267 people).


Several organizations cooperate on state level. A non-profit organization Sweba created in 2004 by blood

centres is the coordinator of the work of all blood centres. The main task of Sweba is to develop the

electronic information exchange system between blood centres, but it also represents Sweden at

European Blood Alliance. The Swedish Transfusion Medicine Association (Svensk Förening för

Transfusionmedicin) has the central role in training transfusion medicine specialists and developing

working standards. Several working groups, e.g. the working group of guidelines and haemovigilance

working group belong to the association. Since 2005, the association also compiles reports gathering the

main indicators of blood service. Information about donation is gathered in the national website

geblod.nu, which also gives information about blood donation sites (including mobile collection sites) and

blood supplies of blood centres.

Sweden has about 405 000 donors, from whom 239 000 donated blood in 2011 (25 donors per 1000

people). There were 45 500 first-time donors. In total, 484 000 doses of blood was donated in 2011, with

an average of 2 donations per donor. 493 000 doses of erythrocytes were produced, from which 97.5%

were used for transfusions. On average, 51 doses of erythrocytes are transfused per 1000 people in

Sweden. 53 000 doses of platelets were produced (5.3 per 1000 people), from which 70% were BC

platelets. All the transfused platelets were leucocytes-free, 55% irradiated and 17% inactivated. 89 000

doses of plasma were transfused (24 tons), 141 tons of plasma was sent to fractionation.

Blood centres receive their income from the sales of blood products and services and from selling plasma

to fractionation. The budgets of blood centres are set by the hospitals, and the hospital budgets are

confirmed by counties. The prices are set by blood centres so they would cover the costs. Blood centres

do not receive additional financial support from the state. (Blodverksamheten i Sverige 2011, website of

Swedish donation, website of Swedish Transfusion Medicine Association)

2.2. Trends in collecting, testing, processing and using blood products in Europe

Statistics about the collection, use and safety of blood and blood products in European countries is

gathered by European Directorate for the Quality of Medicines & Healthcare (EDQM). EDQM issues

annual reports since 2001. In 2011 the first overview of European trends was issued, which aggregates

information from 2001-2005. Based on the analysis of data from 2001-2005, the report concludes (van

der Poel et al 2011b):

1. Blood supplying in Europe is stable, the proportion of first-time donors and the number of donors

and donations per inhabitant has not changed;

2. The use of erythrocytes has increased (0.4 doses per 1000 people);

3. The use of platelets has not changed, but the use of aphaeresis platelets has increased (1.7% per

year);

4. The use of fresh frozen plasma has increased (0.3 doses per 1000 people per year);

5. Proportion of plasma going into fractionation has not changed;

6. Proportion of leukocyte depleted erythrocytes has increased, average of 4.3% per year;

7. No significant changes in using testing methods (information about serological and NAT-tests).


Although according to the research of EDQM there have not been significant changes in the number of

donors in 2001-2005, a risk factor for the future is the aging population. Potential donors are mostly 18-

65-year-olds, recipients mostly over 60. So the aging population in the Western world has two negative

effects on donation – the proportion of people in the appropriate age for donation is decreasing and the

proportion of those in need of blood products is increasing. In Western societies, blood requirements

have steadily increased over the past two decades, mainly due to developments in haematology and

oncology and increasing numbers of major surgical procedures (Greinacher et al 2010). According to the

prognosis of NHSBT, the need for erythrocytes in the UK increases 7% by 2021 and the need for platelets

34% (NHSBT, Strategic Plan 2012─17, 2012). Drackely et al (2012) estimates blood deficit in Canada

already by 2012.

Several steps have been taken to avoid a deficit in blood products. One of the measures has been

expanding the age limits for donation. For example, the UK, Australia and some states in the USA have

removed the upper age limit for donations and in the UK, USA and some blood centres of Denmark have

lowered the age limit to 17 (Ali et al 2010). Another step has been promoting a more optimal use of blood

products i.e. minimizing discarded blood products and avoiding excessive transfusion. The European

project EU Optimal Blood Use has developed a manual discussing several similar matters.

Developing the safety of blood products is also constantly being worked on. Blood transfusion has to be as

safe as possible for the patient, but unfortunately there is always the risk of side effects and virus

transmissions. Viral infections are currently tested with NAT-tests (nucleic acids testing) and antibody

tests, but due to the window-period and fact that only the most common viral diseases and virus subtypes

are tested, the transmission of viral infections is not completely eliminated. Also, the mutation of viruses

can also cause a situation, where the virus cannot be identified with the usual tests. From non-infectious

complications, one of the most serious is TRALI (transfusion related acute lung injury), i.e. post-

transfusion lung damage which can be fatal.

In order to minimize the transmission of viral infections, stricter criteria for donor screening are used to

try to achieve the safety of blood products. For example, the current matter is forbidding blood donation

for people with certain sexual behaviour (MSM – men having sex with men, European Commission, Joint

meeting…., 2010). Secondly, more sensitive tests and/or tests for new viruses are developed. For

example, in addition to antibody tests, NAT-tests are used and avoiding West Nile virus is the current

issue in Europe (European Commission, Joint meeting…. 2010).

Processing technologies are also under development to increase blood product safety. One of the

possibilities to decrease the risk of viral transmissions due to the window-period is pathogen reduction i.e.

pathogen inactivation in blood, which means that blood products are processed with specific extra

subsistence in order to destroy all viral infections. Several methods have been developed for that, which

are used on plasma and platelets. There is yet no efficient method for inactivating erythrocytes. Solvent-

detergent (SD) method used for plasma inactivation is believed to have an effect on reducing or

eliminating the risk of TRALI as well, as the plasma of multiple donors is pooled during processing

(AuBuchon 2011). There are no prospective studies, which have evaluated the incidence of TRALI after

using inactivated plasma. However, there have been no reported cases of TRALI following the transfusions

of Octaplas or other inactivated plasma products. In addition, a recent review of haemovigilance data

from four different European countries (Fleshland 2007) reported no TRALI cases in Norway, where

Octaplas is widely used, while in the three other countries where only fresh frozen plasma is used the

incidence of TRALI was 1.6-8.8 per 100 000 doses (Membe et al 2011).


Based on the research of EDQM, plasma has (almost) completely been replaced with SD-plasma in

Finland, Norway and Ireland, some countries use plasma inactivated with other methods, like Methylen

Blue in Belgium, France and Spain (EDQM, Implementation of Pathogen…, 2011). There is yet no

equivalently effective method found for platelets, therefore the use of inactivated platelets is more scarce

compared to plasma – according to EDQM 2009 data, inactivated platelets are used in Belgium (13% of

the platelets), Norway (16%) and Sweden (4%).

Artificial blood (blood substitute) i.e. synthetic substance with similar functions to blood products (e.g.

transporting oxygen to blood) could have a significant effect on blood services in the future. The search

for substitute products has been ongoing for decades, and by today, several products have reached the

stage of active clinical testing. The biggest problems with substitute products have been a large amount of

undesired side effects, a short time period of useful effect and extra large costs for processing. On the

other hand, substitute products are safe from the aspect of viral transmission and do not need the

conditions specific to blood products e.g. special conditions for storage, blood typing and matching.

Therefore, the wide use of substitute products could bring along drastic changes in transfusion medicine

(Kim, Greenburg 2006).


3. BLOOD SERVICE IN ESTONIA

This chapter gives an overview of Estonian blood service and describes the system of both blood centres

and hospital blood banks. Main focus will still be on blood centres and the tasks, division of

responsibilities and resources of blood centres are described. Separate attention is given to the Estonian

blood information system.

3.1. Structure of Estonian blood service

Estonian blood service as a part of the health care system is coordinated by the Ministry of Social Affairs.

Estonian blood service consist of two parts: blood centres and hospital blood banks. Blood centres collect,

test, process, storage and sell blood products to hospital blood banks. Hospital blood banks handle the

orders, storage and preparations for transfusions.

The role of the Ministry of Social Affairs is mainly creating legislation and financing and supervising the

system through its sub-institutions (q.v. figure 2). Cooperation and coordination takes place rather by

communication or via blood service expert committee, which meets at the Ministry of Social Affairs. The

supervision of blood centres and hospital blood banks are given to State Agency of Medicines and Health

Board, accordingly, whose practice of supervision is based on the Blood Act and the regulations deriving

from that.

North Estonia Medical Centre

Hospital blood banks in North, Central,

Northeast and West Estonia (not Pärnu)

Blood centre

Blood bank

Tartu University Hospital

Blood centre

Blood bank

Pärnu Hospital

Blood centre

Blood bank

Ida-Viru Hospital

Blood centre

Blood bank

Hospital blood banks in South

Estonia

(some) hospital blood banks in

Northeast Estonia

Ministry of Social Affairs

Estonian Health Insurance Fund

(financing)

State Agency of Medicines

(supervision of blood centres)

Health Board

(supervision of hospital blood

banks

B L O O D S Y S T E M

Figure 2. Scheme of Estonian blood system


3.1.1. System of Estonian blood centres

The blood service is decentralized in Estonia. Decentralization means that there is virtually no planning

and coordinating done on the state level. As of 2012, four blood centres are active in Estonia, which are

located in certain hospitals and supply other hospitals in the district with blood products in addition to

their own hospitals.

Estonian blood service has not significantly changed in the last fifteen years. Since 1996 there were five

blood centres in Estonia – North Estonia blood centre, Tartu blood centre, Pärnu Blood service, Kohtla-

Järve Hospital blood bank and Kuressaare Hospital blood department. From those, North Estonia Blood

Centre acted as a state institution and Pärnu Blood service as a municipal institution, the rest were units

of according hospitals. Kuressaare Hospital blood department was closed in 2003. In 2003 and 2006 Pärnu

Blood service and North Estonia Blood Centre were joined accordingly with Pärnu Hospital and North

Estonia Medical Centre.

Since 2003 Estonia has four independent blood centres: North Estonia Medical Centre (PERH) Blood

Centre, Tartu University Hospital blood centre, Pärnu Hospital Blood service and Ida-Viru Hospital Blood

centre (henceforth PERH, Tartu, Pärnu and Ida-Viru blood centre). PERH blood centre supplies the

hospitals of Harju, Lääne, Rapla, Järva, Lääne-Viru, Saare and Hiiu counties and partially Narva Hospital;

Tartu blood centre supplies hospitals of Viljandi, Jõgeva, Tartu, Põlva and Võru counties; Pärnu Blood

centre supplies Pärnu Hospital and Ida-Viru blood centre supplies hospitals of Ida-Viru county (q.v. Figure

3).

PERH blood centre

Ida-Viru blood centre

Pärnu blood centre

Tartu blood centre

Figure 3. Areas of activity of blood centres

Producing plasma products from plasma – fractionation – was stopped in Estonia in 1997, as it was not in

accordance with medicine processing requirements of Europe. The blood centres looked for opportunities

to utilize the leftover plasma by selling it to external fractionators and according to the requirements of

fractionators individual contracts were made with blood centres. In 2004 the fractionation contracts were


not extended as the amounts were small, blood centres did not have resources for buying back the

plasma products and the Estonian Health Insurance Fund could not make a central purchase any more

(Developing Blood donation…, 2010). Since 2009, PERH blood centre has a fractionation contract and

since 2012 Tartu and Pärnu blood centres have contracts as well.

The blood centres differ from each other in size and produced products. The majority of blood is collected

as whole blood donations (97% in 2011, q.v. also Figure 8), but three blood centres also use aphaeresis for

collecting blood; majority of aphaeresis procedures are done in PERH blood centre. One reason for

collecting blood components via aphaeresis is the medical indication (e.g. BC platelets and aphaeresis

platelets are used slightly differently), but also other aspects. Ida-Viru blood centre, which does not

produce platelets and whose plasma use is smaller compared to the use of erythrocytes, uses erythrocyte

aphaeresis; PERH blood centre, which has a fractioning contract for selling plasma, uses plasmapheresis.

As for main blood components, Estonia is self-supplying, with the exception of plasma products, which are

bought from external markets. All blood centres prepare erythrocyte suspension and fresh frozen plasma.

In case of Ida-Viru and Pärnu blood centres, these are almost the only produces (94-99% of products, cf.

81-88% in other centres). A critical mass of donors per day is necessary for preparing platelets, as buffy-

coats of 3-4 donors of the same blood type are needed for preparing one dose of platelets concentrate

from whole blood and buffy-coats cannot be collected during multiple days due to the short storage life of

platelets. PERH and Tartu blood centres produce both BC and aphaeresis platelets, different products for

children, washed, irradiated and filtrated blood products. In total, the blood centres issued 96 000 doses

of blood products in 2001 – 48% PERH, 36% Tartu, 10% Pärnu and 6% Ida-Viru blood centre.

Table 3. Division of responsibility in blood centres, 2011

PERH blood

centre

Tartu blood

centre

Pärnu blood centre Ida-Viru blood

centre

Total

Collected doses of blood

aphaeresis procedures

55%

83% (Pl+P+Mc)

29%

9% (Tr)

11%

0%

5%

9% (E)

100%

100%

Blood tests

immunohemat. tests

virus tests

+

+

+

+ (hospital’s lab)

+

+/- (some in Tartu)

+

- (mostly in Tartu)

Supplying

erythrocytes

platelets

plasma

54%

60%

34%

30%

40%

46%

11%

0%

12%

6%

0%

9%

100%

100%

100%

Amplitude of product

selection

20 19 3 3 28

Source: Annual reports of blood centres, data of blood centres

Note: Health care service lists 28 blood products; Pl – platelets, E – erythrocytes, P – plasma; Mc ─ multiple components

Blood centres also differ in resources. A total of 140 employees worked in blood centres in 2011, filling

132 positions (q.v. Figure 4). 60% of the blood centres’ staff works in PERH blood centres, 23% in Tartu,

11% in Pärnu and 6% in Ida-Viru. 35% of the employees are nursing workers, 30% other workers, 18%

doctors and 17% technicians (q.v. Annex 1), this structure has virtually not changed in the last years. The

structure does differ by blood centres due to the different activities, e.g. Ida-Viru and Pärnu blood centres

do not have separate technicians and therefore the number of nurses is larger in the staff. The number of

technicians in Tartu blood centre is immensely larger compared to PERH blood centre since Tartu Blood


Centre also works as a hospital blood bank performing blood type tests and matching (in other hospitals

blood banks handle these tasks).

Tartu and Ida-Viru blood centres are located in the facilities of hospitals, PERH and Pärnu blood centres in

separate quarters. PERH blood centre has the largest area. In the near future, Tartu blood centre may

move into the new Maarjamõisa facilities and Pärnu blood centre into the facilities of Pärnu Hospital.

Table 4. Resources of blood centres, 2011

PERH blood

centre

Tartu blood

centre

Pärnu blood

centre

Ida-Viru

blood centre

Total

Number of employees 84 32 15 9 140

Filled positions 79.55 29.75 15 7.5 131.8

Facilities, m2 3198 455 566 298 4517

Proportion of equipment in working

age (obtained 2005 and later)

60% 39% 53% 33% 53%

Source: Annual reports of blood centres 2011, data of blood centres

The average optimal age of equipment in blood centres is 5-7 years (Transfusiology development plan).

According to the analysis of the equipment list of blood services, 47% of the equipment is obtained before

2005, having therefore been in use more than seven years. The proportion of new equipment is largest in

PERH blood centre, due to joining with North Estonia Medical Centre in 2006, during which the inventory

of the blood centre was renewed.

3.1.2. System of hospital blood banks

Hospital blood banks are structural units of hospitals under private law in Estonia, which are responsible

for ordering and storing blood products and issuing them within the hospital, performing

immunohematological tests and coordinating and advising the use of blood transfusions for treatment

(Blood Act). In 2011, 27 health care providers performed immunohematological tests and used blood

products, among them all so-called development plan hospitals (q.v. also Annex 2).

Table 5. Number of performers of immunohematological tests, number of users of blood and plasma

products and compensated sums, 2011

Users Sum

Immunohematological tests (stationary + daily treatment) 27 1 593 315

Blood products (except plasma preparations) 27 4 514 799

Plasma preparations 19 2 989 179

Source: Estonian Health Insurance Fund, list of healthcare services

The task of hospital blood banks in a hospital is to ensure the supply of blood and fulfill orders of blood

products. Ensuring blood supplies means that hospital blood banks keep a certain supply of blood

products in the hospital and check the existence of supplies. In those hospital blood banks, the

representatives of which were interviewed for this research, the minimal supply requirement is based on

the instructions agreed upon inside the hospital and the supplies consist of erythrocytes, plasma and


more common blood types. Other blood products and blood types are ordered according to necessity.

Blood products are mostly ordered from the blood centres of their districts.

3.2. Information system of blood service

Blood service Information System (EVI), which was initiated in 1995, is used in Estonia. In the following

two years it was implemented in North Estonia, Tartu and Pärnu blood centres. From 1995-2000 an

intensive development of EVI took place, which was financed by the Ministry of Social Affairs. The system

was acknowledged in 1997 as the most modern blood service information system in Europe by the

European Blood Service Quality Committee, since Estonia was the first country to implement ISBT 128

standard (AS Gennet Lab web page). Since 2000, the development of EVI has been delegated to hospitals

and the capacity of developments has been modest.

EVI collects the data regarding blood processing from blood collection to transfusion of blood products

(q.v. Figure 4).

Figure 4. Main data regarding blood service

Today, all blood centres use EVI (including mobile collection sites), but these are local databases. This

means that the databases of blood centres and hospital blood banks are not compatible, there is no

information exchange and there is no national database of donors, blood product supplies and recipients.

The movement of blood products is traceable only within one blood centre (i.e. from donor to issuing

blood product), with the exception of cases where the EVI of a hospital blood bank is compatible with EVI

of a blood centre. Eight hospital blood banks use EVI, the rest use other information systems or data is

registered on paper. Therefore, in practice the whole process is not traceable and the retrospect

procedure is difficult (e.g. in cases of transfusion reactions) and blood centres cannot see, if a donor has

donated in another blood centre. As the databases are not joined, hospital blood banks and blood centres

do not automatically receive information about tests performed in other blood centres. For a similar

reason, ordering blood products and fulfilling the orders is not completely optimal.

Integrating equipment to information system will help to ensure the safety and quality of blood products,

i.e. the results of analysis and measurements being automatically submitted to databases. The

Collection- Personal data of

donors- Health data and

suitability of donors

- Stationary blood collection

- Mobile collection

Testing- Immunohemat.

test results- Virus test results - Quality control

Processing- Registering

products- Quality control

- Labelling products

Storing and issuing

- Products in stock- Poduct disposal

- Orders and issuing

- Invoices

Transfusion- Products in

hospital stocks - Patient blood tests, matching

- Registering transfusions- Registering transfusion reactions

Traceability vein-to-vein


performance and submitting analysis and measurement results is partially automatic in blood centres, but

usually not in hospital blood banks; also, not all equipment are integrated with EVI in blood centres.

Joining EVI into a whole has been on the agenda for at least ten years, but as the financing of

developments has been delegated to blood centres, it has still not come to life. However, EVI

development is on the agenda again. In early summer of 2012, a public procurement “Analysis of National

Information System for Blood, Tissue and Cells” was carried out with the aim to put together an analysis

for a national information system for blood, tissue and cells – to map today’s situation and needs in order

to obtain an input for a procurement to implement an information system. The project of mapping ends

by the beginning of December 2012.


4. DONATION IN ESTONIA TODAY AND IN THE FUTURE

The following chapter focuses on blood donation in Estonia. The chapter gives an overview of the main

indicators of donation and compares them to the according indicators in other countries it also provides

an analysis of donors by age and residence. Blood collection via mobile collection will also be looked at.

An evaluation of donation and suggestions for developing donation are given in the end of the chapter.

European Union and WHO promote voluntary unpaid donation, as it is considered the most suitable

model from the viewpoint of the blood demand and safety in a country. According to research, in the

countries with 100% voluntary unpaid donation, the proportion of regular donors is larger, which provides

a better supply of blood. This system is also safer: as donors donate blood in order to do good, no

information is hidden about possible risk factors. Voluntary unpaid donation is also in better accordance

with ethical aspects, as blood is donated voluntarily and not because of economic considerations (WHO,

Towards 100% Voluntary Blood Donation…, 2010).

According to the Blood Act, blood is collected from voluntary donors in Estonia. All blood donations are

unpaid. Every healthy person weighing at least 50kg, aged 18-65 can be a donor (Donor eligibility

criteria...). Limits are also set to the frequency of donations – European Commission advises not to donate

blood over 3 litres a year and there must be 8 weeks between two whole blood donations (European

Council recommendation 98/463/EC). Estonia follows the rule that women can donate blood 3-4 and men

4-5 times a year; in case of aphaeresis procedures the period differs – plasmapheresis can be done every

2 weeks, double erythrocytes donation has to be half a year apart.

4.1. Trends in donation

36 000 donors visited Estonian blood centres in 2011, who donated 59 000 doses of blood (q.v. Table 6).

The proportion of active donors from the population has remained relatively stable in 2004-2011, still

showing a slight tendency to rise in the last few years.

Table 6. Dynamics of the number of donors and donations

2004 2005 2006 2007 2008 2009 2010 2011

Donors in total 34 305 32 147 32 254 34 051 34 062 35 251 36 136 36 200

Proportion of donors from the population, %

2.5 2.4 2.4 2.5 2.5 2.6 2.7 2.7

First-time donors 9 997 7 990 7 219 9 237 9 224 9 294 8 669 8 058

Proportion of first-time donors

from all donors, %

29.1 24.9 22.4 27.1 27.1 26.4 24.0 22.3

Donations in total, doses 58 553 54 123 54 701 55 827 54 843 57 503 58 729 59 280

Donations per 1000 inhabitants, doses

43.4 40.2 40.7 41.6 40.9 42.9 43.8 44.2

Donations per donor 1.7 1.7 1.7 1.6 1.6 1.6 1.6 1.6

Source: TAI health statistics and research database


The proportion of donors in the population was 2.7% in Estonia in 2011. According to WHO

recommendations, the blood supplies and self-supplying of a country is ensured if approximately 5% of

the population is active donors (IFRC, Making a difference…, 2007). Later sources have brought out 2.5%

of the population as a minimal level for European countries (WHO, Rising blood-donation rates in Europe,

2012).

Every Estonian donor donated an average of 1.6 doses in 2011 and this amount has practically stayed the

same throughout the observed years. The number of donations per 1000 inhabitants has remained

between 40 to 44 doses.

22% of the donors are first-time donors i.e. donors who donate in the given blood centre for the first

time. A relatively large proportion of first-time donors is a problem for several reasons. A constant

recruitment of new donors causes extra cost, a smaller proportion of regular donors can cause problems

in crisis situations and first-time donors are considered risky from the aspect of blood safety compared to

regular donors. However, it should be noted, that in Estonia a first-time donor is considered a person who

donates blood in the given blood centre for the first time, as the information systems of blood centres are

not unified (q.v. chapter 3.2), thus the proportion of first-time donors may be somewhat overrated in

Estonia.

Compared to other European Union countries, the proportion of donors in the population is average (27

donors per 1000 people) and similar to the UK, the relative number is slightly higher in Finland. The

number of donations per donor (2011 – 1.6) is also comparable to developed countries: e.g. in Sweden it

is 2.0, in the USA 1.6, in the UK 1.3 and 2.0 in Canada (IBM, Performance Review of Canadian blood

services, 2002, Blodverksamheten i Sverige 2011). On the other hand, the proportion of first-time donors

is high in Estonia and by that indicator Estonia is on the sixth position from 31 countries.

Figure 5. Proportion of donors and first-time donors in Estonia (2011) and other European countries

(2008)

Source: van der Poel et al (2011), TAI health statistics and research database

According to the poll conducted by WHO in 165 countries, the average blood donation rate in European

region is 36.5 doses per 1000 people in 2010 and compared to the data from two years ago, the rate has

increased 1.8 doses (WHO, Rising blood-donation rates in Europe, 2012).

2722

0

10

20

30

40

50

60

70

Cyp

rus

Slo

ven

ia

Den

mar

k

Au

stri

a

Gre

ece

Mal

ta

Ger

man

y

Cze

ch

Swed

en

Fin

lan

d

Luxe

mb

ou

rg

Bel

giu

m

Esto

nia

Ital

y

Hu

nga

ry

Un

ited

Kin

gdo

m

Latv

ia

Net

her

lan

ds

Fran

ce

Po

lan

d

Irel

and

Slo

vaki

a

Bu

lgar

ia

Lith

uan

ia

donors per 1000 inhabitants proportion of first-time donors, %


4.2. Age-specific structure and residence of donors

A characteristic trait of Estonian donation is the high proportion of young donors – in 2011 half of the

donors were aged 18-29 and 33% aged 18-24. In 2005-2011 the average age of donors has not changed

(q.v. Table 7). While among population aged 18-29, the proportion of donors is 7.7%, it is only 1.2%

among population over 50.

Table 7. Age specific structure and proportion of donors in population by age groups

2005 2006 2007 2008 2009 2010 2011

Average age 31.8 32.0 32.1 31.9 31.9 31.9 32.2

Age-specific structure of donors

18─29 53% 52% 51% 52% 51% 51% 50%

30─39 23% 24% 25% 24% 24% 24% 24%

40─49 15% 15% 15% 15% 16% 16% 16%

50─66 9% 9% 9% 9% 9% 9% 9%

Proportion of donors in population

18─29 7.2% 6.9% 7.2% 7.2% 7.4% 7.7% 7.7%

30─39 4.1% 4.2% 4.6% 4.4% 4.6% 4.7% 4.7%

40─49 2.6% 2.6% 2.8% 2.9% 3.1% 3.2% 3.4%

50─66 1.1% 1.1% 1.1% 1.1% 1.1% 1.2% 1.2%

Source: extract from the information system of blood centres, Statistics Estonia

The situation is different in other developed countries. According to the WHO poll in 165 countries, on

average less than 8% of donors are aged less than 18, 20% are aged 18-24, 33% are aged 25-44, 34% are

aged 45-64 and 5% are over 65 in countries with higher income (WHO, Blood safety and availability: Key

facts, 2012). From European countries Poland and Luxembourg have an age-specific structure of donors

similar to Estonia, on the other hand, in Finland the proportion of older donors is much higher.

Figure 6. Age-specific structure of donors in Estonia (2011) and selected European Union countries (2008)

Source: WHO Global Database on Blood Safety, extract of information system of Estonian blood centres

Donors are not evenly located based on residence. The counties with the highest proportions of donors

are Harju, Tartu, Pärnu, Ida- and Lääne-Viru counties being in accordance with the location of blood

41%

36%

33%

23%

16%

16%

15%

15%

14%

13%

11%

45%

46%

51%

38%

59%

43%

44%

49%

47%

37%

36%

15%

18%

16%

39%

25%

41%

41%

37%

39%

50%

53%

0% 20% 40% 60% 80% 100%

Poland

Luxembourg

Estonia

France

Bulgaria

UK

Austria

Ireland

Slovenia

Belgium

Finland

aged 24 and under

aged 25-44

aged 45 and over


centres (q.v. Figure 7). More than a third of donors who visited blood centres in 2011 live in Harju county,

18% in Tartu county and 11% in Pärnu county.

Figure 7. Division of donors based on residence, 2011

Source: extract of information system of blood centres

When comparing the population and the number of donors of a county, the counties with the most active

donors can be identified (q.v. Figure 8). Clearly differentiable are Pärnu and Tartu county, where the

proportion of donors in the population is 4.3-4.6% (compared to Estonian average – 2.7%). In the case of

Tartu, one factor is the relatively large proportion of university students (i.e. young people). In addition,

six other counties have a higher proportion of donors in population than the Estonian average (Järva, Hiiu,

Saare, Rapla, Lääne-Viru and Lääne). The least active from the donation aspect are the people in Ida-Viru,

yet this area is characteristic for the widest spread of HIV, which affects donation.

Figure 8. Proportion of donors in the population by county, 2005, 2008 and 2011

Source: Extract of the information system of blood centres, Statistics Estonia

The proportion of donors has increased in most counties compared to 2005, a considerable change occurs

in Pärnu, Järva, Lääne-Viru and Lääne counties (0.7-0.9 percent point) (q.v. Annex 3). On the other hand,

Harju county36%

Tartu county18%

Pärnu county

11%

Ida-Viru county6%

Lääne-Viru county6%

Järva county3%

Rapla county3%

Viljandi county3%

Saare county3%

Jõgeva county2%

Lääne county2% Võru county

2%

Põlva county2%Valga county

2%

Hiiu county1%

4,6

%

4,3

%

3,4

%

3,3

%

3,3

%

3,2

%

3,1

%

3,1

%

2,5

%

2,5

%

2,2

%

2,1

%

2,1

%

2,0

%

1,3

%

0,0%

0,5%

1,0%

1,5%

2,0%

2,5%

3,0%

3,5%

4,0%

4,5%

5,0%

Pär

nu

Tart

u

Järv

a

Hiiu

Saar

e

Rap

la

Lään

e-V

iru

Lään

e

Har

ju

Jõge

va

Põ

lva

Võ

ru

Vilj

and

i

Val

ga

Ida-

Vir

u

2005

2008

2011

Estonian average


the proportion of donors in the population of Viljandi and Valga counties in 2011 has decreased compared

to 2005.

4.3. Collecting donor blood

Majority of blood is collected as whole blood donations in Estonia. Whole blood is collected at blood

centres (PERH blood centre has two locations) and outside blood centres. Mobile collection outside

centres enables donation to donors, who have difficulties going to blood centres (e.g. rural districts, older

people) and therefore possible donors save time and money. Mobile collection has also an important role

in promotion of donation. 44% of whole blood donations were gathered from mobile collection visits in

2011, this indicator has remained stable in the last few years (q.v. Table 8). Aphaeresis procedures are

only performed in blood centres and it is a more time consuming and expensive method compared to

whole blood collection.

Table 8. Number of blood donations in total and in mobile collection, 2004─2011

2004 2005 2006 2007 2008 2009 2010 2011

Blood donation total, doses 58 553 54 123 54 701 55 827 54 843 57 503 58 729 59 280

Whole blood donations, doses 57 797 53 307 53 795 55 072 54 020 56 609 57 293 57 298

Proportion of whole blood donations, %

99% 98% 98% 99% 98% 98% 98% 97%

Whole blood donations collected outside blood centre, doses

27 620 24 941 23 458 25 033 25 271 25 064 23 879 25 060

Proportion of donations collected outside blood centre of all whole blood donations, %

48% 47% 44% 45% 47% 44% 42% 44%

Source: TAI health statistics and research database, reports of blood centres

An average of two mobile collection visits per day was done in Estonia in 2011 and over 200 sites were

visited (q.v. Table 9). In addition to mobile collection, blood is also collected in donor tents in larger cities

during summer periods, where a mobile blood donation point is present usually more than one day. The

donor tent project has been conducted by PERH, Tartu and Pärnu blood centres for several years and has

helped to ensure the supply of blood in summer periods, where the number of donors is lower due to

vacations.

Table 9. Number of mobile collection visits and sites and the proportion of blood collected in mobile

collection by blood centres, 2009─2011

Number of visits Number of sites

Proportion of blood collected*

in mobile collection visits

2009 2010 2011 2009 2010 2011 2009 2010 2011

PERH blood centre 223 185 250 90 75 99 47% 42% 47%

Tartu blood centre 211 203 177 68 60 55 37% 37% 35%

Pärnu blood centre 89 91 87 33 32 32 39% 40% 39%

Ida-Viru blood centre 102 111 122 31 29 35 69% 65% 67%

TOTAL / average 625 590 636 222 196 221 44% 42% 44%

Source: annual reports of blood centres

Note: *no defects, whole blood donations


The proportion of donor blood collected in mobile collection visits is different by centres. The largest

proportion is in Ida-Viru blood centre, where 2/3 of blood is collected in mobile collection visits. According

to the head of Ida-Viru blood centre, donors are not able visit the centre (e.g. no permission from

employers) or the people who do come to centres are not suitable for donation (w.f. drug addicts,

homeless people). This is also reflected in the high proportion of first-time donors in Ida-Viru blood centre

(34% in 2011, compared to 20-23% in other centres). The smallest proportion of blood collected in mobile

collection visits is in Tartu and Pärnu blood centres.

Several economic aspects, like resource calculation, need to be taken into account for the comfort of

donors and safety of collection – how many potential donors will be involved in the mobile collection visit

in order to evaluate proportion of necessary the staff and materials; logistics – can one visit be done to

two close locations etc. The less resource cost occurs and the more blood can be collected in one visit, the

more cost-effective is the arrangement of mobile collection visits. The head of one blood centre stated

that they consider those mobile collection visits effective, where 1-1.1 donors in an hour donate blood

per one employee.

Authors did not find scientific publications which compared the cost-effectiveness of blood collected in

mobile collection visits and in centres. It is also difficult to evaluate the cost of blood collection (i.e.

separately in and outside of centres) in Estonia, but the average number of donations per visit can be

analyzed. In 2011, an average of 39 doses was collected in one mobile collection visit, which is 22% more

compared to the doses donated in centres per day (q.v. Table 10). Based on this analysis, the efficiency of

mobile collection visits is highest for smaller blood centres, as visits collect significantly more blood than

centres.

Table 10. Blood collected in mobile collection visits and centres per work day, 2009─2011

Blood* collected in visits,

doses

Blood* collected in centres per

work day, doses

2009 2010 2011 2009 2010 2011

PERH blood centre 63.9 68.2 57.9 63.3 69.5 65.8

Tartu blood centre 29.0 32.1 32.6 42.2 44.0 43.8

Pärnu blood centre 27.6 28.3 28.7 15.6 15.5 15.5

Ida-Viru blood centre 20.9 19.2 18.7 3.8 4.5 4.5

Average 39.9 40.4 39.3 31.2 33.4 32.4


Note: *no defect, whole blood donations

From the aspect of costs, the main difference in collecting blood in mobile collection visits and centres are

the costs related to location, as the costs on materials, equipment and staff are similar. Mobile collection

visits are an extra cost, as there are transportation costs (fuel, vehicle, etc) and possible rental fees to

rooms, yet centres have costs related to facilities (amortization, maintenance, rent).

The costs per dose related to donor blood collection and medical examination in product prices are as

follows: mobile unit vehicle 1.74 Euros, donor blood collection room 1.40 Euros and reception office 0.34

Euros, but this can vary by blood centres in reality. Therefore the cost-effectiveness of blood collected in

mobile collection visits depends on the costs of a particular blood centre, but also on the amount of blood

collected in visits. The results would probably differ by centres.


4.4. Forecast of the number of donors

In scientific literature, the forecast of the number of donors is associated with changes in the gender-age

structure of the population and the analysis is performed together with the forecast of blood product use

(blood demand and supply). For example, Currie et al (2004) has estimated, that demand will exceed

blood supply by 20% in the UK within 20 years; Drackley et al (2012) evaluates that blood demand will

outpace blood supply in Canada in the next few years; Ali et al (2010) has brought out using the data of

Finland and selected countries, that the increasing proportion of elderly people in most countries will

result in increasing demand for erythrocytes.

In the context of Estonia, these estimates are worrisome, as the most active age group in donation

currently – 18-29, who make 50% of donors – will decrease 40% by 2025 according to Eurostat population

projection (q.v. Figure 9).

Figure 9. Population projection by age groups in Estonia, 2025 vs 2010, %

Source: Eurostat

In addition to changes in the structure of population, the spread of diseases affects donation – the more

viruses can be identified, the more limits will be set to donors. The method of collection can affect the

amount of blood in several ways – collecting erythrocytes can prolong the period between donations, the

collection of platelets and plasma shortens it.

Based on the changes of the age-specific structure of the population, the Eurostat population projections

for 2025 and presuming that the age-specific structure of donors does not change, the number of donors

will decrease to 29 000 by 2025.

-2%

7%

-40%

-1%

3%

-7%

18% 16%

-50%

-40%

-30%

-20%

-10%

0%

10%

20%

30%

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70+


Figure 10. Prognosis of number of donors based on the population projections

Source: Estonian Statistics, data from blood centres on donors by age

Note: The population projections for 2025 have been conducted as a simplified cohort-analysis based on the data of

Estonian Statistics i.e. it is presumed that every person of every age is alive in the following year

The Transfusiology development plan forecasted the number of donors from 28 000 in 2000 to 34 000 in

2010 and 35 000 by 2015. This estimation has been surpassed by today, 36 200 donors visited blood

centres in 2011. Although there was no decrease in active age groups – the number of 20-29-year-olds

increased 9% in 2000-2012 - it still implies that the changes in the age-specific structure of population do

not reflect the same way in the number of donors. Secondly, it is important to consider whether the

attitudes toward donation are lasting and will current donors donate also at an older age. This is

contradicted by the relatively high proportion of first-time donors today. Therefore, it is important to

analyze the reasons for discontinuing (permission from employers, no connection to donation, centres

opened on unsuitable times for full-time employees etc).

4.5. Evaluation to donation

The proportion of donors in Estonian population is barely over the critical limit (2.5% of population in

European countries), which implies that the vital supply of blood is ensured. There are no cases from the

near past, where a deficit in blood products would have caused a life-threatening situation to a patient.

Working near the critical limit means, that the number of collected donations is sufficient in an everyday

situation, but there might be problems in emergency situations, e.g. in case of a sudden increase in

demand (mass accidents) or in need of specific blood types.

The number of donors has remained stable throughout the years, but a fifth of the donors are first-time

donors. First-time donors do not have a habit of donation and this needs supplementary effort and causes

extra costs on recruitment and ensuring safety. A third of donors are aged 18-24. Relying on the young

1

2

3

4

5

5

10

15

20

25

18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64

Do

no

rs (

tho

usa

nd

s)

Po

pu

lati

on

(th

ou

san

ds)

Age

Population 2000 Population 2012 Population 2025 (f)

Donors 2011 Donors 2025 (f)


can be a problem as they are is significantly more mobile (i.e. travels abroad or within country), so

connections to blood centres can be lost.

In addition to previously mentioned factors, developments which could affect donation in the future

should also be taken into account. Considering that the number of youth in Estonian population will

decrease in the future, and the number of elderly will increase, a decrease in the number of donors is

expected in the next ten years if the age-specific structure of donors remains the same. A possible spread

of diseases and raising the criteria for donor eligibility can decrease the number of donors as well.

The following steps should be considered in order to avoid that:

• Develop donor policy for supporting and encouraging regular donation in age groups and

districts, where the donor activity is low with the goal to expand the donor base.

• Promote donation more actively. The donor tents from the last six years, which also promote

donation, might be the reason why the number of donors has constantly increased since 2009.

The following activities should be considered in addition:

- Find cooperation partners from media organizations;

- Work with passive donors and contribute into creating a reminder-system for donors;

- Seek cooperation with employers.

• Centralize the promotion of donation, as it is not economically reasonable for every blood centre

to organize it separately.

• Develop Estonian blood information system into a unified national donor database in order to

observe developments. This would enable to have an overview of the number of donors (i.e. the

real number of first-time donors, not the first-time donors of a specific blood centres), donations

and health conditions of every donor.

• Give more attention to middle-aged people in developing donation, who have a low rate of

donation currently. For example, by organizing mobile collection visits to larger organizations.

Donation promotion should also be target group based, e.g. promoting donation to the older age

groups is not reasonable via Internet channels.

• Increase the number of mobile collection visits, especially to counties where the proportion of

donors is currently low.

• National planning and organization of mobile collection visits. Publishing the schedule (in

quarters) of visits and targeted publishing for regular donors in order to enable the possibility to

plan ahead.


5. USE OF BLOOD PRODUCTS IN ESTONIA

The following chapter gives an overview of the use of blood products in hospitals and the data is

compared to according indicators in other countries. The efficiency of blood products use is also observed

i.e. how much donor blood reaches to transfusion. The availability of blood products is also evaluated. The

demand of blood products in the near future is estimated. An evaluation to the use of blood products is

given in the end of the chapter.

Estonia is self-sufficient in supplying itself with blood products, only plasma products are imported from

external producers. 28 of the 37 blood products given in the blood product list implemented in the

beginning of 2012 are prepared in Estonia (i.e. all except plasma products, see whole list in Annex 4):

Erythrocytes:

1. Erythrocyte suspension with low leucocytes content

2. Erythrocyte suspension with low leucocytes content, paediatric dose

3. Washed erythrocyte suspension

4. Washed erythrocyte suspension, paediatric dose

5. Erythrocyte suspension with low leucocytes content, filtered

6. Erythrocyte suspension with low leucocytes content, paediatric dose, filtered

7. Washed erythrocyte suspension, filtered

8. Washed erythrocyte suspension, paediatric dose, filtered

9. Aphaeresis erythrocytes

Plasma:

1. Blood plasma (from whole blood and aphaeresis)

2. Blood plasma, paediatric dose (from whole blood and aphaeresis)

Platelets:

1. Aphaeresis platelets concentrate of one donor

2. 4 BC platelets concentrate


4. Decreased capacity 4 BC platelets concentrate


6. Decreased capacity aphaeresis platelets concentrate for children

7. Aphaeresis platelets concentrate for children

8. 4 BC platelets concentrate, filtrated

9. 3 BC platelets concentrate, filtrated

10. Decreased capacity 4 BC platelets concentrate for children, filtrated

11. Aphaeresis platelets concentrate, washed

12. Decreased capacity aphaeresis platelets concentrate, washed

13. Aphaeresis platelets concentrate, paediatric dose, washed

Other products and procedures:

1. Whole blood

2. Cryoprecipitate

3. Divided red blood cell units

4. Irradiated blood products


Seven of these blood products are made from blood components collected via aphaeresis, blood plasma

codes also reflect plasma collected via plasmapheresis. According to procedures performed on blood

products, washing and filtration are used on seven products; irradiation is on the list as a separate service.

Two products – erythrocyte suspension with low leucocytes content and blood plasma made 84% of the

issued products in 2011.

5.1. Trends in the use of blood products in Estonia and the users of blood products

Central information about the use of blood products is gathered in two ways in state level – hospitals

submit statistics about transfused blood products and secondly, the data about transfused blood products

reflected in the bills submitted to Estonian Health Insurance Fund. These two data sources (Ministry of

Social Affairs and Estonian Health Insurance Fund) do not give the same results – the used amount of

blood products is larger than the amount of compensated blood products (q.v. Figure 11).

87 000 doses of blood products were transfused to 18 000 patients in 2011 (q.v. Table 11). The number of

transfused blood products and patients and therefore the number of blood products per patient have not

significantly changed in the observed period.

Table 11. Number of patients, who received transfusion treatment and number of products transfused

2004 2005 2006 2007 2008 2009 2010 2011

Number of patients on transfusion treatments

20 521 18 889 18 381 17 899 18 654 17 607 18 611 18 178

Number of products transfused, doses

92 695 86 742 85 519 86 557 88 126 85 866 102 615 87 377

Transfused products per patient 4.5 4.6 4.7 4.8 4.7 4.9 5.5 4.8


According to the statistics submitted by hospitals, 53 600 doses of erythrocytes, 23 900 doses of plasma

and 6300 doses of platelets were transfused to patients in 2011 (q.v. Figure 11). Based on this data, the

transfusion of erythrocytes has not changed – compared to 2002 it has increased 14%, but this is due to

the low level in base year, the average annual change is close to zero (q.v. Annex 5). On the other hand,

plasma transfusion has decreased 18% in ten years and platelets transfusion has increased 89%. Platelets

transfusion increased intensely until 2007, then decreased slightly in three years and in 2011 rose to the

highest level of the observed period.


Figure 11. Use of blood components (thousand doses)

Source: TAI health statistics and research database, Estonian Health Insurance Fund

Note: plasma was measured in litres until 2008, since then in doses, 1 dose = 280 ml. EHIF – Estonian Health Insurance

Fund, MoSA – Ministry of Social Affairs. Blood product list has changed almost every year.

In addition to a decrease in plasma use, the use of most plasma products has increased in Estonia. The

largest increase in the last eight years has been in the uses of albumin and F VIII. The use of albumin and F

VIII has also increased in Sweden – 56% and 42% accordingly since 2004, but compared to the beginning

of 1990s, the use of albumin has decreased almost twice (Blodverksamheten i Sverige 2011).

Table 12. Use of plasma products in Estonia

2004 2005 2006 2007 2008 2009 2010 2011 2004/2011 change

Albumin 5%, l 697 545 511 488 809 462 800 721 3%

Albumin 20%, l 357 442 442 714 508 759 475 895 151%

F VIII, thousand IU 1 759 1914 2 223 1928 1 942 2 437 3 246 3576 103%

F IX, thousand IU 272 95 144 105 131 154 189 315 16%

IVIG, gr 8 683 9 923 9 213 14 861 11 314 10 508 10 581 12 022 38%

Anti-D immunoglobulin,

thousand IU

586 616 752 728 866 792 839 661 13%


According to the data of Estonian Health Insurance Fund (i.e. the compensated bills) 28 healthcare

institutions used blood products in 2011, including all hospitals listed in the state development plan for

hospital network. Based on the structure of hospital network, the transfusion of blood products is highest

in regional hospitals and especially notable in the case of platelets (q.v. use of blood products by types of

hospitals Annex 6). 32% of erythrocytes, 43% of platelets and 21% of plasma were transfused in PERH; the

according numbers are 24%, 40% and 40% for Tartu University Hospital (q.v. Table 13). In addition to the

above mentioned, one of the biggest users of blood products is also East-Tallinn Central Hospital, the rest

3

6

9

12

15

18

10

20

30

40

50

60

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Tran

sfu

sed

pla

tele

ts, t

ho

usa

nd

do

ses

Tran

sfu

sed

ery

thro

cyte

s an

d p

lasm

a, t

ho

usa

nd

d

ose

s

Erythrocytes (MoSA)

Erythrocytes (EHIF)

Plasma (MoSA)

Plasma (EHIF)

Platelets (MoSA), right axisPlatelets (EHIF), right axis


of the hospitals transfused together about a third of erythrocytes and plasma and 14% of platelets.

Therefore, the transfusion of blood products has concentrated in Harju and Tartu counties in Estonia and

as in the regional hospitals in the mentioned counties people from other counties are treated as well, the

use of blood products per 1000 inhabitants is significantly higher than average in these counties (q.v.

Annex 7).

Table 13. Compensated blood products by blood components and hospitals

Number of doses Proportion (%)

Hospital 2008 2009 2010 2011 2008 2009 2010 2011

Erythrocytes TOTAL 47914 48485 51509 51232

PERH 14 932 15 135 15 024 16 218 31% 31% 29% 32%

Tartu University

Hospital

11 145 12 092 13 102 12 383 23% 25% 25% 24%

East Tallinn CH 4 758 4 607 4 825 5 595 10% 10% 9% 11%

West Tallinn CH 3 024 3 072 3 133 2 872 6% 6% 6% 6%

Ida-Viru CH 2 396 2 657 2 829 2 609 5% 5% 5% 5%

Pärnu Hospital 2 705 2 352 2 838 2 600 6% 5% 6% 5%

Other 8 954 8 570 9 758 8 955 19% 18% 19% 17%

Platelets TOTAL 5430 5461 5584 5839

PERH 2 579 2 277 2 172 2 520 47% 42% 39% 43%

Tartu University

Hospital

1 625 2 035 2 205 2 315 30% 37% 39% 40%

East Tallinn CH 284 216 202 190 5% 4% 4% 3%

West Tallinn CH 89 136 112 99 2% 2% 2% 2%

Ida-Viru CH 121 158 166 129 2% 3% 3% 2%

Pärnu Hospital 151 162 157 251 3% 3% 3% 4%

Other 582 477 570 335 11% 9% 10% 6%

Plasma TOTAL 29728 26226 26475 24699

PERH 4 678 4 682 4 877 5 096 16% 18% 18% 21%

Tartu University

Hospital

10 497 11 047 10 401 9 858 35% 42% 39% 40%

East Tallinn CH 3 681 2 380 2 336 2 543 12% 9% 9% 10%

West Tallinn CH 3 986 1 409 1 345 900 13% 5% 5% 4%

Ida-Viru CH 1 151 1 297 1 728 1 107 4% 5% 7% 4%

Pärnu Hospital 1 217 1 196 1 202 877 4% 5% 5% 4%

Other 4 517 4 215 4 586 4 318 15% 16% 17% 17%

Source: Estonian Health Insurance Fund

There have not been any significant changes in the use of erythrocytes during the observed period. The

transfusion of platelets has annually increased in the Tartu University Hospital leading to the use of

platelets being practically even in Tartu University Hospital and PERH in 2010-2011. Plasma transfusion

has significantly decreased in East and West Tallinn Central Hospitals and somewhat in the Tartu

University Hospital, but increased slightly in PERH in the comparison of 2008 and 2011. The largest plasma

user is still the Tartu University Hospital and the plasma transfusions at PERH are twice lower.


Estonian blood centres are located at the areas of the largest blood products use. It should still be noted

that the scales are very different and although the processing capacities of blood centres are different,

the processing capacity and demand of the area are not always in accordance – e.g. Pärnu blood centre

prepares more erythrocytes and significantly more plasma than is needed at Pärnu Hospital. PERH also

prepares a lot more plasma than necessary, but the leftovers are sent to fractionation. On the other hand,

Ida-Viru blood centre does not prepare enough to ensure the demand of Ida-Viru hospitals. Due to this

mismatch, blood products are sold outside the centre’s operating area in Estonia, which causes

competition.

Figure 12. Comparison of blood product supply (prepared in centres) and demand (transfused in centre’s

region) by blood centres regions, 2011

Source: Annual reports of blood centres 2011, Estonian Health Insurance Fund

Note: the amount of plasma prepared at PERH blood centre includes the amount sent to fractionation (27 000 doses).

5.2. Practice of blood product use

The intensity of blood product use in hospitals is partially affected by the number of patients and

operations, but also by differences in treatment methods. In 2005 the manual by Estonian Transfusion

Medicine Association for using medicine preparations from human blood came out, which stated that

“choosing transfusion treatment tactics is based on very different principles in Estonia, which may not,

considering the huge difference in practices compared to the rest of the world, mean the most high-

quality treatment for the patient”. According to the analysis below, the treatment methods are still very

different by hospitals.

Table 14 compares the amount of transfused blood products with the number of patients and operations

by hospitals. It should be pointed out that the total number of operations does not reflect their content

and therefore hospitals of different types cannot be compared. In the comparison of regional hospitals,

PERH Tartu PärnuIda-Viru



erythrocytes plasma platelets

prepared 30928 16823 6342 3332 34437 16579 6374 2489 4067 3034 0 0

transfused 29296 15311 2600 4022 10274 11059 877 2489 3062 2356 251 170

% 106% 110% 244% 83% 335% 150% 727% 100% 133% 129% 0% 0%

0%

100%

200%

300%

400%

500%

600%

700%

800%

0

5000

10000

15000

20000

25000

30000

35000

40000

Pro

po

rtio

n o

f p

rep

ared

pro

du

cts

fro

m t

ran

sfu

sed

p

rod

uct

s, %

Blo

od

pro

du

cts

pre

par

ed a

nd

tra

nsf

use

d,

do

ses

prepared transfused %


the use of erythrocytes is the most intensive in PERH, where 27% more of erythrocytes are transfused per

1000 operations compared to Tartu University Hospital. The situation with plasma is the opposite and

102% more plasma is transfused per 1000 operations in Tartu University Hospital compared to PERH. The

transfusion practices also differ in general hospitals – e.g. in Pärnu hospital and West Tallinn Central

Hospital the amount of blood products per 1000 operations is a lot less compared to other general

hospitals.

Table 14. Transfusion of blood products per 1000 patients and 1000 operations, 2010

Stationary patients

Stationary operations *

Transfused blood products, doses

Transfused blood products per 1000

patients

Transfused blood products per 1000

operations

E Pl P E Pl P E Pl P

PERH 36000 18000 15 024 2 172 4 877 417 60 135 835 121 271

Tartu University Hospital

42000 19000 13 102 2 205 10 401 312 53 248 690 116 547

East Tallinn CH 31000 7300 4 825 202 2 336 156 7 75 661 28 320

West Tallinn CH 21000 6700 3 133 112 1 345 149 5 64 468 17 201

Ida-Viru CH - 3000 2 829 166 1 728 - - - 943 55 576

Pärnu Hospital 16300 8000 2 838 157 1 202 174 10 74 355 20 150

Source: Estonian Health Insurance Fund; reports of financial year 2010 of PERH, Tartu University Hospital

and West Tallinn Central Hospital, website of East Tallinn Central Hospital, report of Ida-Viru Central

Hospital economic activities 2010, information folder of Pärnu Hospital 2011

Note: *number of all operations in East Tallinn Central Hospital, West Tallinn Central Hospital and Pärnu. E – erythrocytes,

Pl – platelets, P – plasma

Analyzing the plasma per erythrocytes is also common in evaluating practices of use (q.v. Table 15). This

indicator also implies that the use of plasma is the most intensive in Tartu University Hospital. A

noticeable decrease in plasma transfusion compared to erythrocytes has occurred in East Tallinn and

West Tallinn Central Hospitals in the observed period and this is also reflected in the aggregate indicator

of Estonia.

Table 15. Transfused plasma per erythrocytes in larger hospitals

2008 2009 2010 2011

Estonia in total (TAI data on transfusions) 0.66 0.56 0.53 0.50

Estonia in total (Estonian Health Insurance Fund data on compensations) 0.62 0.54 0.51 0.48

North Estonia Medical Centre 0.31 0.31 0.32 0.31

Tartu University Hospital 0.94 0.91 0.79 0.80

East Tallinn Central Hospital 0.77 0.52 0.48 0.45

West Tallinn Central Hospital 1.32 0.46 0.43 0.31

Pärnu Hospital 0.45 0.51 0.42 0.34

Ida-Viru Central Hospital 0.48 0.49 0.61 0.42

Source: Data of Estonian Health Insurance Fund, TAI health statistics and research database

When comparing the transfusion practices in Estonia with other countries, it appears that Estonia is on an

average level in developed countries with the use of erythrocytes. On the other hand, plasma is used

twice as much as in other countries (q.v. Figure 13). This is also reflected in plasma per erythrocytes.


According to the EDQM research the indicator is between 0.21-0.28 in Denmark, Finland, Germany,

Norway and Sweden, but 0.50 in Estonia in 2011.

Figure 13. Use of erythrocytes and plasma in Estonia (2011) and in selected European countries (2008)

Source: van der Poel et al (2011), TAI health statistics and research database, Estonian Statistics

Plasma transfusion could also affect the amount of plasma sent to fractionation – the less plasma is

transfused, the more leftovers can be sent to fractionation. In case of European countries, the amount of

plasma sent to fractionation is immensely larger than the transfused (q.v. Table 16). This is not so in

Estonia, but the proportion of plasma sent to fractionation will probably increase as Tartu and Pärnu

blood centres have also entered into fractionation contracts in addition to PERH blood centre. 79% of

plasma from PERH blood centre was sent to fractionation in 2001, which is 45% of the whole collected

plasma in Estonia.

Table 16. Plasma use in Estonia (2011) and selected European Union countries (2008)

Plasma sent to fractionation per 1000 inhabitants (doses)

Plasma for transfusions per 1000 inhabitants (doses)

Estonia 20.2 20.0

Denmark 47.5 12.3

Finland 46.1 9.9

Germany 110.0 16.3

Norway 40.4 9.9

Sweden 43.9 11.4

Source: van der Poel et al (2011), TAI health statistics and research database, Estonian Statistics

Information about the transfusion practices of platelets in other countries is scarce, but according to

Cobain et al (2007), 6.0 doses of platelets per 1000 inhabitants was transfused in the USA, 2.0 doses in the

UK, 3.0 doses in Australia and 4.7 doses in Denmark. The according indicator in Estonia was 4.7 doses in

2011. International comparisons about the use of platelets are difficult due to the differences in the term

of platelets concentrate (the buffy-coat of how many donors is usually pooled).

40

20

0,21

0,28

0,22 0,210,24

0,50

0,13

0

0,1

0,2

0,3

0,4

0,5

0,6

0

10

20

30

40

50

60

70

Den

mar

k

Ger

man

y

Swed

en

Fin

lan

d

No

rway

Esto

nia

Un

ited

Kin

gdo

m

Erythrocyte transfusions per 1000 inhabitants (doses)

Plasma transfusions per 1000 inhabitants (doses)

Plasma per erythrocytes (P/E), right axis


5.3. Efficiency of using donor blood

In using donor blood it is important that it is done as efficiently as possible. This means, that the

proportion of blood products that does not reach transfusion stage should be minimal. To some extent

the existence of discarded products is unavoidable and necessary – some of the blood could be infected,

there could be defects in the collected blood and blood products, prepared products could expire etc. The

discard rate could depend on testing methods, processing techniques and also logistics between blood

centres and hospital blood banks and transfusion practices in hospitals.

Figure 14. Preparing blood products from donor blood, their transfusion and wastage during the process

Two data sources were used for evaluating the efficiency of blood use – firstly the TAI data on blood

collection, prepared and issued blood products submitted by blood centres; secondly the data from the

same database about transfused blood products submitted by hospitals. The analysis was conducted by

blood components and also by stages of vein-to-vein chain.

The so-called wastage analysis often includes erythrocytes and platelets (q.v. e.g. Veihola 2008, NAO audit

2000, FRCBS Annual Report 2011). The current analysis focuses on the use of platelets and erythrocytes as

the amount of prepared plasma is larger compared to use and therefore the analysis of plasma use is not

relevant to efficiency. A good indicator for the whole process (from collection to transfusion) is the

proportion of transfused erythrocytes as every dose of collected donor blood should give one dose of

erythrocytes.

In case of erythrocytes, it can be concluded that donor blood is most efficiently used in the processing

stage, where less than 1% of collected blood is not used to prepare erythrocytes (q.v. Table 17, q.v.

methods Annex 9). The least efficient is the transfusion stage, where 5.5% of the issued erythrocytes are

not transfused to patients.

In case of platelets, issuing and transfusion stages are analyzed; buffy-coat (BC) platelets and aphaeresis

platelets have been analyzed separately. The transfusion stage is also the least efficient in case of BC

platelets, 10% of issued platelets are not transfused to patients. The loss of BC platelets is higher than

erythrocytes due to the shorter expiration period of platelets. On the other hand, the use of aphaeresis

platelets is very efficient and practically all issued doses are transfused. This can be explained by the fact

that according to the head of one blood centre, most aphaeresis platelets are prepared only in case of a

specific order.

Collected blood (blood centre)

Prepared products

(blood centre) Issued products

(blood centre)

Transfused

products

(hospitals)

(Blood Centre) Defects

Infections

etc

Defects

Infections

etc

Defects

Infections

etc


Table 17. Efficiency of the use of blood and blood products in Estonia compared to data of some other

countries, 2010/2011 average

Blood component Collection Processing Issuing Transfusion

Loss compared to number of blood collections or number of prepared products

Erythrocytes 100% ─0.6% ─4.1% Cf. Canada ─8.4%

─9.3% Cf. Finland ─7% UK ─12%

BC platelets 100% ─8.6% ─17.9%

Aphaeresis platelets 100% ─1.6% ─2.5%

Loss compared to amount of previous stage of process

Erythrocytes 100% ─0.6% ─3.5% ─5.5% Cf. UK ─4.6% USA ─2.6…─3.3%

BC platelets 100% ─8.6% ─10.2%

Aphaeresis platelets 100% ─1.6% ─0.9%

Source: TAI health statistics and research database, annual reports of blood centres, NAO audit 2000,

FRCBS Annual Report 2011, Canadian BS report 2007/08, Novis et al 2002 (3 researches involving over

1600 hospital in the USA)

Presuming that one dose of erythrocytes can be produced from every dose of collected whole blood the

efficiency of vein-to-vein can roughly be evaluated as well. According to calculations, about 9% of

erythrocytes are not transfused compared to collection. The result is similar to the according results on

some other countries – e.g. in the UK the loss of erythrocytes in the whole process was 12% and 7% in

Finland.

Similar analysis about the losses in the whole process can be performed about platelets in the whole

process, but here the basis for comparison is the amount of prepared platelets. According to this, 18% of

BC platelets and 2.5% of aphaeresis platelets are not transfused compared to the number of prepared

products. It is hard to find similar data from other countries, as the summing of different types of platelets

(e.g. 2BC, 3BC, 4BC etc) for comparison requires a more detailed analysis. Still, a research involving 17

blood centres from 10 European countries is used as an example, according to which the average annual

loss of platelets in 2000-2004 was 13% (Veihola 2008).

The efficiency of blood and blood product use is not similar by blood centres and hospital blood banks.

For example, in 2011 a total of 4.1% less erythrocytes were issued than collected in Estonia and the

proportion varied from 3.1% to 6.1% in different centres. According to the interviews conducted in

hospital blood banks, there was practically no losses in one department during a year (1 dose in half a

year), but ca 4% and ca 9% in other blood banks.

To estimate monetary value of the losses, the number of prepared and transfused products should be

compared and the monetary value could be estimated through the product prices. Alternatively, the price

of losses has been calculated by multiplying the cost per unit and number of discarded blood products

(q.v. Veihola et al 2008). Unfortunately the authors do not have sufficiently detailed information for either

of the approaches, but the total cost of issued blood products and the total cost of compensated blood

products could be compared as an approximation. Presuming that all blood products were issued to


hospitals at prices agreed on state level, the difference between the total costs of issued blood products

and blood products compensated by Estonian Health Insurance Fund were 0.52 million Euros (=5.03

million – 4.51 million Euros).

Although the efficiency of blood product use is more and more important from the aspect of ensuring

blood demand, no international normative values of are set to wastage rates, but, for example, in the

UK’s blood service, the wastage rate is assigned as one of the quality indicators (q.v. NHSBT Strategic Plan

2009/2012). It is equally important to minimize and evaluate wastage in the whole process i.e. from

collecting donor blood to transfusion and in Estonia it would require data exchange between blood

centres and hospital blood banks (i.e. developing EVI system).

5.4. Sufficiency and availability of blood products

As blood products (except plasma) cannot be stockpiled due to short expiration time, the factors

describing the quality of blood service are also reliability and speed of deliveries to hospitals i.e. whether

hospitals receive blood products in a necessary amount and time. For example, in the UK blood service,

two quality indicators are observed – fulfilling hospital’s orders and transporting products within two

hours (NAO audit 2000). Therefore, the operative communication between blood centres and blood banks

is very important in order to ensure that the production volumes are in accordance with the demand.

Well-functioning logistics between hospital blood banks and centres is also necessary from the aspect of

blood product availability.

Hospital blood banks, the representatives of which were interviewed, stored A-, B-, and 0-type

erythrocytes, a maximum of 10 doses per product depending on the hospital, type and rhesus (e.g. more

0-type and A positive, less B-type). AB-type products and platelets are not stored in hospital blood banks.

In storing blood products the hospital blood banks rely on agreed directions about minimal supplies and in

communication with the doctors. Blood products are usually ordered from the district blood centre, but

sometimes also from centres of other districts – mainly in cases where the district centre does not have

necessary products or another centre offers a lower price.

Logistics is organized differently in hospital blood banks and depends on whether the situation is simply

renewing supplies or an emergency. Blood products are transported by either the regular transportation

vehicle of the hospital (regular trips to a regional hospital), Cargo, ambulance or taxi and the

transportation costs are paid by the hospital blood bank (i.e. hospital). Similar logistics are used in cases

where blood is sent to blood centres for matching due to antibodies. Blood products are registered on

paper at arrival; two blood banks use EVI in addition. Interviewed hospital blood bank employees could

not point out any major problems regarding ordering and receiving blood products from centres. In the

cases of problems which have occurred (e.g. lack of a certain product and finding replacement), solutions

have been found in cooperation. One hospital blood bank highlighted that blood centres should observe

that smaller hospitals receive as fresh products as possible.

Ensuring blood supplies means constant optimization and keeping an eye on expiration dates. Hospital

blood banks are interested in the most optimal use of products, balancing between the smallest supplies

possible and extra costs accompanying unexpected blood necessities. Communicating with doctors and

observing the actual demand is a way to optimize blood products. For example, it could be decided not to


order the blood dose lacking from the agreed norm if the blood of this type is not planned to be used at

the time of ordering. Also, if there is a lack of a certain blood type and 0-negative type will soon expire, 0-

negative blood could be used if agreed with doctors. One hospital blood bank orders less blood products

in summer as there are fewer operations.

A separate set of questions from the aspect of sufficiency and availability is related to the need to be

prepared for crisis situations. Besides donation (meaning a sufficient and regular base of donors and/or

the population’s readiness for donation in crisis situation, q.v. chapter 4.5) it is important to have a

coordinated communication between hospital blood banks and blood centres in those situations – i.e.

division of responsibilities, logistics and notification system. Currently, Estonian blood service is not ready

for crisis situations, as there is no unified database of donors and products and no code of conduct exists

for reacting in crisis situations. The state program for developing blood donation and blood product self-

supplying for 2010-2015 also points out that preparedness for a national crisis situation is insufficient: the

only current measure for crisis is a certain supply of necessary materials for blood collection at the Tartu

University Hospital. The evaluation also brings out that blood centres do not have special vehicles for

mobile blood collection, as currently the blood is collected in facilities into which staff and equipment are

transported, but this might not be a sufficiently flexible solution in a crisis situation. Lack of preparedness

is also referred to by the fact, that at the major accident training (100 victims) organized by the Ministry

of Defence in April 2011, the blood centres ran out of blood supplies by the end of the same day (Expert

Committee of blood service, report of the meeting, 2011). However, this year (2012) a crisis plan is

developed in cooperation with the Health Board.

5.5. Estimation of the use of blood products for 10-15 years

The changes in demographic situation are often the basis for the long-term forecast of the blood demand,

because blood is mostly transfused to older patients. For example, Currie et al (2004) has stated that 46%

of blood products in the UK are transfused to patients aged 70 and over and only 10% are transfused to

patients under 30. Ali et al (2010) notes that in Finland, the use of erythrocytes on 70-80-year-old patients

is eight times higher compared to 20-40-year-olds. In addition to the use of blood products, developments

in donation are analyzed i.e. demand and supply of blood. This approach was used by Drackely et al

(2012) for evaluating the blood demand in Canada and Currie et al (2004) for the demand in the UK. Both

estimations showed an increase in blood demand. Pan American Health Organization (sub-organization of

WHO) also recommends to start the estimation of blood demand with the current transfusion of blood

products by gender and age groups, and correct it with the estimated changes in age groups. In addition,

it is recommended to add 4% to the estimation for crisis situations (PAHO, WHO, Recommendations for

Estimating the Need…, 2010).

Table 18. Developments affecting blood demand

Developments which might increase

blood demand

Developments which might decrease

blood demand

Developments with unknown

effects to blood demand

Ageing population Developments in health technologies (e.g.

laparoscopic operations, artificial blood)

Transition to inactivated blood

products

Morbidity + capability to diagnose

diseases

More optimal transfusion of blood

products (guidelines)


The weakness of this approach is that health technologies developments, which could decrease the

demand of blood products, and epidemiologic developments (incl. capability of diagnosing diseases),

which could increase the demand of blood products, are not considered. In addition, more and more

discussions are held about more optimal use of blood products and developing guidelines, which could

decrease the demand through more optimal use of blood.

So far it is not known how the use of inactivated blood products could affect the demand of blood

products. Osselaer et al (2009), for example, has found that inactivation would not affect the demand.

The demand of blood products in Estonia is estimated in the Transfusiology development plan in 2001.

The estimation was mostly based on earlier trends and practices of foreign countries. The estimation is

fairly accurate for erythrocytes and platelets, but the decrease in plasma use has not been as sudden as

was estimated. The estimation for 2010:

14% increase in demand for erythrocytes (2000 – 47 200 doses, 2010 – 53 500), including a

processing wastage of 2%, 2-3% disposed in centres, 1% disposed in hospitals. Actual use was

only 4% smaller than estimated (actual use in 2010 – 51 500 doses)

24% decrease in demand for plasma (2000 – 28 200 doses, 2010 – 21 400), including 800 litres

catastrophe supplies. Actual use was 27% higher than estimated (actual use in 2010 – 27 200

doses)

108% increase in demand for platelets (2000 – 2400 doses, 2010 – 5000). Actual use was 8%

higher than estimated (actual use in 2010 - 5400 doses)

This research used data on factors affecting transfusion for developing estimation for the demand of

blood products, expert opinions were also asked from specialized associations (Estonian

Anaesthesiologists Association, Estonian Haematologists Association). In conclusion, it can be estimated

that the current trends will continue.

Demand for erythrocytes increases 15% by 2020 (to 61 600 doses)

- current trends – 14% increase in erythrocyte transfusion in 2002-2011

- ageing population – number of people over 70 increases 15% in the next 10-15 years

(Eurostat)

- more intensive surgical intervention – number of operations has increased 28% in 2004-

2010, number of procedures 35% (q.v. Table 19)

- increase in number of injuries – 30% in 2004─2010

Demand for plasma decreases 20% by 2020 (to 21 500 doses)

- current trends – 18% decrease of plasma transfusions in 2002─2011

- current excessive use compared to other European countries (q.v. chapter 5.2)

- restoring fractionation contracts in three blood centres and resulting economic

considerations

Demand for platelets increases 30% by 2020 (to 8100 doses)

- current trends – 89% increase in platelets transfusions in 2002─2011

- Incidence of cancer and malignant haematogenesis and lymphatic system diseases

increases due to rising life expectancy – 116% increase in identifying benign and

unspecified tumours in 2004─2010 (q.v. Table 19).


Table 19. Number of operations and procedures, number of certain medical conditions, number of

curative care beds (thousand)

2004 2005 2006 2007 2008 2009 2010 Change 2004─ 2010

Number of operations (hospital and day care)

99.2 111.0 125.1 129.5 132.7 126.1 127.4 28%

Number of procedures (inpatient and day surgery)

137.0 151.8 168.2 179.7 189.6 178.4 184.4 35%

Benign and unspecified tumours 18.8 25.1 27.5 31.4 33.7 36.9 40.6 116%

Blood- and haematogenesis diseases, certain conditions related to immune mechanism

8.0 9.2 10.2 11.9 11.0 11.6 11.7 47%

Injuries, poisonings and consequences of specific external causes

194.7 197.1 207.8 287.1 287.6 259.3 253.4 30%

Number of curative care beds 5.8 5.1 5.3 5.1 5.2 4.8 4.6 -19%


This estimation does not take into account possible changes in Estonian hospital network as there is no

basis to believe that this would affect blood use as a whole. It would rather change the distribution of

patients between districts and hospitals and the demand of blood products of Tartu and Tallinn hospitals

may potentially increase with developments like these. A decrease of curative care beds in the last ten

years has also not been taken into consideration as this might not reflect in the demand for blood

products. The Transfusiology development plan also highlights that every curative care patient does not

need blood products and even in the case of decrease in the beds, the remaining beds would work more

intensively.

5.6. Evaluation to the use of blood products

The demand for blood products has slightly changed in Estonia in ten years: while erythrocytes are still

needed around 52-53 000 doses, demand for platelets has almost doubled and demand for plasma has

decreased by a fifth. Most blood products are transfused in two hospitals – North Estonia Medical Centre

and Tartu University Hospital transfuse over half of the erythrocytes, 2/3 of plasma and 83% of platelets.

This implies that the demand and supply of blood products is generally geographically balanced, but over-

and underproduction are still present. Overproduction can cause unnecessary competition between blood

centres and expiration or dismissal of blood products.

Although there is a decrease in plasma use, plasma transfusion in Estonia is still relatively higher than in

other European countries – compared to Finland, there are twice as many plasma transfusions per 1000

inhabitants in Estonia. Blood products transfusion practices are still relatively different by hospitals,

especially regarding plasma. Although there are guidelines for the use of blood products, it has not yet led

to unified practices of use.

Based on current trends, comparisons with foreign countries and factors known to affect the use of blood

products, authors estimate a 15% increase in demand for erythrocytes, 30% increase in demand for

platelets and 20% decrease in demand for plasma by 2020.


When analyzing the use of blood products in broader sense i.e. from collection to processing, issuing and

transfusion, it can be concluded that blood products are used efficiently in Estonia. 9% of erythrocytes

doses do not reach transfusion in Estonia while the same indicator is 7% in Finnish blood service. Analysis

by stages shows that the least efficient stage is the transfusion of blood products in hospitals, which is

quite expected and even necessary. Although interviews in hospital blood banks implied that hospital

blood banks are constantly attempting to find balance between ordering blood products and expiration,

excessive optimization can be a threat to patient treatment.

Although the current system is stable and the demand and supply of blood products is generally in

balance, it should be emphasized that there is no national preparedness for crisis situations. As it is

basically impossible to produce blood products for long-time supplies, division of responsibilities and

logistics should be agreed on and financing for this must be ensured.

Recommendations:

• It is necessary to achieve a real-time overview of blood supplies in Estonia as a whole, which

requires a significant development in the existing information system.

• It is necessary to achieve a real-time overview of blood product transfusions in Estonia as a whole

and the regular analysis of it in order to estimate blood demand and to guarantee safety.

• It is necessary to analyze how to use every collected doses of blood more efficiently especially in

the case of platelets.

• An action plan for operatively distributing blood products in crisis situations should be developed.

Cooperation agreements with another country should be considered as also recommended by

European Blood Alliance.


6. QUALITY OF BLOOD PRODUCTS

The following chapter gives an overview of the factors affecting the quality of blood products. The quality

requirements, supervision and its content are also focused on. In addition, an overview of statistics

describing the safety of products is given.

Blood and blood products are classified as medicine in legislation and must meet to the general

requirements of preparing and handling medicines together with distinctions deriving from the Blood Act.

The quality of blood products means that the products prepared in Estonia must have certain properties

and be safe for the users’ health when used as advised. This can be ensured if agreed and set rules for

handling blood are followed and a national system of haemovigilance is present, where every blood

product is traceable from donor to recipient and vice versa.

The evaluation of quality and safety of blood products is based on three aspects – what is the

epidemiological situation in the country, what requirements are set for blood products and processing

and whether these requirements are filled. The latter is based on the evaluation of State Agency of

Medicines as a competent supervision institution, but also on the statistics on blood transfusion adverse

effects.

6.1. Content of the quality and quality requirements for blood products in Estonia

Ensuring quality is a thorough part of the process of blood handling, from screening the donors to

ensuring conditions of storage and transportations in hospitals, involving staff, facilities, materials and

equipment. In addition to the listed inputs, all the activities related to handling blood must be relevant i.e.

the quality of the process must be ensured. An important part of the system ensuring quality is quality

control, both in regards to internal control and external supervision. Differentiating between parts of

quality system is conditional and in reality the inputs and activities are closely related (q.v. Figure 15).

Ensuring quality begins with choosing donors. The person suitable for donation must fill certain criteria.

For example, in Estonia a person aged 18-65, weighing at least 50 kg with a haemoglobin level according

to gender is at least 125-135 g/l and has no certain chronic and infectious diseases can become a donor

(Donor Eligibility Criteria).

Every blood donation is checked for certain infections in order to ensure the safety of blood. In Estonia

these include HIV, hepatitis B (HBV), hepatitis C (HCV) and syphilis. All Estonian blood centres use

molecular methods to identify DNA or RNA of viruses in the blood to avoid transfusion of HBV, HCV and

HIV in addition to serological tests set in the requirements (Pathogens in relation to donors and donor

blood…). Molecular tests are more sensitive than serological and improve the safety of blood

components; these are the most innovative methods of testing and the risk of virus transmissions can

only be even more decreased by inactivation. The automatic movement of virus test results into the

information system of blood centres also helps to raise the safety of blood products.

Immunohematological tests are also important next to virus tests, which identify the blood type and


existence of antibodies in donor blood as patients can generally only receive blood from their own blood

type.

S E L F - C O N T R O L Internal audits participation in external tests

E X T E R N A L C O N T R O L State supervision neighbour watch

Equipment-quality control

-age of equipment

Staff-sufficiency and turnover

-training

Facilities-sufficiency and location

Materials, tests-quality control

Product of quality

Blood collection-from whom blood is collected?

Storing blood products-where and how stored?

Transporting blood products-how transported to hospitals?

Blood processing-which products are prepared?

-quality control

Blood testing-which infections are tested for?

-which tests are used?

Transfusing blood products-are there transfusion reactions?

INP

UTS

(w

ith

wh

ich

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PR

OC

ESS

(Ho

w?)

QU

AL

IT

Y

SY

ST

EM

Figure 15. Parts of quality system

Quality of blood products is influenced by processing techniques, e.g. whether products are filtrated,

washed or irradiated. Blood centres also constantly observe whether products meet the requirements.

Deviations from reference values refer to problems in the processing process and to the necessity to

make changes. 1% of prepared standard blood products, but not less than 4 units of every component and

10 units in case of platelets per month, should be sent to quality control in every blood centre in Estonia

(Requirements for quality of blood components…). Often more products are sent to quality control than

required.

Correct storing and transportation to hospitals is also a part of blood product quality, as different

products have different shelf time and storage conditions (q.v. 1.4). Collecting information on transfusion

reactions occurring during (or after) transfusion is also necessary for ensuring the quality of the process.

The quality of blood products is ensured by competent staff and relevant equipment, materials and

facilities. The staff is responsible for the quality requirements being filled and therefore it is important to

have sufficient and competent staff. Minimal staff turnover and regular training help to ensure

competence by refreshing and checking employees’ knowledge and awareness of correct methods and

valid requirements.

Facilities need to be in accordance with the requirements, with sufficient measures and location so

different stages could be differentiated to decrease the possibility of mistakes e.g. mixing products or

tests or false marking. The selected materials (e.g. blood bags) and equipment and the condition of

equipment are also important in ensuring quality.


The quality of inputs is closely related to the results of quality control, where aberrancies reflect problems

with staff, materials or equipment. Inputs also affect the safety of blood products, for example in order to

avoid contamination of blood products, it is ensured that all materials coming into contact with the blood

are safe and all activities are conducted with the minimal risk of contamination.

Inputs necessary for preparing blood products and implemented processes together form a quality system

which should be in accordance with guidelines, regulations and development plans of blood centres. The

quality system of blood service is complete, if it covers all stages up to transfusions i.e. the quality system

covers everything done in blood centres and healthcare institutions.

In addition to setting requirements, it is important to check them. State Agency of Medicines conducts

supervision over Estonian blood centres, but in addition to external control, blood centres also conduct

self-control via internal or external audits (q.v. chapters 6.2 and 6.3). Development plans and resources

for implementing developments are connected to the sustainability of the quality system.

Blood processing and use in Estonia are regulated via legislation, which in turn is in accordance with the

requirements of European Union. The Blood Act and regulations based on it regulate the area of ensuring

quality of blood products in Estonia:

Blood Act (RT 2005, 13, 63) establishes the general requirements and the organization for

handling blood and regulates the financing and conducting state supervision of blood handling.

Donor eligibility criteria, conditions and procedure of evaluation and list of diseases and other

factors restricting or limiting blood donation (RTL 2005, 50, 707) brings out the criteria for

evaluating donor eligibility including list of diseases and other factors restricting or limiting

donation, conditions and procedure of selecting donors based on the principle of voluntary and

free blood donation.

The conditions and procedure for immunohematological testing (RTL 2005, 50, 703) establishes

mandatory immunohematological tests of patient and donor blood and the conditions and

procedure for conducting these tests.

The procedure for screening donor blood and blood components for infectious agents (RTL

2003, 116, 1851) establishes the procedure for mandatory tests on donor blood, methods and

evaluation of results.

The rules for manufacture of blood components (RTL 2006, 2, 23) sets, in accordance with

European Union good manufacturing practices, the requirements on collection, testing,

processing, marking, storing and issuing of blood products and solving pretensions and

withdrawal of blood components.

The requirements for the quality of blood components, and the conditions and procedure for

quality control and microbiological testing of blood components (RTL 2005, 64, 922) sets the

requirements for conducting quality control and microbiological testing.

The conditions and procedure for haemovigilance and withdrawal of blood components (RTL

2005, 111, 1712) sets requirements for blood component haemovigilance, including giving

information about adverse effects, and withdrawal of blood components.

The conditions and procedure for transfusion (RTL 2005, 50, 704) describes the activities before

and after blood transfusion and which tests must be conducted for ensuring the suitability and

safety of blood transfusion.

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Medicinal Product Act (RT I 2005, 2, 4) sets the procedure for applying for activity license for

blood handling and for supervision.

The listed legal acts are based on the laws of European Union (European Parliament and European Union

Council Directive 2002/98/EC and directives related to it). Directive 2002/98/EC establishes requirements

to blood service, but specific steps for meeting the requirements are decided by each country themselves.

For example, it is required that “member countries take all necessary measures to ensure that the blood

and blood components collected, tested, prepared, stored, released and/or distributed in their area are

traceable from donor to recipient and vice versa”, but the specific way for ensuring this is decided by the

state. Recommendations also have a role in addition to the directive and one of the main documents

related to blood service is the Guide to the Preparation, Use and Quality Assurance of Blood Components

developed by European Directorate for the Quality of Medicines & HealthCare, which brings out the

minimal requirements related to blood collection, testing and blood processing (the part Standards is

based on the directives) and the background information and developments (part Principles).

The implementation of Directive 2002/98/EC is checked once in every three years, the last reports were

submitted in 2010 based on the questionnaires filled by member states (European Commission,

Commission report to European Parliament…, 2010). As Estonia was the only exception not to fill it, the

document does not evaluate the accordance of Estonian blood service with the directive. The spread of

voluntary free donation is evaluated separately, last report was done in 2011 and according to that,

Estonia fills the requirements (European Commission, Commission report to European Parliament…,

2011).

The quality of blood products and quality requirements are not constant in time and additional

requirements could be set for infectious disease testing or additional restrictions to donors due to

developments in new tests or spreading of infectious diseases. The currently actual matter in Estonia is

whether or not pathogen inactivation should be implemented.

6.2. Content and organization of supervision by the State Agency of Medicines

The State Agency of Medicines conducts state supervision over blood centres by issuing activity licenses

and conducting inspections. In addition, all blood centres notify State Agency of Medicines of serious

adverse events, which occur during manufacture and serious adverse effects which occur after

transfusion.

According to the Blood Act, the function of a blood centre is to prepare safe blood products of quality by

following requirements set in legal acts. State Agency of Medicines supervises whether the work of blood

centres is in accordance with the Blood Act and regulations set by it. If activities not directly required by

Estonian legislation are implemented in blood centres for improving quality (e.g. HBV DNA is identified in

every donor’s blood), the accordance to regulations of those activities are also checked – e.g. whether the

procedure is documented, the staff is trained for this activity, the procedure is validated and used

equipment qualified.



The inspections can be divided in two – general inspections and targeted inspections. General inspections

are done every two years, during which facilities, equipment, procedures, staff, documentation and other

things related to manufacturing are checked. In addition to general inspections, targeted inspections are

also conducted which are of smaller capacity and focus on a specific area. Targeted inspections are

conducted when problems of immediate intervention (with equipment, procedures, etc) occur in blood

centres between two general inspections. 14 inspections in total were conducted in blood centres in

2007-2011.

An inspection plan is put together before every inspection, which states how thoroughly and what is

checked during the inspection. As blood centres differ from each other by activities performed – e.g. not

all centres perform irradiation and the list of conducted analyses is different, every centre has an

individual inspection plan. Therefore, the number of inspected activities is higher in larger centres. When

developing an inspection plan, the problems identified in the last inspection are also taken into

consideration to check that the centre has eliminated the problems.

Inspections are conducted based on documentations or by observing the work at the site.

Documentation-based inspection checks the structure of the quality system, how procedures are

described, whether guidelines for processes are present and sufficient, if and how registration and

solution of danger situations and evaluation of consequences of adverse incidents are described. The

documentation also shows how staff training, audits etc are organized. The facilities, equipment, work

conducting, used materials are checked at the site and it is observed whether the actual activities in blood

centres are in accordance with the documentation of blood centres. For example, legal acts require that

plasma is stored in temperature -26 degrees, during inspections it is checked whether plasma is stored in

freezers, how and how often the temperature is checked and whether it is documented.

State Agency of Medicines can base their supervision on specific objective requirements set by legal acts.

For example, there are specific numeric requirements for the number of products sent to quality control

and a requirement that a blood centre must have a training plan. It is more difficult to conduct

supervision on requirements containing subjective evaluation – e.g. one requirement in the Guidelines for

manufacture of blood components is the sufficiency of staff, but sufficiency depends on work capacity

and work organization and thus can be defined differently.

State Agency of Medicines also observes adverse incidents in addition to inspections. Blood centres must

report the State Agency of Medicines of serious adverse events, which occur during processing, storing,

transportation etc, and serious adverse effects. All blood centres reported serious adverse events in 2010,

28 cases in total were reported (2009 – 24 cases, all centres reported). The task of the State Agency of

Medicines is to analyze the causes of adverse incidents and to implement measures to prevent any similar

situations.

Supervising hospital blood banks is not the task of the State Agency of Medicines. This role has been given

to the Health Board, who has to conduct supervision in health care according to their statute. Based on

the interviews conducted with representatives of hospital blood banks, the Health Board does not

conduct regular inspections in hospital blood banks.


6.3. Self-control and training

As state supervision cannot check every single thing, blood centres have internal quality management and

control. This means identifying risk factors, developing measures to decrease risks and documentation.

Regular and systematic internal control of blood centres is required by the Guidelines for manufacture of

blood components.

The main tool for self-control is internal audits, during which the work of equipment and competence and

staff skill-set are checked in addition to the timeliness of documentation (e.g. guidelines). An annual plan

is developed for internal audits. All elements of the quality system and the critical stages of processing

must be checked annually in addition to major changes in the work process. The audit results also have a

critical importance – what are the conclusions of the audit and which are the resulting development plans

and recommendations for improvement. Quality control of blood products also gives information for self-

control as it reflects the quality of used equipment and implemented procedures. If quality control is

consistent, it enables to identify major disturbances and mistakes quickly.

Self-control can be supported by external control. Blood centres can participate in external quality control

for lab-activities. During the control, previously tested samples are sent to blood centres, where the

laboratory must identify certain indicators in the samples (e.g. pathogen markers). The results are

checked and it helps to identify whether the equipment, materials and the work of the staff used in the

labs enable correct results. Blood centres can also conduct audits in labs which are not units of the blood

centres – this has been used by Tartu blood centre, for example.

Staff control is conducted through regular evaluation of staff competence. The necessity of staff training is

set by the blood centre according to the work results and competence evaluation tests and compiled into

training plans. State Agency of Medicines checks whether training is offered for staff in general e.g.

whether the centre has a training plan, but the content of the training plans is decided by the blood

centre.

6.4. Safety of blood products and haemovigilance in Estonia

Safety of blood products means that no pathogens can transfer to patients with blood products, therefore

it is important to take the background system into consideration in ensuring safety i.e. how wide-spread

are infectious diseases among the population. Although the donor population is pre-selected in relation to

infectious diseases, widely spread infections in the population in general can still affect the safety of

products.

A comparison with selected European countries implies that in 2008 significantly more HIV, HBV and HCV

pathogens were found in donor blood in Estonia (q.v. Table 20). Compared to Finland, the differences

were ten times larger although the same source states that Finland used NAT-tests for all viral infections,

but Estonia only for HIV and HCV.


Table 20. Spread of virus infections and health of donors in Estonia and selected European countries, 2008

Prevalence per 100 000 first-time donors

Incidence per 100 000 repetitive donors

HIV 1/2 HBV HCV HIV 1/2 HBV HCV

Estonia 32.52 162.62 704.68 8.05 16.10 24.16

Norway 0.00 35.93 93.42 0.00 1.07 1.07

Sweden 0.00 24.76 42.77 0.81 0.41 0.00

Finland 4.43 13.29 62.02 0.71 1.42 2.13

UK 5.99 34.76 30.37 0.96 0.07 0.52

Germany 6.84 136.67 71.58 2.57 1.43 2.23

Ireland 6.87 27.48 20.61 0.00 2.43 0.00

Denmark 7.68 38.38 11.51 0.44 0.00 0.00

Source: van der Poel et al (2011)

According to Estonian statistics, there is no noticeable downward trend in the findings of pathogens in

2008-2011 (q.v. Table 21), so the spread of viral infections is a problem in Estonia even today.

Table 21. Findings of pathogens in blood in Estonia

Test Erythrocytes Plasma

2008 2009 2010 2011 2008 2009 2010 2011

HBV surface antigen (HBsAg) 19 6 15 12 19 9 9 12

HCV antibodies (aHCV) 24 29 31 34 24 40 35 34

HCV antigen or HCV NAT test (HCV NAT/Ag) 51 42 50 9 51 38 41 9

HIV antibodies (aHIV 1/2) 2 22 4 3 2 10 6 3

HIV antibodies or HIV NAT test (HIV NAT/Ag) 3 3 5 0 3 1 13 0

Syphilis 65 33 20 17 65 33 20 17


Note: contains confirmed positive results. No findings for aphaeresis platelets.

In addition to pathogen transfusion, blood safety is also described by cases of serious adverse effects i.e.

transfusion reactions. A serious adverse effect is a dangerous and unwanted effect to the recipient’s

health occurred during or after the transfusion and can cause a severe health disorder or death. In case of

occurrence of serious adverse effects after blood transfusion, hospitals must report to the blood centre,

who in turn will report it to the State Agency of Medicines. This process has two downsides which can

affect the statistics – firstly, whether transfusion reactions are always identified, and secondly, whether

they are always reported. A typical example of under-diagnosing is TRALI, which is considered as the main

cause of death due to blood transfusion, and the existing data about the prevalence of which is

considered underestimated due to TRALI being difficult to diagnose (q.v. Kleinman et al 2004).

130 cases of transfusion reactions were reported in Estonia in 2011, most of them were temperature

reactions and mild allergic reactions (q.v. Table 22). From serious adverse effects, TRALI was diagnosed on

two patients and one infectious disease transfer occurred.


Table 22. Occurrences of transfusion reactions in Estonia

2004 2005 2006 2007 2008 2009 2010 2011

Number of patients of transfusion treatment 20 521 18 889 18 381 17 899 18 654 17 607 18 611 18 178

Total of transfusion reactions 169 142 120 118 91 82 100 130

..anaphylactic reaction 5 6 2 0 1 1 2 2

..acute haemolytic reaction 0 3 0 0 2 0 0 2

..bacterial infection 0 0 0 3 0 0 0 0

..febrile non-haemolytic transfusion reaction 93 63 66 57 33 44 41 52

..transfusion-related acute lung injury (TRALI) 0 2 2 0 0 0 0 2

..urticaria and other mild allergic reactions 64 59 46 56 51 31 44 50

..delayed haemolytic reaction 2 1 0 0 2 0 8 7

..post-transfusion purpura (PTP) 2 0 0 0 0 0 0 0

..transfusion-associated graft-vs-host disease 0 0 0 0 0 0 0 0

..transfusion-transmitted infections 0 0 0 0 0 0 0 1

..other reactions 3 8 4 2 2 6 5 14


In comparison with European countries, Estonia had the similar number of serious transfusion reactions

(q.v. Table 23), but the small size of the country should be taken into account in case of Estonia. For

example, there is only one case behind the relatively high number of viral infections and it should be

noted that there have not been any registered cases of virus transfers in the previous eight years. There

have been no known cases of patient dying after transfusion from 2003-2011 in Estonia.

Table 23. Transfusion reactions in Estonia (2011) and selected European countries (2008)

Serious adverse effects* per 100 000 transfused doses

TRALI per 100 000 transfused doses

Viral infection transfers per 100 000 doses

Estonia 4.5 (2008) 2.29 (2011) 1.14 (2011)

Norway 5.2 No data No data

Sweden 4.6 0.64 No data

Finland 2 0 0

The UK 6.4 0.36 0*

Germany 0.7 0.23 0.02 (only HBV)

Ireland 53.4 0 0

Denmark 0.7 No data No data

Belgium 5.5 0.44 No data

Czech 2 0.33 0

France 17.4 0.91 10.59

Hungary 2.2 1.23 0

Holland 10.8 2.39 0.14 (only HBV)

Slovakia 0.4 0 0

Slovenia 5.8 0 0

Switzerland 7.6 0.49 No data

Source: van der Poel et al (2011), TAI health statistics and research database, *MHRA report 2012

Note: only the number of serious adverse effects which are probably or certainly cause by transfused blood products

(imputability grade 2, 3) is given, not in the case of Estonian data from 2011


Product safety is closely related to haemovigilance, which means that all collected doses and prepared

products are traceable in all stages of blood handling from blood donation to transfusion to recipients.

This means that when serious adverse effects occur, a retrospect procedure is conducted to identify the

donor, whose blood was used in processing; their previous donations and products from the same blood

are examined.

Although in comparison with foreign countries, it does not appear that Estonian products would be any

more dangerous, the wider spread of viral infections in Estonia should be taken into account. Therefore

the use of NAT tests in centres is reasonable. A thorough retrospect procedure has been conducted by

blood centres when serious adverse effects occur and the nature of the dangerous occurrence has

required it. An important weakness from the aspect of haemovigilance is the lack of direct connection for

tracing donors and recipients between hospitals and blood centres as there is no unified database of

donors and recipients. Therefore, blood centres often do not have information about recipients and in

cases where the retrospect procedure shows that there is a potential threat related to issued blood

products, blood centres do not have the opportunity to trace the movement of issued products as

hospital blood banks and centres cannot trace the blood products from start to end.

There is also currently no agreement in Estonia on how recipients should be informed and examined, if

there is a potential risk of infection identified significantly – e.g. years – later. Cases like these can occur

when a repetitive donor is identified positive pathogen markers and the retrospect procedure identifies

that previous donations could also be infectious. Currently the blood centres cannot state if and how

recipient control is performed as they have no right to access recipient data.

6.5. Evaluation to blood product quality

The quality of blood products prepared in Estonia is on a good European level, mostly due to the quality

control systems and self-control implemented in blood centres.

More analyses and tests are conducted in blood centres to ensure safety than is required by Estonian

legal acts or European Union requirements. The wide spread of transferrable viral infections in Estonian

population justifies the supplementary steps in testing (using NAT tests) and new diagnostic methods

should be implemented.

For ensuring the sustainability of developments in blood product quality, it is important to implement

modern technologies which require updates in machinery and investments in facilities which might not be

constant budget priorities of hospitals managing blood centres. It would be reasonable to gather certain

specific procedures into one or two blood centres, similar cooperation is currently present in virus testing.

It helps to improve quality management in addition to more optimal utilization of equipment.

The biggest obstacle and weakness in developing haemovigilance is that the electronic traceability of

blood products is interrupted in health care institutions as not all hospital blood banks use the

information system (EVI is only used in 8 hospital blood banks). It is necessary to unite the registration of

blood transfusions with EVI to create a national unified database, which would show the movement of

blood products from donor to recipient i.e. include data about donor selection and test results up to the

results of transfusions. The same information system should reflect the supplies of blood products which

would support the more efficient use of products.


A better overview of the activities in hospital blood banks for ensuring product safety is also necessary

e.g. how self-control is done in every department and how employees are trained.

Recommendations:

• New diagnostic methods should be implemented, which is justified by the wide spread of viral

infections in Estonian population.

• Unite the registration of blood transfusions to EVI in order to create a unified national database,

which would show the blood products movement from donor to recipient.

• Include all hospital blood banks in the national and unified quality management system.


7. ECONOMIC EFFICIENCY OF BLOOD SERVICE

The following chapter gives an overview of the costs of the blood centres by types of costs and also the

income. Then the indicators describing the productivity of blood centres and unit price of blood products

are given. The chapter focuses on economic indicators of blood centres, but the costs of hospital blood

banks are also evaluated in order to estimate the total costs of the blood service.

An economic analysis of blood centres often focuses on the analysis of inputs and outputs instead of the

analysis of the costs of blood centres. The inclusion of costs less frequently in the efficiency analysis often

derives from the low availability of data, but also from the difficulty of interpreting the results of analysis,

including the lack of suitable reference values. In analyzing the costs of blood centres, the cost of the

entire system is often evaluated, including the costs connected to transfusion stages (e.g. Rautonen

2007).

7.1. Costs and structure of costs of the blood service

When evaluating the costs of the blood service, all activities from collecting donor blood to issuing blood

products to hospitals should be taken into consideration, but also the costs from matching to transfusion

– i.e. the expenses connected to the whole vein-to-vein chain. Blood centres produce costs related to

blood collection, testing, processing, storing and issuing of blood products; hospitals produce costs

related to transportation, receiving and preparing blood products for transfusion. For example, Rautonen

(2007) has evaluated based on Finnish data that 76% of the blood service costs are connected to the work

of blood centres and 24% of costs are made in hospitals. However, only the costs of blood centres are

available about other countries and even then mostly only about countries with centralized systems (e.g.

Finland, UK, Canada), where the costs of blood centres are introduced in annual reports.

The 2010-2011 financial reports were gathered from Estonian blood centres, which included detailed data

about cost items. It is a lot more difficult to measure the costs of hospital blood banks, as there are

significantly more of them and in smaller hospitals the hospital blood banks do not make up structural

units with independent budgets. Therefore the costs of hospital blood banks can only be evaluated.

The costs of blood service have been divided into five in this analysis:

1) Staff-related costs – salaries, training etc;

2) Equipment-related costs – purchasing, maintenance;

3) Costs of disposable materials – blood bags, tests;

4) Costs related to facilities – repairs, maintenance;

5) Other costs – bureau and economic costs, etc.

Majority of blood centres’ expenses are semi-fixed costs, i.e. costs which are not one-on-one related to

processing capacities, but are fixed in certain ranges of production capacities or related to the size of

product selection. These costs are e.g. staff, equipment and facilities in some cases. Variable costs are

expenses on disposable materials (e.g. blood bags, tests), which are directly related to how many units of


blood is collected, tested or prepared. Fixed costs are bureau and economic costs, which are necessary

regardless of the capacities the blood centre handles (e.g. IT-costs, management costs etc). The division of

costs to fixed or variable costs is important, as it enables to evaluate if and how much more efficiently a

blood centre could work in case of larger capacities.

The biggest cost items of Estonian blood centres are the material cost and costs on purchased medical

services (47%) and staff-related costs (28%), which together make three-quarters of costs (q.v. how costs

are divided to cost items Annex 9). Bureau, economic, and management costs make up 18% of the costs.

The expenses to facilities and equipment make up a small proportion of costs, both coming to 3% of total

costs.

The small proportion of equipment-related costs can be explained by the large proportion of aged

equipment – half of the equipment on average is older than the optimal age of use and are probably

reflected in financial reports with zero amortization (q.v. also Table 4 in chapter 3.1.1). In addition, it

should be taken into consideration, that some equipment may be rented instead of purchased and the

expenses are reflected in material costs.

Figure 16. Structure of the costs of blood centres, average of 2010─2011

Source: financial reports of blood centres 2010, 2011

Compared to developed countries, the proportion of salaries is relatively small in Estonia, for example in

Canada the proportion of staff-related expenses is 59%, 48% in Finland and 47% in the UK, being

therefore the main cost item. Material costs were 18%, 25% and 18% accordingly in Canada, Finland and

the UK (CBS Report 2007/08, FRCBS Annual Report 2011, and NHSBT Annual Review 2011─2012).

In different blood centres the proportion of cost items varies a lot depending on work arrangements (e.g.

whether testing is done on spot or purchased as a service) and product selection. The largest variation is

in material costs and costs on medical services (q.v. Table 24).

Material / purchased

med. services;

47,1%Salaries and

training; 28,3%

Equipment; 3,3%

Facilities; 3,0%

Other costs; 18,3%


Table 24. Differences in costs structure by blood centres, 2010─2011

2010 2011 Proportion by blood centres

(2010/2011)

Material 30.9% 30.3% 12.1─37.4%

Salaries 27.6% 28.6% 23.5─31.2%

Purchased med. services 16.5% 16.5% 0.4─36.6%

General costs 7.5% 7.9% 4.5─10.1%

Value added tax 7.6% 6.2% 4.9─7.9%

Other activity costs 3.5% 4.0% 0.7─7.7%

Equipment 3.4% 3.3% 0.8─5.2%

Facilities 2.9% 3.0% 0.9 ─7.4%

Training 0.2% 0.2% 0.1─0.3%

Source: financial reports of blood centres 2010, 2011

In addition to the cost analysis by different cost items, costs should also be observed by stages of process

– collection, processing, testing, storing and issuing. Unfortunately the blood centres do not generally

differentiate between costs by stages and it is hard to perform this analysis based on financial reports as it

would require very detailed information about the division of employees, equipment, materials etc. A

certain differentiation of costs is done in PERH blood centre, where the costs are differentiated by

processing department, quality control, referent laboratory and the rest of the blood centre. According to

the financial report of the blood centre, the costs of the processing department made 48% of the costs in

2010/2011, quality control made 35% of the costs, referent lab 3% and the rest of the centre 14% of the

costs.

For estimating the costs occurring by stages, the data of the Estonian Health Insurance Fund cost-model

was analyzed, according to which the product prices are set. Product prices are developed as the sum of

costs on activities required for the preparation of blood products and costs on materials. By grouping the

activities and materials according to stages of process, the estimation to costs was received by stages.

According to the analysis, 25% of the costs are related to blood collection, 34% to testing, 35% to

processing (including 1% to quality control) and 6% of costs are related to other activities. In Finnish blood

service, 55% of the costs are related to donor activities, 24% to lab services and 16% to processing (FRCBS

Annual Report 2011). This major difference might be related to differences in staff-related costs, as the

donor activities need the largest capacity of staff and 42% of the blood centre staff was working on

collecting blood in Finland on 2011 (FRCBS Annual Report 2011).

In total the costs of four blood centres in Estonia were 5.8 million Euros in 2011, which has not

considerably changed compared to the previous year (2010 – 5.7 million Euros). It should be noted, that

these are operating costs and the number cannot be interpreted as the costs necessary for preparation of

blood products, as these costs do not take into account investment needs.

Estimation of costs related to hospital blood banks was based on the compensation of services connected

to blood transfusion (immunohematological tests, including identifying blood type, rhesus, antibodies,

matching in hospital and day care, q.v. Annex 8) and it was assumed that the product prices cover all the

expenses regarding blood transfusion. According to the given assumptions, the cost of hospital blood

banks in 2011 was 1.6 million Euros. Therefore the vein-to-vein process in Estonia costs 7.4 million Euros,

from which the proportion of blood centres and hospital blood banks is accordingly 79% and 21%. It


should be taken into consideration, that the immunohematological tests are also done in larger blood

centres (or referent labs), but based on the data of PERH blood centre, the proportion of those is not

larger than 5%. Secondly, the evaluation does not reflect the costs of other activities in hospital blood

banks (ordering and storing blood products).

7.2. Income of blood centres

The financing of blood centres is similar to the rest of the health care based on products and services in

Estonia – majority of income of blood centres comes from the sales of blood products, less from providing

services. Blood centres sell blood products and offer services to hospitals, which submit invoices for

transfused blood products and provided services to the Estonian Health Insurance Fund. Estonian Health

Insurance Fund compensates the blood products and procedures listed in the health care service list

according to the agreed prices. Blood centres are not forbidden to sell products and services with lower

prices than the agreed prices and sometimes that is implemented.

Only the operating costs of the referent lab located at the PERH blood centre are regularly financed from

the state budget. Ministry of Social Affairs gave 99 888 Euros for 2012 to the referent lab (Ministry of

Finances, letter of explanation of the state budget law of 2012). Donation development was financed

from state budget in 2011 and 2012 (6000 and 16 750 Euros respectively). The use of money is jointly

decided upon in the expert committee, for example, in 2011 radio advertisements were produced and in

2012 the money is used for a video clip. However, the finances are insufficient for promoting donation -

for example, there is not enough finances for distributing the produced clip in 2012. According to an

interviewed expert, the financing for donation promotion is not guaranteed, as there is no legal basis for

the financing, which would ensure constant financing.

The product prices are presented in the Estonian Health Insurance Fund health care service list as a

separate chapter (Blood products and procedures with blood products). The product prices take into

consideration the costs from collecting the blood to storing, and costs on staff, facilities and materials.

Exceptions are the donation development and investments, which are not accounted for in the product

prices. To calculate the product price per dose, the resource expenses are allocated on the amount of

blood products issued to hospitals, not the prepared amount. In most cases the processed and issued

amounts are fairly similar, but in case of plasma, the issued amount is significantly smaller than the

processed (q.v. Table 25). Therefore, the issued amount is smaller than the processed amount and the

product price per dose is higher.

Table 25. Differences in the amount of processed and issued blood products, 2010─2011

Collected/produced Issued Proportion

2010 2011 2010 2011 2010 2011

Erythrocytes 56 809 56 967 54 739 55 181 96% 97%

Plasma 58 253 60 019 30 826 28 862 53% 48%

Platelets 6 612 7 101 6 086 6 636 92% 93%

Source: Annual reports of blood centres 2010, 2011

Note: blood collected via aphaeresis is also taken into account in the processed amount of blood products; paediatric doses

are not taken into account.


Blood service as a whole was in surplus in 2011 and in deficit in 2010 (q.v. Table 26). Considering the

maximum possible sales revenue (number of issued blood products x product prices), the sales of blood

products make up the majority of blood centre income – 85%. Yet the data implies that the sales of blood

products alone do not cover the operating costs of blood centres and the need for investments.

Table 26. Overview of blood centres, 2010─2011

2010 2011

Costs total, million € 5.70 5.82

Income total, million € 5.66 5.91

Accounting surplus/deficit, million € ─0.40 0.88

Estimated income from blood product sales*, million €

5.03

Source: financial reports of blood centres 2010, 2011; data on issued products of blood centres, list of

healthcare services

Note: *product price x number of issued products, incomes from sales within Estonia, real income can be smaller as blood

centres can sell products with lower prices

Presented overview of costs and incomes gives a slightly distorted image of the situation of blood centres

for two reasons. Firstly the budgets and costs of blood centres do not show a large part of investments,

which are usually not differentiable from other investments in hospital budgets. Secondly the blood

centres outcome does not reflect the obligations coming from the sales of plasma for fractionation (e.g.

the requirement of purchasing plasma products or industrial plasma). Therefore the income from plasma

sales is not net profit, as there are obligations.

7.3. Productivity and unit price in blood centres

Blood centre productivity is by nature the relationship between all the inputs used in the processing of all

blood products and the final product. The less resource is used for producing a certain amount of product

or the more blood products are produced with certain resources the more productive is the blood centre.

In practice, measuring and comparing all the inputs and outputs is a difficult task, as the inputs for blood

products manufacturing make up a complicated set of equipment, materials, facilities and staff. In

addition, usually more than one blood product is prepared. Due to this complication, labour productivity

or unit price is often observed instead in scientific literature, as a measure of blood centre productivity

(e.g. Veihola 2008, Bell et al 2008, IBM, Performance Review of Canadian Blood service 2002). This can be

explained with Veihola’s et al (2008) idea that, as staff is the main cost item, it is also the most probable

area for raising efficiency.

To calculate the labour productivity, either the whole-time equivalent or working hours are set as input.

As output, it is easier to use blood donations in case of Estonia, as the product range in very different by

blood centres and adding up the different blood products does not reflect the differences in processing. In

the following table (q.v. table 27), the first three indicators can be interpreted as labour productivity.

According to the first and third indicators, labour productivity is highest in Tartu blood centre and it does

not differ significantly from the other blood centres. This can be explained by two things. Firstly, although

the product range in Tartu and PERH blood centres is similar, the arrangement of testing differs – in PERH

blood centre, the testing is performed locally by their own staff, while Tartu blood centre uses the


services of Tartu University Hospital lab, decreasing the number of employees of the centre. Secondly,

PERH blood centre has taken up some tasks for developing and coordinating blood centres (e.g. collecting

data, representation on international conferences), so the proportion of people not directly to the

processing is larger. This also reflects in the annual reports of blood centres (q.v. Annex 1). When

excluding the so-called non-specialist employees from the staff, the labour productivity varies a lot more

by blood centres.

Table 27. Efficiency indicators of blood centres, 2011

PERH

blood

centre

Tartu

blood

centre

Pärnu

blood

centre

Ida-Viru

blood

centre

Average Comparison

Blood donations per position,

doses

411 571 425 432 450 Finland 470*

Canada 205**

Blood donations per specialist

position (doctor, nurse,

technician), doses

660 772 579 432 658

Work hours per collected whole

blood doses, hours

5.41 3.74 4.97 5.16 4.86 Canada 8,56

Sweden 3,73

UK 3,40***

Cost per donated blood, Euros 94.4 102.3 98.1 115.9 98.2 USA**** $190

(ca €150)

Cost per issued products, Euros 66.8 51.1 65.3 65.7 61 Canada**

$376 (ca €300)

Cost per issued products excl.

plasma, Euros

84.8 83.6 102.6 118.0 87.9

Source: calculations: annual reports, financial reports, data about issued products from blood centres

2011,*FRCBS Annual Report 2011, **CBS Report 2007/08, ***IBM, Performance Review of Canadian

Blood services 2002, ****Custer et al (2005), whole blood donations

The latest data available for Finland and Canada is used for making international comparisons and the

ratio of blood donations per filled positions is calculated. The average number of Estonia is quite similar to

the number in Finland, but is a lot higher compared to Canada. It should be taken into consideration that

in several countries with centralized blood services, other activities are done within the service (e.g. bone

marrow, organ donation etc data bases) and therefore the number of employees is larger. The third

indicator reflects only staff in blood service, according to which, the average blood centre labour

productivity in Estonia is lower than in Sweden and the UK, but a lot higher than the according Canadian

indicator. It is hard to explain the differences without knowing the specific characteristics of blood

services in other countries.

Product unit price can also be used for comparison in addition to labour productivity. Two indicators are

used in this research – the unit price of blood donations and the unit price of issued blood products. The

unit price of blood donation does not significantly vary in different blood centres, remaining between 94-

116 Euros (q.v. Table 27). The unit price of collected whole blood in USA is brought as a comparison,

which is 1.5 times higher than the average indicator of Estonian blood centres. When using monetary

indicators in international comparisons, caution should still be taken, as the standard of living, structure

of costs, blood centre financing, etc, differ in countries.


It is a lot more complicated to compare unit price of issued blood products in different centres, as they

prepare and issue different products in different amounts. It should also be considered that blood centres

react to the needs of hospitals, meaning that the structure and amount of issued blood products depends

on the specific nature of the users in the district. This is clearly shown in the following. Taking into account

all the issued products, the unit price is lower in Tartu blood centre than in others. When leaving plasma

out of the calculations, the unit prices of Tartu and PERH blood centre are equal and lower than the unit

prices of Pärnu and Ida-Viru blood centres.

The analysis of scale effect is closely related to the analysis of unit price. The scale effect of blood

processing has not been researched a lot in scientific literature and the conclusions are controversial

(Pereira 2006, Veihola 2008). For example, Pierskalla (1987) found clear increasing returns to scale in the

stages of storage and issuing in blood centres, but a less noticeable connection in the stages of collecting

and processing blood. He concluded that a blood centre is most efficient with an annual processing

volumes of 50 000 – 75 000 doses of erythrocytes. Pereira (2006) found that the optimal processing

capacity of blood centres is 75 000 – 100 000 doses of erythrocytes per year. Veihola et al (2006)

concluded in his analysis, that blood centres collecting over 60 000 doses of blood a year are more

efficient compared to smaller centres.

Increasing returns to scale enables to allocate fixed costs to a larger amount of produced units, maximal

utilisation of equipment and staff (minimizing waiting period) and the increase in efficiency due to the

staff specializing (Pereira 2006).

According to the data of Estonian blood centres, there is a linear connection between the costs and

number of blood donations and there are no notable increasing returns to scale in blood collection (q.v.

Figure 17). In case of the number of issued products the connection is rather linear, but larger centres

issue relatively more products with the given blood donations. Therefore a proportionally larger income

occurs with the given level of cost and a positive connection between the outcome and number of

donations/issued products occurs.

Figure 17. Connection between costs and number of blood donations/issued products in blood centres

Source: annual reports, financial reports of blood centres 2011

0

0,5

1

1,5

2

2,5

3

3,5

0 10000 20000 30000 40000 50000

Co

sts,

mill

ion

Eu

ros

Number of blood donations / Number of issued products

costs per donations

costs per issued products

costs per issued products (excl. plasma)


The small size of all Estonian blood centres should be noted in the analysis. For example, if efficiency is

achieved in 50 000-75 000 doses (as referred to by Pierskalla 1987) all blood centres work with inefficient

processing capacities. In addition, the analysis was conducted based on operating costs and the costs do

not reflect investment needs, therefore the proportion of fixed costs is small and there are no increasing

returns.

In addition it should be considered, that although cost savings are connected to good management, from

a certain level, savings are not advisable as the quality will suffer. For example, the number of staff or size

of facilities cannot be decreased at some point, without it bringing forth some risks to the safety of blood

products.

7.4. Evaluation of economic efficiency

The estimated total cost of Estonian blood service was 7.4 million Euros in 2011, from which 79% – 5.8

million – was spent on the work of blood centres. In 2011, the centres in total were in surplus, 0.9 million

Euros, a year earlier the centres were in loss (-0.4 million Euros).

The largest cost items are materials and medical services, which take up almost a half of the budgets of

blood centres, the second largest cost item is staff-related costs, which take up a quarter (28%) of the

total costs. This shows that a large part of blood centres costs are variable costs or semi-fixed costs which

do not depend on the processing capacity directly. The structure of cost items is still different by centres.

The main source of income for blood centres is the blood product sale to hospitals. The prices of blood

products are cost-based, meaning they should reflect the costs of blood processing. A cost-based price

calculation forces to act efficiently and is therefore reasonable in conditions of limited budgets. Yet there

are three problems in the blood product financing today, two of which are connected with the general

financing principles and are not applicable only on blood products:

The calculation of products prices is based on the “average” costs of four blood centres. As the

blood centres are very different in their functions and cost structures, this leads to inequality

(over and down payments).

The prices of blood products to not include costs on developing donation and investments of

blood centres, which are vital for ensuring the demand and quality of blood products.

The prices of blood products are overestimated when it comes to plasma, as the total cost of

plasma processing is calculated in the prices, although almost half of the plasma goes to

fractionation and produces income.

The limited investment opportunities have resulted in aged equipment in several blood centres (q.v. Table

4) and old, inefficient facilities.

The labour productivity of blood centres is on a comparable level, for example, with the according

indicator in Finland, but also in Sweden and the UK, showing that blood centres work efficiently. The

productivity still differs by centres. The unit cost also varies, but no increasing returns to scale occur as

larger blood centres do not have significantly smaller unit costs compared to smaller blood centres. This is

a result of product-based financing, a large proportion of variable costs, but also the small size of Estonia,

where economic relations do not reveal.


Considering investments alongside operating costs, it is clear that with larger amounts, a better efficiency

and savings can be achieved. The main area for increasing returns is purchasing new equipment, which

would be more optimally used with a larger processing or testing capacity, but the same applies to

facilities and staff.

Recommendations:

Blood centres are supervised from the aspect of safety, the economic efficiency is not observed.

It would be reasonable to use benchmarking.

Financing blood centres should cover all types of costs.

Concentrating certain services into one location should be considered, in order to achieve

optimal utilisation of resources (mainly equipment), which would make the use of new

technologies more cost-effective.


8. GENERAL EVALUATION AND RECOMMENDATIONS

Estonian blood service is based on a relatively stable base of donors, a working supply chain has

developed and the safety of blood products is ensured. A clear division of tasks and responsibility for

everyday orders have developed between blood centres. The work of blood centres is efficient from the

aspect of using donor blood and resources.

Taking into consideration future developments and the limited healthcare budget of Estonia, the main

problems from the aspect of further development of blood service and optimizing cost-effectiveness are

as follows:

1. Little central planning and coordination of the blood service. Development of the blood service is

left to four hospitals and depends on their financial capability, which can affect the quality of

blood products and processing in conditions of a tight budget.

2. Decrease in donor base in Estonia, as there are a lot of first-time donors and youngsters among

donors, whose proportion will greatly decrease in 10 years.

3. Blood processing and use of blood products is not regionally balanced, over and underproduction

occur, and overproduction can cause unnecessary competition.

4. According to estimation, the use of platelets decreases by a third in the near future, therefore the

use of donor blood should be optimized even more.

5. Plasma use is uneven in Estonia and surpasses the general level of Europe; it is possible to send

the leftovers to fractionation.

6. Blood centres work under optimal production capacity.

7. Estonian epidemiologic situation causes a need to additionally and systematically invest in the

safety of blood products.

8. The current financing mechanism does not support development activities and causes

unnecessary stimuli for competition.

9. Insufficient development of the blood service information system. Hospital blood banks and

blood transfusion are not involved in the information system, therefore giving no overview of

donors, blood product supplies and it is not possible to observe the chain from donor to patient.

10. Lack of preparations for a crisis situation.

Several of the points overlap with previous evaluations of Estonian blood service (q.v. chapter 1), which

implies that many of today’s problems are not new, but have rather deepened in time.

In previous chapters, solutions are offered for the problems in the according area in the end. This chapter

assembles recommendations found most important and separate scenarios regarding the division of

responsibilities for blood centres are brought out, which could help to solve several problems.

Recommendations based on the given evaluation to the situation of Estonian blood service are divided

into critical needs vital for implementation and recommendations which should be considered.

NB! All re-arrangements in Estonian blood service are only possible by according agreements between

hospitals managing blood centres and by making changes in the legislation and financing of blood

products. However, the re-arrangements are necessary for blood system development and help to

decrease risks.


8.1. Critical needs

1. Developing donation

The current donation development, including recruiting new donors and raising the awareness of the

population, is left as the task of blood centres, i.e. hospitals in Estonia. This does not ensure an even

development by districts and there is no systematic national promotion for raising awareness and forming

attitudes in Estonia. Unfortunately the healthcare budget does not have resources for developing

donation, the finances from the state budgets of the last two years were too small for real impact and this

financing is not necessarily ensured for the following years. 16 750 Euros have been allocated for

donation development in 2013, which will be used to cover the distribution costs of the video clip

produced in 2012, and the expenses of donor tents.

There should be separate financial means for developing donation and these should be distributed to the

centres either as direct financing or centrally from the budget of the Ministry of Social Affairs. The

financing could be divided into two: 1) raising awareness among the population and shaping attitudes

with the aim to find new donors; 2) motivating current donors and involving the passive donors.

Several activities could help to shape the attitudes, e.g. cooperation with schools and organizations,

campaigns and articles in media (e.g. producing and distributing a commercial), finding new cooperation

partners (informational days with local municipalities’ leaders, an approximate sum per event 200 Euros).

Motivating current donors could be done by events directed to donors (donor family day, approximate

sum per event 3500 Euros) and contacting passive donors (approximate sum per donors 1 Euro,

approximately 100 000 inactive donors in Estonia). The sums are based on the calculations brought out in

the State program of developing blood donation and blood product self-sufficiency.

2. Blood service information system

The current blood service information system (EVI) has been used in blood centres for organizing their

own work and it does not enable information exchange between blood centres. Not all hospital blood

banks have joined the blood service information system and it does not work as an operative tool for

haemovigilance. The development of blood service information system has been left to the hospitals and

therefore depends on the budget priorities of every hospital. That is why there is still no clear overview of

donors, blood products supplies and recipients on a national level and there is no way to observe the

blood from donor to recipient. In addition, the implementation of the information system is on different

levels of development in different blood centres and hospital blood banks.

Blood information system needs to be joined into a centralized system, which shows all donations of

every donor, their test results, prepared blood products and possible aberrances; all hospital blood banks

need to be added into the system. Financial measures for this development have to be allocated and

divided to the centres as direct financing or from the budget of the Ministry of Social Affairs.

With a centralized information system it would be possible to consider its development into an automatic

ordering system, which monitors the blood supplies of hospitals and performs automatic orders. A similar

system is, for example, used in the Finnish blood service (FRCBS Annual Report 2010). The described

ordering system could be combined with planning logistics – i.e. combining the transportation for

everyday orders (like Rakvere – Kohtla-Järve – Narva), which would help to cut back on transportation

costs.


Preparations for a centralized information system have been started in 2012, with the first stage being

mapping the situation and analyzing the needs; developments are planned for the upcoming two years.

The plan states the creation of a central information system, where all important data regarding blood

handling would be submitted. Thereby, the donor eligibility control would be improved, finding the

suitable donor for the patient would be faster, blood traceability is ensured, an overview of product

supplies is given, opportunities for electronic ordering and submitting statistic reports are enabled.

According to initial evaluation, the central system and creating opportunities for integrating local systems

will cost 500 000 Euros, plus management expenses. The developments are financed by the Ministry of

Social Affairs. Alongside the central information system, local information systems (e.g. EVI) will remain,

the maintenance and development of which will be done by the hospitals. Local systems (at least EVI)

need to be renewed within a 5-10 year perspective, estimated cost of the new software is 3-5 million

Euros (Analysis of the national information system of blood, tissue and cells 2012).

3. Financing blood service

Currently the financing is based on the issued blood products – the more products are sold, the bigger the

income. Financing by product prices has ensured an efficient use of donor blood and a high level of

productivity in blood centres, but developing activities – e.g. promoting donation, developing information

system – have received less attention and incentives for competition have occurred. Implementing only

product-based financing focuses attention on sales of blood products and does not support developments

in areas which do not directly result in revenue, e.g. training the staff and quality management. Product-

based financing also does not support cooperation, where the biggest problem is creating a unified

national information system, but finding necessary resources for that from the sales revenue of blood

products is not possible for blood centres as the price calculation does not take into consideration

expenses for developing EVI.

A combined financing system should be implemented in financing Estonian blood service, which would

consist of elements of product-based financing and base-financing. Activities related to the development

of the blood service (promoting donation, developing the information system, training, quality

management) would be financed by base-financing, processing by product prices. In this case, activities

covered by base-financing should be excluded from product price calculation. In current prices it is mainly

quality management, donation development and EVI are not calculated into product prices today and

these costs should be covered by base-financing.

4. Selling blood plasma for fractionation

The issue of blood plasma price needs special attention. The current price calculation of Estonian Health

Insurance Fund assumes that the product prices cover all costs from donation to transfusion and blood

centres do not have other sources of income from the collected blood. In a time where this pricing model

was created, blood centres did not have additional revenues and the leftover plasma was thrown away.

Today, blood centres can dispose of the leftover plasma by selling it to fractionation. Considering the

current product prices and the difference between the prepared and issued plasma the collection and

processing of fractionated plasma has been compensated through blood prices with 400 000-500 000

Euros per year in the last few years (i.e. ca. 10% of total compensation of blood products).

Selling plasma leftovers is legal in Estonia and a very reasonable activity from the view point of a specific

blood centre (or hospital). Leftover plasma is common in blood processing, but it needs discussion


whether the use of the income from selling blood plasma should purely belong to the blood centre

producing the plasma or should general interests be taken into account. This is a supplementary reason

for reviewing the product price calculations.

8.2. Recommendations

1. Aggregating information necessary for donors

Currently the information about blood centres is scattered on websites of hospitals and on the website

verekeskus.ee in the case of PERH blood centre.

For developing donation and creating a shared image, it is necessary to gather the information regarding

blood centres and donation into one website (e.g. www.doonor.ee). This helps to promote donation

better (e.g. banners online, which lead to one common webpage instead of a certain blood centre), is

easier for people and economically more reasonable.

The shared website should have information about blood donation locations and schedules of mobile

collection visits (e.g. for the next quarter), which would enable permanent donors to plan their time

ahead. A similar blood centre website about donation is created in Sweden (geblod.nu), where the blood

service is also decentralized. The website could compile relevant information (contacts of blood centres,

information about blood supplies) and other topics important to donors and people considering donation.

Latter has been done to some extent in the website verekeskus.ee.

Blood services need to cooperate in order for a collective website to work properly, a coordinating and

responsible role should be given to one blood centre (together with separate finances) or it could be the

task of a coordinator at the Ministry of Social Affairs.

2. Determining on the role of a central coordinator

Currently there is no central coordination and planning done on a state level. If no reorganisation of blood

service is planned, the solution would be the creation of the position of a blood service specialist at the

Ministry of Social Affairs. The specialist’s tasks would be the coordination of the work of blood centres,

donation promotion, blood service information system development, planning the demand of blood

products on a state level and finding solutions for areas in need of development. Joint procurements

should also be considered for certain materials. The role of the coordinator could be given to one of the

blood centres (together with separate finances), but in this case it would be difficult to implement

decisions, as the blood centres, i.e. hospitals, are private organizations.

3. Purchase of blood vehicles

Currently, mobile collection means transportation of staff and equipment to certain destinations. This

requires previous inspection and evaluation of suitability of the facilities. Such arrangements also require

time for preparing blood collection sites and, later on, for gathering equipment and materials.

Therefore, purchase of special blood vehicles should be considered, which would enable mobile collection

visits to places that would not be suitable for blood collection otherwise (e.g. shopping centres). Mobile

vehicles are also necessary for potential crisis situations.

http://www.doonor.ee/


The cost of purchasing 2 vehicles is estimated to 2 million Euros (State program of blood donation

development and blood product self-supplying for 2010-2015), but the actual cost of blood vehicles would

require an independent analysis.

4. Inactivating blood products

Inactivated blood products are used in several European countries and, for example, Finland has

completely switched to inactivated plasma (Octapharma product Octaplas). The use of inactivated blood

products is scarce in Estonia.

Inactivated blood products help to reduce the virus transfer risk arising from window-period and, in case

of Octaplas, a decrease in the risk of TRALI due to pooling is also thought to occur (q.v. chapter 2.2). As

inactivated products are expensive, the cost-effectiveness should be considered compared to fresh frozen

plasma, by comparing the costs and benefits of obtaining both of the blood products. Benefits are often

expressed in life years gained (LYG or QALY – quality adjusted life years), in the case of Octaplas life years

are also affected by the lower probability of viral or TRALI transferral. In the table below, six researches

are presented, where the cost-effectiveness of fresh frozen plasma and solvent-detergent plasma are

compared.

Table 28. Cost-effectiveness of fresh frozen plasma and inactivated plasma

Author, year, state, financer

Clinical

outputs

SD-FP/Octaplas vs FFP Conclusion of authors QALY ICER per QALY*

1 AuBuchon, Birkmeyer (1994), USA

Financer not stated

Viral infections

0.000067 $289 300 SD-FP produces small income and high costs

2 Pereira (1999), Spain

Spanish government (partially)

Viral

infections

0.00014

$2 156 398

Virus-inactivated plasma

produces little income and

very high cost

3 Riedler et al (2003), UK

Octapharma

Viral

infections,

TRALI

$22 728

(newborns) –

$98 465 (70-y-

o)

SD-FP is cost-effective in

patients < 48 years old and in

older patients with good

clinical prognosis

4 van Eerd MC et al (2010), UK

Octapharma

Viral

infections,

TRALI

0.03

$1632

Octaplas is cost-effective when

compared to FFP at a

threshold of $47 548 per QALY

5 Membe et al (2011), Canada

Canadian government (partially)

Viral

infections,

TRALI

0.0002

$934 000 Octaplas is more costly than

FFP and is associated with

negligible increases in QALYs

6 van Eerd MC (2011), USA

Octapharma

Viral

infections,

TRALI

0.012

─$29 906

Octaplas is a cost-effective

alternative compared to FFP

Source: AuBuchon, Birkmeyer (1994), Pereira (1999), Riedler et al (2003), van Eerd et al (2010), Membe et

al (2011), van Eerd (2011)

Note: *excl. Rielder et al (2003) – ICER per LY. SD-FP: solvent-detergent plasma, FFP: fresh frozen plasma. Interpretation:

QALY – how many quality-adjusted life years are gained more from solvent-detergent plasma compared to fresh frozen

plasma; ICER per QALY – how much solvent-detergent plasma costs more or less per one QALY compared to fresh frozen

plasma


The previous overview implies that the conclusions about the cost-effectiveness of solvent-detergent

plasma are controversial. Four articles find that solvent-detergent plasma is not cost-effective compared

to fresh frozen plasma, as it is a lot more expensive and does not bring forth any remarkable benefit in

gained life years. Two articles (from the same author) have come to the opposite conclusion and both

researches were financed by Octapharma. The reasons could lie in different assumptions in models. For

example, Riedler et al (2003) has noted that some earlier research (e.g. AuBuchon, Birkmeyer 1994,

Pereira 1999) have underestimated the advantages of solvent-detergent plasma in their research as they

have not considered the possible decrease in transfusion reactions using solvent-detergent plasma.

AuBuchon (2011) has brought out, that inactivation does not bring along a remarkable extra cost-

effectiveness, as methods for avoiding most risk factors have already been implemented, inactivation

helps to avoid bacterial contamination and not as much viral infections. In addition, the evaluation for the

cost-effectiveness of solvent-detergent plasma depends on the context i.e. the situation of blood safety in

a state – the more there are viral infections and events of TRALI, the larger the theoretical benefit of using

solvent-detergent plasma.

Considering the more complicated epidemiologic situation of Estonia and the larger probability of viral

infection risks, the use of inactivated products should be considered. Today there are two options –

inactivation industrially (only for plasma, Octapharma product Octaplas) or inactivation in the blood

centre (both plasma and platelets). As both plasma and platelets inactivation is done with the same

device and the only difference is in the additional set for the processing, it would be economically more

reasonable to either inactivate both components in the blood centre or not buy the device when

purchasing Octaplas (and platelets would not be inactivated).

In the decision, whether to start using inactivated products and which method to prefer, the following

circumstances should be taken into account:

erythrocytes (most used blood component) cannot be inactivated, therefore traditional testing

would remain;

inactivating platelets is necessary to decrease risk of both viral infections and bacterial

contamination;

inactivating in the blood centre would prolong processing, which decreases the time period

during which platelets can be used;

inactivation does not eliminate all viruses (effect is smaller in case of non-enveloped viruses

(Member et al 2011)), on the other hand, not all viruses are tested today;

purchasing Octaplas could become the prerequisite of Octapharma for buying plasma.

The costs of Octaplas and inactivating in blood centres also differ.

Table 29. Costs of Octaplas and inactivating in blood centres (thousand Euros)

Yearly extra cost

Octaplas (additional cost compared to fresh frozen plasma) 869

Inactivating plasma in blood centres (costs related to service) 754

Inactivating platelets in blood centres (costs related to service) 351

Source: applications submitted to Estonian Health Insurance Fund (Octaplas – submitted 2011,

inactivating in blood centres – submitted in 2008) and evaluation of Estonian Health Insurance Fund to

applications, Estonian Health Insurance Fund data


The total cost of inactivated products depends on the used amounts in the future: the costs of inactivated

plasma products could decrease and cost of inactivated platelets increase.

According to the calculations of Estonian Health Insurance Fund, both Octaplas and plasma inactivated in

blood centres would be cost-effective, but the latter would provide more cost-effectiveness.

The precondition for starting to use inactivated products would be a total transition to inactivated

products i.e. it is unethical to use inactivated (i.e. with a higher quality) products only in some hospitals

and for only some patients. An exception could be children as a special target group, but in the case of

inactivating in blood centres, the amounts would be unreasonably small for purchasing equipment.

5. Fractionation of plasma leftovers and purchasing plasma products

Currently there are a lot of fresh frozen plasma transfusions in Estonia compared to other developed

countries and therefore the proportion of plasma going to fractionation is relatively small compared to

the transfused plasma. Fractionation contracts of blood centres are different and the prerequisite of

plasma sales could become the purchase of Octaplas at some point. A situation could also occur, where

some health care institutions receive plasma products cheaper and other must buy them with a higher

price.

If the use of fresh frozen plasma would be more optimal in Estonia, more plasma could be sent to

fractionation and the resulting income would be larger. But the question of how to treat the allocation of

revenue from plasma leftover needs further discussion. Increasing the utilisation of plasma leftovers is

possible with good cooperation between blood centres and by centralizing the quality management of the

blood service.

8.3. Scenarios describing blood service division of responsibilities

Considering the future of Estonian blood service, four scenarios are offered which differ in cooperation

and level of consolidation and where supplementary cost-effectiveness is achieved mainly by cutting back

on future investment needs. The cooperation between hospitals under private law managing blood

centres could be achieved with contracts which stipulate the obligations of parties and enable a central

use of equipment. Legislation should also be adapted in order to ensure the sustainability of such

cooperation.

This scenario analysis uses the method of the UK blood service to estimate the financial impacts of

consolidation process.

NB! Several assumptions have been made based on expert opinions and cost reports for the calculations.

Detailed assumptions concerning production capacity and costs are necessary for calculating financial

impacts and should not be taken as recommendations.


8.3.1. Scenario 1: maintaining current division of responsibilities

Current division of responsibilities:

Blood collection: four centres, all collecting inside and outside centres

Testing: four centres, immunohematological tests performed in all centres, but viral tests only

partially in Pärnu and Ida-Viru centres

Processing: four centres, Pärnu and Ida-Viru prepare only two main products and not platelets

Distribution: four centres, Pärnu and Ida-Viru issue only 2 blood products

Tallinn blood centre

Pärnu blood centre

Tartu blood centre


Collecting

Testing

Processing

Distribution

Hospitals in South Estonia

Hospitals in North,

Central and West Estonia

Pärnu hospital

Hospitals in Ida-Viru county

In centerIn district

Some viral testing

Specific blood products

Figure 17. Division of responsibilities in Estonian blood service: scenario 1 (current division)

Estimated impacts on the amount and quality of blood products:

Small amounts in blood collection and processing do not ensure optimal use of blood;

Quality of blood products can become somewhat different if one of the centres obtains newer

technology (e.g. inactivating or supplementary testing) and others do not, presuming that newer

technologies enable to produce products with higher quality (i.e. safer).

Estimated operating costs of blood service

The estimation of blood service operating costs is based on the current 2.2% annual growth of operating

costs (i.e. inflation coefficient). According to the estimation for the current blood system, operating costs

will be 7.06 million Euros by 2020.

Table 30. Forecast of Estonian blood service operating costs (thousand Euros) – scenario 1

2010 2011 2012pr 2013pr 2014pr 2015pr 2016pr 2017pr 2018pr 2019pr 2020pr

Total costs 5 698 5 821 5 948 6 076 6 208 6 343 6 480 6 620 6 764 6 910 7 060


8.3.2. Scenario 2: consolidating processing and testing

The aim of this scenario is the consolidation of processing, testing and mobile collection to optimize the

use of resources (both donor blood and equipment). Scenario is based on the current legal status, i.e.

blood centres being structural units of hospitals. Today, there is already cooperation between blood

centres in testing and ordering specific blood products and platelets for Pärnu and Ida-Viru hospitals.

DESCRIPTION AND JUSTIFICATION OF SCENARIO

New division of responsibilities: two blood centres and one stationary donor centre (q.v. figure 19)

Blood collection: two blood centres in Tallinn and Tartu and a donor centre in Pärnu. Mobile

collection is organized from both blood centres, incl. into current locations of Pärnu and Ida-Viru

from Tallinn.

Testing, processing and distribution: two centres in Tallinn and Tartu.


Pärnu blood centre

Tartu blood centre


Collecting

Testing

Processing

Distribution


Hospitals in North,


Pärnu hospital


In centreIn district

Figure 18. Division of responsibilities in Estonian blood service: scenario 2

Note: light gray lines show movement which will disappear compared to current system and dark grey indicate new

movements.

The organization of mobile collection is assembled into two centres as there is no greater difference from

the cost aspect, where the car heads back to, therefore it is more reasonable to gather the collected

blood into one-two locations. Visits to current locations in Pärnu and Ida-Viru district will be done from

Tallinn, the staff from the donor centre should be involved in some of the mobile collection visits (in cases

the location is close to the donor centre, which saves the time resources of the staff). Gathering the

collected blood from mobile collection to PERH blood centre results from their sufficient facilities.

Pärnu donor centre would only collect whole blood as obtaining an aphaeresis device is not very cost-

effective with the small amount of collection. The collected blood is transported to Tallinn daily. Ida-Viru

would not have a stationary blood collection facility due to the small amount of donations – currently the


centre collects 800 whole blood doses annually, i.e. an average of 3 donors a day visits the Ida-Viru blood

centre. An alternative could be collecting blood at the hospital blood bank or creating a stationary blood

collection point in a different location in the area (e.g. Rakvere), but this adds daily transportation costs to

Tallinn and the solution would require separate analysis.

The reason for concentrating mobile collection, but also processing and testing, is to optimise the use of

resources (blood vehicles, equipment, staff, facilities) – concentrating main activities enables a better

quality management as well. Gathering processing into two centres enables to optimise the use of donor

blood and simplifies the transition to inactivated products nation-wide, in case inactivation in blood

centres is decided upon (this is implied to in the evaluation of Estonian Health Insurance Fund, which

states that this method is more cost-effective compared to Octaplas). Processing in two centres helps to

diversify the risks.

IMPACTS OF THE SCENARIO


number of collected donations remains the same;

preparation of platelets increases (estimation of 20%5);

quality improves due to improvement in quality management as main activities are consolidated;

if inactivation is introduced in two centres (not reasonable in four centres), the safety of blood

products improves nation-wide;

no reason to think that the availability of blood products decreases in Pärnu, Ida-Viru and Narva

hospitals, since the ordering and storing of blood products can be organized similarly to other

hospitals.

Estimated financial impacts and investment need

In estimating the financial impacts, the expenses related to the expansion of PERH blood centre (increase

in staff, new equipment, etc) and the costs related to changes in the tasks of Pärnu and Ida-Viru blood

centres were taken into consideration. Only the costs which appear or disappear with the changes in

division of responsibilities were considered, but not the transition of costs from one centre to another

(e.g. material costs). Cost estimation does not include possible revenue from unnecessary equipment

(sales value or saved rental costs) or avoided future investments in Pärnu and Ida-Viru blood centres

(renewal of facilities and equipment, developments like EVI). In addition, external factors (inflation,

increase in maintenance prices of equipments, etc) and external effects of blood service (e.g. increasing

transportation costs in Pärnu, Ida-Viru and Narva hospitals) were not considered. The transition time of

the new system is assumed 1 year and 3 months. The assumptions made for calculations are shown in

Annex 9.

5 Currently Tartu and PERH blood centres prepare 5600 BC platelets doses from 48 000 whole blood doses. Majority is 4BC

platelets (~90% of used BC platelets), therefore 5600/(48 000/4)=47% of the potential use is prepared. By adding 10 000 whole blood doses, 10 000/4*47/=1100 doses can be prepared, increase of 20%.


Table 31. Changes in total costs due to the new division of responsibilities (thousand Euros): scenario 2

2013 2014 2015 2016 2017 2018 2019 2020 TOTAL

Non-recurring costs 61.9 25.6 87.6

.. costs related to re-location 35.9 25.6

61.6

..purchase of equipment 26.0

26.0

Recurring costs 72.9 72.9 72.9 72.9 72.9 72.9 72.9 510.4

.. recruiting new employees

59.8 59.8 59.8 59.8 59.8 59.8 59.8 418.6

..maintenance of new equipment

0.3 0.3 0.3 0.3 0.3 0.3 0.3 2.1

..increase in transportation costs

12.8 12.8 12.8 12.8 12.8 12.8 12.8 89.8

TOTAL COSTS 61.9 98.6 72.9 72.9 72.9 72.9 72.9 72.9 598.0

Annual savings ─177.2 ─236.3 ─236.3 ─236.3 ─236.3 ─236.3 ─236.3 ─1 594.7

..decrease in costs on salaries

─149.9 ─199.9 ─199.9 ─199.9 ─199.9 ─199.9 ─199.9 ─1 349.3

..decrease in maintenance and rental costs of equipment and facilities

─15.2 ─20.3 ─20.3 ─20.3 ─20.3 ─20.3 ─20.3 ─137.0

.. decrease in management costs

─12.0 ─16.1 ─16.1 ─16.1 ─16.1 ─16.1 ─16.1 ─108.4

TOTAL 61.9 ─78.6 ─163.3 ─163.3 ─163.3 ─163.3 ─163.3 ─163.3 ─996.7

According to the estimation, the change in the division of responsibilities pays off in 1.75 years. After re-

arrangements the annual savings is 163 thousand Euros and the operating costs of blood service would be

6.9 million Euros by 2020. After 8 years, the savings resulting from changes in division of responsibilities is

almost a million Euros. It should be emphasized that this is a conservative estimation, as the significant

savings arising from losing investment needs in two blood centres are not included in the estimation.

Table 32. Estimated operating costs of Estonian blood service (thousand Euros): scenario 2

2013 2014 2015 2016 2017 2018 2019 2020

Scenario 1: current division of

responsibilities

6 076 6 208 6 343 6 480 6 620 6 764 6 910 7 060

Scenario 2: consolidated

processing and testing 6 138 6 130 6 179 6 317 6 457 6 601 6 747 6 897

This scenario is more cost-effective compared to the current division of responsibilities as it brings forth

savings, the amount of collected blood does not decrease, the processing of platelets might increase and

prerequisites for improving the quality of products are created.

8.3.3. Scenario 3: centralized (national) blood service with two blood centres

The aim of the scenario is similarly to the previous to consolidate the processing, testing and mobile

collection, but also creating a national blood service. The scenario requires a change in the legal status of

blood centres (public or other form, but as one institution).


DESCRPITION AND JUSTIFICATION OF SCENARIO

New division of responsibilities: one centralized blood service with 2 blood centres and one donor centre

(q.v. Figure 20).

Blood collection: two blood centres in Tallinn and Tartu and a donor centre in Pärnu. Mobile

collection is organized from both blood centres, incl. into current locations of Pärnu and Ida-Viru

from Tallinn.

Testing, processing and distribution: two centres in Tallinn and Tartu.


Pärnu blood centre

Tartu blood centre


Collecting

Testing

Processing

Distribution


Hospitals in North,


Pärnu hospital




Note: light gray lines show movement which will disappear compared to current system and dark grey indicate new

movements

The scenario is based on the same division of responsibilities as scenario 2 (and therefore the reasons are

similar), but the legal status of blood centres and the donor centre will change and one centralized blood

service will be created. A centralized institution enables the blood service to act as a coordinator and

planner, to concentrate competence and it is easier to implement necessary developments and changes.

In a centralized institution, it would be easier to collect plasma leftovers and make one fractionation

contract. Also, blood centres and blood banks (i.e. provider and user of blood products) will be separated,

avoiding possible conflicts of interest.

IMPACTS OF THE SCENARIO

As the division of responsibilities is similar to scenario 2, the estimated impacts on the amount and quality

of blood products and financial impacts are similar. Due to centralization, the scenario has indirect

positive impacts e.g. it is possible to make better use of the current best practice (e.g. Pärnu donation

experience), development activities and crisis plans can be coordinated better, there could occur an extra

savings from procurement (decrease in material costs as a larger amount is purchased at once).


8.3.4. Scenario 4: centralized (national) blood service with one blood centre

The aim of the scenario is to consolidate processing and testing into one blood centre to optimize the use

or resources (i.e. both donor blood and equipment). Scenario requires change in the legal status of blood

centres (public or other form but as one institution), but similar division is also possible in the current

system by making detailed cooperation agreements.

DESCRIPTION AND JUSTIFICATION OF SCENARIO

New division of responsibilities: one national blood service with one blood centre and two donor centres

(q.v. Figure 21).

Blood collection: one blood centre in Tallinn and two donor centres in Tartu and Pärnu, collected

blood will be daily transported to Tallinn. Mobile collections are organized from Tallinn and Tartu,

incl. into current locations of Pärnu and Ida-Viru from Tallinn.

Testing and processing: once centre in Tallinn.

Distribution: Tallinn blood centre and Tartu donor centre.


Pärnu blood centre

Tartu blood centre


Collecting

Testing

Processing

Distribution


Hospitals in North,


Pärnu hospital




Note: light gray lines show movement which will disappear compared to the today and dark grey indicate new movements.

Similarly to scenarios 2 and 3, processing, mobile collection and testing are consolidated, but in this

scenario the processing and testing is concentrated into one centre in order to more optimize the use of

resources. Blood processing is planned into Tallinn since the current PERH blood centre has sufficient

facilities and the largest number of users of blood products is situated in Tallinn.

Distribution of blood products would be done from Tartu donor centre in addition to Tallinn, as there

would be a supply of blood products stored in an intermediate depot. This ensures equal availability of

blood products in South Estonian district as the furthest district from Tallinn.


As it is one institution, it is easily possible to gather plasma leftovers and make one fractionation contract.

IMPACTS OF SCENARIO


number of collected donations remains the same;

production of platelets increases (estimation of 20%);

quality improves due to the improvements of quality management as main activities are

centralized;

if inactivation is introduced (not reasonable in four centres), safety of blood products improves

nation-wide;

availability remains the same, as Tartu has a supply of blood products.

Estimated financial impacts and investment need

In estimating financial impacts, the expenses of the expansion of Tallinn blood center (increase in staff,

new devices, etc) and the costs related to changes in the tasks of Tartu, Pärnu and Ida-Viru blood centres

were taken into consideration. External factors (inflation, increase in maintenance prices of equipment,

etc) have not been taken into account. Also, the costs associated with changing the current system into a

national system have not been taken into account, but only the costs arising from changes in division of

responsibilities.

Similarly to scenario 2, only the expenses which appear or disappear with the changes in division of

responsibilities were taken into account in the estimation. Possible revenues from unnecessary

equipment and avoided future investments in Tartu, Pärnu and Ida-Viru blood centres have not been

included in the calculations. The transition time of the new system is assumed 1 year and 9 months. The

assumptions made for calculations are shown in Annex 9.

Table 33. Changes in the total cost of blood services due to new division of responsibilities (thousand

Euros): scenario 4

2013 2014 2015 2016 2017 2018 2019 2020 TOTAL

Non-recurrent costs 210.7 58.4 269.1

.. re-location costs 62.7 58.4

121.1

..purchasing equipment 148.0

148.0

Recurrent costs 153.6 153.6 153.6 153.6 153.6 153.6 153.6 1 075.1

.. recruiting new employees

129.6 129.6 129.6 129.6 129.6 129.6 129.6 906.9

..maintenance of new equipment

1.7 1.7 1.7 1.7 1.7 1.7 1.7 11.8

..increase in transportation costs

22.3 22.3 22.3 22.3 22.3 22.3 22.3 156.3

TOTAL COSTS 210.7 212.0 153.6 153.6 153.6 153.6 153.6 153.6 1 344.2

Annual savings -93.4 ─373.5 ─373.5 ─373.5 ─373.5 ─373.5 ─373.5 ─2 334.3

..decrease in salary costs

─81.3 ─325.1 ─325.1 ─325.1 ─325.1 ─325.1 ─325.1 ─2 031.7

.. decrease in maintenance and rental costs of equipment and facilities

─7.7 ─30.7 ─30.7 ─30.7 ─30.7 ─30.7 ─30.7 ─191.7

.. decrease in management costs

─4.4 ─17.7 ─17.7 ─17.7 ─17.7 ─17.7 ─17.7 ─110.9

TOTAL 210.7 118.6 ─219.9 ─219.9 ─219.9 ─219.9 ─219.9 ─219.9 ─990.1


According to the estimation, the changes in division of responsibilities will pay off in 3.5 years. After re-

arrangement, the annual savings would be 220 thousand Euros and the operating costs of blood service

would be 6.84 million Euros by 2020. The initial investment of the scenario would be larger compared to

previous scenarios and therefore the payback period is longer. After 8 years, the savings resulting from

the changes would be 990 thousand Euros, and it should be considered as a conservative estimation, as

significant savings arising from losing the investment needs in three blood centres are not included in the

estimation.

Table 34. Forecast of operating costs of Estonian blood service (thousand Euros): scenario 4

2013 2014 2015 2016 2017 2018 2019 2020

Scenario 1: current division of

responsibilities

6 076 6 208 6 343 6 480 6 620 6 764 6 910 7 060

Scenario 2/3: consolidated

processing and testing 6 138 6 130 6 179 6 317 6 457 6 601 6 747 6 897

Scenario 4: centralized system 6 287 6 327 6 123 6 260 6 401 6 544 6 691 6 840

Compared to current division of responsibilities, scenario 4 is more cost-effective as it enables savings, the

amount of collected blood does not decrease and prerequisites for raising quality of products are created.

On the eight years, total savings in current scenario are similar to savings in scenarios 2 and 3, but after

the ninth years the total savings will be higher. Similar financial impact on the eighth year comes partially

from the fact that, in this scenario, the amount of staff is decreased in Tartu blood centre, but labour

productivity is highest currently in Tartu – thus there is no remarkable extra savings in operating costs. It

should again be emphasized that the calculations do not take into account the savings from future

investments, which should be the highest in this scenario due to centralization of main activities. There

can be indirect positive effects due to the formation of the coordination and planning role (e.g. more

optimal processing and distribution).

Possible negative impacts:

No backup for processing and testing i.e. if there is an unexpected situation, where processing or

testing is disturbed in Tallinn, all Estonian hospitals will be affected since there are no

alternatives.

8.3.5. Sensitivity analysis of the financial impacts of the scenarios

A sensitivity analysis was conducted to estimate the sensitivity of financial impact in different scenarios.

The aim was to test how assumptions made in scenarios affect total savings and payback period. So-called

negative events included in the sensitivity analysis i.e. test on what would happen to the payback period

and total savings, if certain costs would be larger than assumed. As staff-related costs are the main cost

component of financial impact, several observed cases are related to the assumptions made for staff.

The sensitivity of five assumptions was analyzed:

1. Tallinn blood centre needs 30% more staff than assumed (according to scenarios 1.8 and 3.9

positions more);

2. Pärnu blood centre needs 30% more staff than assumed (1.5 positions more);


3. Tartu blood centre needs 30% more staff than assumed (6.3 positions more, only in scenario 4)

4. Non-recurrent costs (including initial investment) are twice as large as assumed;

5. Transportation costs are twice as large as assumed.

Taking the assumptions in scenarios 2 and 3 under observation, the impact of assumptions tested in

sensitivity analysis remains between 88-126 thousand Euros for total savings, and between 0.2-0.7 years

for payback period (q.v. table 35). The largest negative impact on the total savings would occur if Tallinn

blood centre would require 30% more staff than assumed, as the annual cost would be the largest

compared to other cases. Payback period will be longest, if initial investment would double – it would be

2.4 years.

Table 35. Sensitivity analysis of financial impact of division of responsibilities – scenarios 2 and 3

Changes in assumptions Total savings

by 2020

Impact to

total savings

Payback

period

Impact to

payback

period

Current assumptions ─997 1.8

1: Tallinn needs 30% more staff ─871 126 2.0 0.3

2: Pärnu needs 30% more staff ─901 96 1.9 0.2

4: Initial investment 100% more ─909 88 2.4 0.7

5: Increase in transportation cost 100% more ─907 90 1.9 0.2

In scenario 4, the largest negative impact on total savings would be in a situation, where Tartu blood

centre would need more employees than assumed. This assumption would halve the total saving. The

largest negative effect on payback period would be if the initial investment would double. The impact of

different assumptions on total savings is between 89-556 thousand Euros and 0.1-1.3 years on the

payback period.

Table 36. Sensitivity analysis of financial impact of division of responsibilities – scenario 4

Changes in assumptions Total savings

by 2020

Impact on

total savings

Payback

period

Impact on

payback

period

Current assumptions ─990 3.5

1: Tallinn needs 30% more staff ─718 272 4.0 0.5

2: Pärnu needs 30% more staff ─901 89 3.6 0.1

3: Tartu needs 30% more staff ─434 556 4.7 1.2

4: Initial investment 100% more ─721 269 4.8 1.3

5: Increase in transportation cost 100% more ─834 156 3.8 0.3

In conclusion, the impact of analyzed cases is similar by scenarios. In the case of a central blood service

(scenario 4), the total savings in the sensitivity analysis are 9-56% smaller and the payback period 2-36%

longer. Therefore, in the most negative situation, the total savings would be 434 thousand Euros by 2020

and the payback period 4.8 years instead of the estimated 990 thousand Euros and 3.5 years. In scenarios

2 and 3, total savings decreased 9-13% and the payback period prolonged 10-38% in the sensitivity

analysis. From the analysed cases, in the most negative case, the total savings would be 871 thousand

Euros by 2020 and the payback period would be 2.4 years instead of the estimated 997 thousand Euros

and 1.8 years.


CONCLUSION

The main goal of the blood service is to ensure sufficient blood supply based on donors in the country and

considering the safety of blood products. The goal of this analysis is to offer the most optimal nationwide

model for donation development and self-supplying with blood products in Estonia from the aspect of

cost-effectiveness, which would be based on the current system and consider possible future

developments. Cost-effectiveness of blood service in this analysis means a situation where more products

with better quality can be provided with the same costs or the same amount and same quality products

with less costs.

In the analysis, different data sources are used: scientific literature and previous reports, legislation

regulating blood service and other relevant documentation, interviews conducted with representatives

from blood centres, hospital blood banks, State Agency of Medicines, Estonian Health Insurance Fund etc

(15 specialists were involved in the research via interviews) and statistical data (main sources: TAI health

statistics and research database and Estonian Health Insurance Fund data). Several calculations were

based on the data to describe and analyze the efficiency of Estonian blood service and, if possible,

comparisons were made with statistics from other countries. A separate analysis evaluated the financial

impact of scenarios for division of responsibilities and therefore the cost-effectiveness of the scenarios.

Evaluation to Estonian blood service

As a general evaluation it can be said, that Estonian blood service is based on a relatively stable base of

donors, there is a working chain of blood product movement and the safety of blood products is

ensured. A clear division of task and responsibility for ensuring daily orders has developed between

blood centres. The work of blood centres is efficient from the aspect of donor blood and resource use.

1. Donation

A critically needed level of donors is assured, meaning that the number of collected donations is

sufficient in normal situations, but there could be problems in special circumstances. Although the

number of donors has remained stable in the last few years, a risk factor is the circumstance that a third

of the donors are first-time donors, which causes extra costs on recruitment and ensuring safety. The

number of donors could decrease in the near future at the current age-specific structure, as a third of

Estonian donors are aged 18-24 and the proportion of youth will decrease in the population in the next

10-15 years according to population projections. A problematic part from the aspect of donation

development and blood product safety is the lack of a central database of donors.

2. Use of blood products

Blood and blood products are used efficiently in Estonia, e.g. 9% of prepared erythrocyte doses are not

transfused in Estonia. In Estonia, a significantly larger number of plasma transfusions is performed

compared to other European countries (twice the amount per 1000 people than in Finland). The

continuous efficient use of blood products is necessary as the authors estimate a 15% increase in

erythrocytes demand, a 30% increase in platelets demand and 20% decrease in plasma demand by 2020.


The demand and supply of blood products is, in general, geographically balanced, but there occurs both

over and underproduction which can cause unnecessary competition between blood centres and the

expiration and discard of blood products. Blood products are available in normal situations, but there is

no preparedness for crisis situations. There is also no overview of product supplies on a state level.

3. Blood products safety

The quality of blood products prepared in Estonia is on a good European level and more tests than set in

minimal requirements are conducted in blood centres. Conducting supplementary analyses is justified due

to the wide spread of viral infections and this is also the basis for recommending the use of new health

technologies to ensure even more safety. Currently it is not possible to trace the blood movement from

donor to patient. In addition, the work of hospital blood banks should be more involved in the quality

management system.

4. Economic efficiency of blood service

Financing blood service, which is mainly based on the blood product prices, covers the operating costs

of blood centres, but not larger development actions. Product-based financing has ensured that blood

centres are economically efficient, e.g. the labour productivity is on a comparable level with the Finnish

blood service. Although, by centres, the unit cost differs, there is no increasing returns to scale, since half

of the blood centre costs are materials i.e. variable costs, and also due to product-based financing. Taking

into account investments (e.g. new devices), in addition to operating costs, it is clear that a larger

efficiency can be achieved with larger capacities due to optimal work load.

Problematic sides of the current system

Taking into account future developments and the limited health care budget of Estonia, from the aspect

of developing blood system and optimizing cost-effectiveness, the most important problems of the

current system are:

1. Lack of central planning and coordination of the blood service. The development of blood service

information system is left to four hospitals and depends on their financial capacity, which can affect

the quality of blood products and processing in case of a tight budget.

2. Decrease in the Estonian donor base, as there are a lot of first-time donors and youth, whose

proportion will decrease in the next 10 years.

3. Blood production and use of blood products is not regionally balanced, as over and underproduction

occurs and this can cause unnecessary competition.

4. The demand for platelets will increase by a third in the near future, according to estimation, thus the

use of donor blood should be optimized.

5. Plasma use in Estonia is uneven and exceeds the general level of Europe, plasma leftovers can be

sent to fractionation.

6. Unused production capacities in blood centres.

7. Estonian epidemiological situation (more dangerous than in neighbouring countries) raises the need

for systematic and supplementary investments in product safety.

8. Current financing mechanism does not support development activities and causes unnecessary

stimuli for competition.


9. Lack of development in the blood service informational system. Hospital blood banks and blood

transfusion are not involved in the information system, thus there is no overview of donors and

supplies and no possibilities to trace the process from donor to patient.

10. Lack of preparations for actions in crisis situations.

Recommendations

Critical needs vital to be implemented or which need decisions:

1. A donor policy needs to be developed for donation developments, and sufficient financial

resources should be ensured for involving current donors and raising awareness among the

population.

2. The blood information system needs to be centralized, reflecting donations, test results, prepared

blood components of every donor and possible adverse effects. All hospital blood banks should be

included in the system; financial resources should be ensured for funding the development.

3. A combined financing system should be implemented for financing the blood service, which

involves elements of product-based financing and base-financing; activities related to blood service

development (developing donation and information system, trainings, quality management) are

financed by base-financing, processing by blood prices.

4. Selling blood plasma to fractionation — due to the additional income from selling plasma leftovers,

the price-calculation of blood products should be adjusted. A separate discussion should be held

over the use of revenues from plasma sales – whether the decision should be made by the blood

centre (or hospital) preparing the plasma or should general interest be taken into account.

Recommendations to consider in developing blood service:

7. Information regarding blood centres, blood donation sites and donation should be gathered into

one website to develop a shared image and donation in general.

8. A central coordinator/planner should be agreed on. Presuming that the division of responsibilities in

blood centres does not significantly change, the creation of a blood service specialist at the Ministry

of Social Affairs should be considered. The specialist would work on coordinating the work of blood

centres, promoting donation, developing blood service information system, planning the demand of

products on a state level and finding solutions in areas in need of development.

9. In order to expand mobile collection visits into places currently not suitable for blood collection, and

to be prepared for a crisis situation, the purchase of special vehicles adapted for blood collection

should be considered.

10. Taking into account the wider spread of viral infections in Estonia compared to other European

countries, financing inactivated products should be considered.

Future scenarios of Estonian blood service

Four scenarios are offered considering future developments in Estonian blood service, which all focus on

possible models of division of responsibilities, but differ in the level of cooperation or consolidation.


Scenario 1 states maintaining the current division of responsibilities, which means collecting blood in

four centres (including mobile collection), testing and processing divided mainly to two centres and

partially to other two. This division does not ensure the completely optimal use of blood and the quality

of products can differ by centres if any of the centres implements new technologies. Estimated operating

costs are 7.06 million Euros by 2020.

Scenario 2 describes a division of consolidated processing and testing, according to which the collection

is done in three centres, mobile collection is organized from two and the testing, processing and

distribution are consolidated into two centres. No significant changes in the amount of collected blood or

availability of products could be presumed, but the production of platelets and quality of products might

increase due to the centralized main activities and improvements in quality management. The costs

occurring due to changes in division of responsibilities would be covered in 1.75 years, the savings from a

perspective of 8 years is 997 thousand Euros and the operating costs would be 6.90 million Euros by 2020.

Scenario 3 describes a public blood service with two main centres, which similarly to the previous

scenario would concentrate the collection into three centres, mobile collection is organized from two and

the testing, processing and distribution are into two centres. As the division is similar to scenario 2, the

assumptions about the amount and quality are similar, but there could be positive additional effects due

to the centralized management e.g. a better use of the current best practice, easier implementation of

necessary developments, extra savings on central purchases etc.

Scenario 4 describes a public blood service with one main centre, according to which, collection is done

in three centres, mobile collection is organized from two, testing and processing in one and distribution

from two centres. Described changes do not cause any significant changes in the amount and availability

of products, but the production of platelets and quality of products may increase. According to

estimation, the costs of changes are covered in 3.5 years, in a perspective of eight years, the savings are

990 thousand Euros and the operating costs would be 6.84 million Euros by 2020. There could also be

positive additional effects due to centralized management.

In conclusion, scenarios 2, 3 and 4 are more cost-effective compared to the current division of

responsibilities. Scenarios cause savings, there are no changes in the amount of collected blood and

quality of products may increase. The economic efficiency of the re-arrangements is even higher

considering additional savings due to reduced future investment needs. Scenario 4 has a longer payback

period compared to scenarios 2 and 3, due to a larger initial investment, but after eight years, the total

savings of operating costs is larger. The scenario also provides larger savings from reduced future

investments. Sensitivity analysis of financial impacts shows that, from the observed cases describing

larger costs than assumed in scenarios, in the most negative case the payback period is not significantly

longer than in base case (payback period was 0.6 years and 1.3 years longer accordingly by scenarios 2/3

and 4).


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Sotsiaalministri määrus, avaldatud RTL 2006, 2, 23

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http://www.kliinikum.ee/images/stories/tutvustus/tegevusaruanded/Sihtasutuse_Tartu_Ylikooli_Kliinikum_2010a_tegevusaruanne.pdf

http://www.kliinikum.ee/verekeskus/attachments/010_Verepreparaatide_kasutamise_kord_ver_2.pdf

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http://pxweb.tai.ee/esf/pxweb2008/dialog/statfile2.asp

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http://www.edqm.eu/medias/fichiers/The_Collection_Testing_and_Use_of_Blood_and_Blood_3.pdf

http://www.edqm.eu/medias/fichiers/The_Collection_Testing_and_Use_of_Blood_and_Blood_3.pdf

http://www.edqm.eu/medias/fichiers/Trends_and_Observations_on_the_Collection_Testing_.pdf


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published RTL 2005, 111, 1712

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http://www.euro.who.int/en/what-we-do/health-topics/Health-systems/blood-safety/news/news/2012/06/rising-blood-donation-rates-in-europe


ANNEXES

Annex 1. Number of blood centre employees and filled positions

PERH

blood centre

Tartu

blood centre

Pärnu blood

centre

Ida-Viru

blood centre Total

2010 2011 2010 2011 2010 2011 2010 2011 2010 2011

Full-time employees

Total 82 84 32 32 15 15 9 9 138 140

Doctors 15 14 5 5 3 3 2 2 25 24

Nurses 26 29 7 7 8 8 7 7 48 51

Lab-technicians 12 11 11 11 0 0 0 0 23 22

Registrar, operator 20 19 5 5 1 1 0 0 26 25

Others 9 11 4 4 3 3 0 0 16 18

Filled positions

Total 76.8 79.6 29 29.8 15 15 7.25 7.5 128.05 131.8

Doctors 14 13.5 5 5 3 3 2 2 24 23.5

Nurses 24.3 25.6 5.75 6.5 8 8 5.25 5.5 43.3 45.6

Lab-technicians 11 10.5 10.5 10.5 0 0 0 21.5 21

Registrar, operator 18.5 19 4.75 4.75 1 1 0 0 24.25 24.75

Others 9 11 3 3 3 3 0 0 15 17

Filled positions

Total 100% 100% 100% 100% 100% 100% 100% 100%

Doctors 18% 17% 17% 17% 20% 20% 28% 27%

Nurses 32% 32% 20% 22% 53% 53% 72% 73%

Lab-technicians 14% 13% 36% 35% 0% 0% 0% 0%

Registrar, operator 24% 24% 16% 16% 7% 7% 0% 0%

Others 12% 14% 10% 10% 20% 20% 0% 0%



Annex 2. Compensating immunohematological testing in stationary and daily treatment, blood products

and plasma preparations by Estonian Health Insurance Fund by healthcare institutions, 2011

Amount of use

Immuno-hematological testing

Blood products Plasma products

Regional hospitals 135 414 52 730 26 571

North Estonia Medical Centre 81 231 25 806 11 036

Tartu University Hospital 50 416 25 940 9 955

Tallinn Children’s Hospital 3 767 984 5 580

Central hospitals 83 414 20 151 8 106

East Tallinn Central Hospital 43 379 8 474 3 220

West Tallinn Central Hospital 15 815 3 902 2 409

Pärnu Hospital 12 146 3 806 233

Ida-Viru Central Hospital 12 074 3 969 2 244

General and local hospitals 31 180 11 602 515

Rakvere Hospital 6 243 1 920 51

Narva Hospital 5 232 2 836 195

Kuressaare Hospital 4 007 1 091 1

Valga Hospital 3 550 1 017 11

Viljandi Hospital 2 991 1 153 11

South Estonia Hospital 2 190 998 10

Põlva Hospital 1 477 522 70

Rapla County Hospital 1 465 271 37

Lääne County Hospital 1 321 600 94

Järva County Hospital 1 303 644 25

Jõgeva Hospital 1 217 418 10

Hiiumaa Hospital 184 132

Other 2 891 1 177 2

TOTAL 252 899 85 660 35 195



Annex 3. Number of donors in counties and proportion of donors in population by county

Number of donors in county

2005 2006 2007 2008 2009 2010 2011

Harju county 11764 12122 13049 12664 12683 13200 13039

Hiiu county 322 317 360 335 350 341 334

Ida-Viru county 2204 2053 2233 2212 2405 2236 2137

Jõgeva county 893 799 854 817 833 861 901

Järva county 1006 953 927 992 1053 1171 1206

Lääne county 692 628 847 756 765 769 857

Lääne-Viru county 1628 1567 1621 1653 1939 1945 2101

Põlva county 615 549 589 581 607 669 680

Pärnu county 3340 3418 3686 3696 3845 4040 4076

Rapla county 1149 1023 984 1058 1192 1191 1191

Saare county 1043 816 874 987 1171 1090 1141

Tartu county 5735 5904 6086 6197 6259 6404 6432

Valga county 732 667 646 567 576 643 669

Viljandi county 1390 1219 1189 1180 1289 1251 1149

Võru county 694 630 620 597 739 818 798

TOTAL 33207 32665 34565 34292 35706 36629 36711

Proportion of donors in population of county

2005 2006 2007 2008 2009 2010 2011 Change 2005/2011

Harju county 2.3% 2.3% 2.5% 2.4% 2.4% 2.5% 2.5% 0.2%

Hiiu county 3.1% 3.1% 3.5% 3.3% 3.5% 3.4% 3.3% 0.2%

Ida-Viru county 1.3% 1.2% 1.3% 1.3% 1.4% 1.3% 1.3% 0.0%

Jõgeva county 2.4% 2.1% 2.3% 2.2% 2.3% 2.3% 2.5% 0.1%

Järva county 2.6% 2.6% 2.6% 2.7% 2.9% 3.2% 3.4% 0.7%

Lääne county 2.5% 2.3% 3.1% 2.7% 2.8% 2.8% 3.1% 0.7%

Lääne-Viru county 2.4% 2.3% 2.4% 2.5% 2.9% 2.9% 3.1% 0.7%

Põlva county 1.9% 1.7% 1.9% 1.9% 2.0% 2.2% 2.2% 0.3%

Pärnu county 3.7% 3.8% 4.2% 4.2% 4.3% 4.6% 4.6% 0.9%

Rapla county 3.1% 2.8% 2.7% 2.9% 3.2% 3.3% 3.2% 0.1%

Saare county 3.0% 2.3% 2.5% 2.8% 3.4% 3.1% 3.3% 0.3%

Tartu county 3.9% 4.0% 4.1% 4.2% 4.2% 4.3% 4.3% 0.4%

Valga county 2.1% 1.9% 1.9% 1.7% 1.7% 1.9% 2.0% ─0.1%

Viljandi county 2.5% 2.2% 2.1% 2.1% 2.3% 2.3% 2.1% ─0.4%

Võru county 1.8% 1.6% 1.6% 1.6% 2.0% 2.2% 2.1% 0.3%

TOTAL 2.5% 2.4% 2.6% 2.6% 2.7% 2.7% 2.7% 0.3%

Source: extract from information system of blood centres, Estonian Statistics


Annex 4. List of healthcare services by Estonian Health Insurance Fund: blood products and procedures

with blood products (RT I, 22.12.2011, 42)

Code Title of blood product Unit Limit price

4001 Whole blood (1 dose 468–558 ml) One dose 70.61

4002 Erythrocyte suspension with low leucocytes content (1 dose 230–350 ml) One dose 52.76

4003 Erythrocyte suspension with low leucocytes content, paediatric dose (1 dose up to 150 ml)

One dose 49.52

4005 Washed erythrocyte suspension (1 dose 250–350 ml) One dose 52.57

4006 Washed erythrocyte suspension, paediatric dose (1 dose up to 100 ml) One dose 88.34

4011 Blood plasma One dose 32.83

4013 Blood plasma, paediatric dose (1 dose up to 120 ml) One dose 37.89

4016 One donor aphaeresis platelets concentrate, platelets content 150–300×109 One dose 222.89

4017 Cryoprecipitate (70–150 TÜ/dose) One dose 66.2

4018 4 BC platelets concentrate, platelets content 180–340×109 One dose 113.72

4019 3 BC platelets concentrate, platelets content 150–250×109 One dose 86

4020 Decreased capacity 4 BC platelets concentrate One dose 151.24

4021 1 BC platelets concentrate 45–85×109 One dose 58

4022 Divided red blood cells unit One dose 131.52

4051 Sol. Albumini 1 gram 2.1

4060 Decreased capacity aphaeresis platelets concentrate, paediatric, platelets content 150–300×10

9

One dose 227.6

4064 Aphaeresis platelets concentrate, paediatric, platelets content 45–85×109 One dose 136.83

4065 Erythrocyte suspension with low leucocytes content (1 dose 230–350 ml), filtered One dose 80.86

4066 Erythrocyte suspension with low leucocytes content, paediatric dose (1 dose up to 150 ml), filtrated

One dose 66.47

4068 Washed erythrocyte suspension (1 dose 230–300 ml), filtrated One dose 96.05

4069 Washed erythrocyte suspension, paediatric dose (1 dose up to 100 ml), filtrated One dose 94.68

4073 4 BC platelets concentrate, platelets content 180–340×109, filtrated One dose 128.91

4074 3 BC platelets concentrate, platelets content 180–340×109, filtrated One dose 124.33

4075 Decreased capacity 4 BC platelets concentrate, paediatric, filtrated One dose 164.6

4081 VIII coagulation factor 500 activity units

164.89

4084 Dose containing 100 activity units of Willebrant factor One dose 51.45

4085 VIII coagulation factor ant-inhibitor-coagulant group 500 activity units

450.39

4086 Immunoglobulin 1 gram 52.66

4087 Irradiating blood products One dose 16.62

4088 Aphaeresis platelets concentrate, washed One dose 250.85

4089 Decreased capacity aphaeresis platelets concentrate, washed One dose 292.01

4090 Aphaeresis platelets concentrate, paediatric dose, washed One dose 79.31

4091 Recombinant activated VIII coagulation factor 1 milligram

839.48

4092 Aphaeresis erythrocytes One dose 84.04

4093 Human protrombin complex 500 activity units

301.27

4094 VII coagulation factor 100 activity units

41.27

4095 IX coagulation factor 100 activity units

54.05

Source: List of health care services

Note: codes in cursive are new compared to the previous list


Annex 5. Use of blood products and change in use by blood components

Use in doses Data collector 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Erythrocytes EHIF 35 959 43 119 44 900 44 382 46 478 47 962 48 463 51 509 51 232

Erythrocytes Ministry of Social Affairs

46 946 52 267 53 280 48 614 51 432 52 949 51 234 51 069 51 567 53 598

Platelets EHIF 3 134 3 646 4 337 4 856 5 551 5 418 5 461 5 584 5 840

Platelets Ministry of Social Affairs

3 308 3 946 4 600 4 674 5 415 6 037 5 899 5 691 5 416 6 259

Plasma EHIF 31 417 32 054 36 972 30 807 31 169 30 126 26 226 26 475 24 699

Plasma Ministry of Social Affairs

32 748 35 646 41 506 39 366 35 354 34 505 33 902 28 394 27 196 26 863

Annual change in use

Data collector 2003 2004 2005 2006 2007 2008 2009 2010 2011

Erythrocytes EHIF 20% 4% 5% 3% 1% 6% ─1%

Erythrocytes Ministry of Social Affairs 11% 2% ─9% 6% 3% ─3% 0% 1% 4%

Platelets EHIF 16% 19% 14% ─2% 1% 2% 5%

Platelets Ministry of Social Affairs 19% 17% 2% 16% 11% ─2% ─4% ─5% 16%

Plasma EHIF 2% 15% 1% ─3% ─13% 1% ─7%

Plasma Ministry of Social Affairs 9% 16% ─5% ─10% ─2% ─2% ─16% ─4% ─1%

Change in use Data collector Change in use 2011 vs 2002

Erythrocytes EHIF 42%

Erythrocytes Ministry of Social Affairs 14%

Platelets EHIF 86%

Platelets Ministry of Social Affairs 89%

Plasma EHIF ─21%

Plasma Ministry of Social Affairs ─18%

Source: Estonian Health Insurance Fund (EHIF), TAI health statistics and research database


Annex 6. Use of blood products by hospitals – number of doses and proportion in Estonia

Type of hospital 2008 2009 2010 2011 2008 2009 2010 2011

Erythrocytes TOTAL 47914 48485 51509 51232

Regional hospital 26691 27907 28879 29074 56% 58% 56% 57%

Central hospital 12883 12688 13625 13676 27% 26% 26% 27%

General and local hospital

7504 6930 8103 7618 16% 14% 16% 15%

Other 836 960 902 864 2% 2% 2% 2%

Platelets TOTAL 5430 5461 5584 5839




177 93 78 110 3% 2% 1% 2%

Other 9 25 25 20 0% 0% 0% 0%

Plasma TOTAL 29728 26226 26475 24699




4112 3734 4125 3867 14% 14% 16% 16%

Other 333 382 240 293 1% 1% 1% 1%



Annex 7. Use of blood products by counties – number of doses and proportion in Estonia

County 2008 2009 2010 2011 2008 2009 2010 2011 Per 1000 people, 2011

Erythrocytes TOTAL 47 914 48 485 51 509 51 232 100% 100% 100% 100%

Harju 24 146 24 442 24 604 25 970 50.4% 50.4% 47.8% 50.7% 49.0

Hiiu 81 41 34 68 0.2% 0.1% 0.1% 0.1% 6.8

Ida-Viru 3 461 3 669 4 269 4 022 7.2% 7.6% 8.3% 7.9% 24.1

Jõgeva 277 299 408 315 0.6% 0.6% 0.8% 0.6% 8.7

Järva 480 524 601 552 1.0% 1.1% 1.2% 1.1% 15.4

Lääne 477 434 361 470 1.0% 0.9% 0.7% 0.9% 17.3

Lääne-Viru 1 219 897 1 024 1 060 2.5% 1.9% 2.0% 2.1% 15.9

Põlva 395 445 487 448 0.8% 0.9% 0.9% 0.9% 14.6

Pärnu 2 705 2 352 2 838 2 600 5.6% 4.9% 5.5% 5.1% 29.5

Rapla 522 430 442 251 1.1% 0.9% 0.9% 0.5% 6.9

Saare 853 798 1 071 925 1.8% 1.6% 2.1% 1.8% 26.8

Tartu 11 163 12 104 13 135 12 432 23.3% 25.0% 25.5% 24.3% 82.4

Valga 487 498 674 699 1.0% 1.0% 1.3% 1.4% 20.7

Viljandi 802 799 695 718 1.7% 1.6% 1.3% 1.4% 13.0

Võru 846 753 866 699 1.8% 1.6% 1.7% 1.4% 18.7

Platelets Total 5 430 5 461 5 584 5 839 100% 100% 100% 100%

Harju 3 357 3 013 2 977 3 034 61.8% 55.2% 53.3% 52.0% 5.7

Hiiu 2 3 0.0% 0.0% 0.0% 0.1% 0.3

Ida-Viru 152 161 167 170 2.8% 2.9% 3.0% 2.9% 1.0

Jõgeva 2 2 2 0.0% 0.0% 0.0% 0.0% 0.1

Lääne 12 25 15 4 0.2% 0.5% 0.3% 0.1% 0.1

Lääne-Viru 56 12 35 18 1.0% 0.2% 0.6% 0.3% 0.3

Põlva 1 1 4 1 0.0% 0.0% 0.1% 0.0% 0.0

Pärnu 151 162 157 251 2.8% 3.0% 2.8% 4.3% 2.8

Rapla 3 8 4 0.1% 0.1% 0.1% 0.0% 0.0

Saare 3 0.0% 0.0% 0.0% 0.1% 0.1

Tartu 1 625 2 035 2 206 2 315 29.9% 37.3% 39.5% 39.6% 15.3

Valga 1 6 16 0.0% 0.0% 0.1% 0.3% 0.5

Viljandi 66 18 7 5 1.2% 0.3% 0.1% 0.1% 0.1

Võru 5 26 2 17 0.1% 0.5% 0.0% 0.3% 0.5

Plasma TOTAL 29 728 26 226 26 475 24 699 100% 100% 100% 100%

Harju 12 750 8 946 9 013 8 977 42.9% 34.1% 34.0% 36.3% 16.9

Hiiu 54 48 60 55 0.2% 0.2% 0.2% 0.2% 5.5

Ida-Viru 2 141 2 113 2 877 2 489 7.2% 8.1% 10.9% 10.1% 14.9

Jõgeva 78 60 47 101 0.3% 0.2% 0.2% 0.4% 2.8

Järva 118 146 160 92 0.4% 0.6% 0.6% 0.4% 2.6

Lääne 123 124 149 126 0.4% 0.5% 0.6% 0.5% 4.6

Lääne-Viru 1 260 989 995 842 4.2% 3.8% 3.8% 3.4% 12.6

Põlva 78 84 109 73 0.3% 0.3% 0.4% 0.3% 2.4

Pärnu 1 217 1 196 1 202 877 4.1% 4.6% 4.5% 3.6% 10.0

Rapla 68 59 78 20 0.2% 0.2% 0.3% 0.1% 0.5

Saare 215 225 236 162 0.7% 0.9% 0.9% 0.7% 4.7

Tartu 10 497 11 052 10 406 9 871 35.3% 42.1% 39.3% 40.0% 65.4

Valga 235 209 252 302 0.8% 0.8% 1.0% 1.2% 9.0

Viljandi 626 641 551 430 2.1% 2.4% 2.1% 1.7% 7.8

Võru 266 334 339 282 0.9% 1.3% 1.3% 1.1% 7.5

Source: Estonian Health Insurance Fund, Estonian Statistics


Annex 8. Compensated immunohematological tests used in stationary and daily treatment by Estonian

Health Insurance Fund, 2011

Code Title Number Sum

66400 Confirming identification of AB0 blood type and Rh(D) (AB0 type identified by direct and reverse reaction)

47 861 482 917

66401 Identifying AB0 blood type and Rh(D) (AB0 type identified by direct reaction)

21 315 155 600

66402 Identifying AB0-blood type in identifying patient or erytrhrocomponent check

65 805 67 121

66403 Erythrocytic antibodies testing with two erythrocytes 43 318 329 650

66404 Erythrocytic antibodies testing with three erythrocytes 4 773 40 809

66405 Erythrocytic antibodies typing on one panel 928 19 701

66406 Erythrocytic antibodies titration 68 1 323

66407 Identifying one antigen in other blood type systems 2 086 18 273

66408 Identifying Rh-fenotype 539 6 252

66409 Matching test (one cross-reaction) 63 779 449 642

66410 Complex analysis of newborn blood 1 505 14 990

66411 Direct Coombs test 834 5 680

66412 Differentiating direct Coombs test (typing or titration) 88 1 357

TOTAL 252 899 1 593 315


Note: prices of 2011 are the basis of calculating the sum.


Annex 9. Methodology

ANALYSIS OF EFFICIENCY OF DONOR BLOOD USE

Data sources used in the analysis:

Collected blood (in blood centre) – TAI database, table VK1: donors and number of donations; an

average of 2 doses is expected from a procedure of aphaeresis erythrocytes;

Prepared blood products (in blood centre) – TAI database, table VK5: components prepared in

blood centre;

Issued blood products (from blood centre) – annual report of blood centres: issued blood

components and use;

Transfused blood products (in hospital) – TAI database VK2: use of blood, blood components and

preparations;

Compensated blood products (to hospital) – Estonian Health Insurance Fund.

Paediatric doses are included with weights of 0.5 in calculations.

Table. Efficiency of blood and blood products use, average of 2010/2011

Blood component Processing Issuing Hospital orders

Transfusion Compensation

Chain index (amount compared to previous stage)

Erythrocytes 100% ─3.5% ─1.7% ─3.8% ─1.6%

BC platelets 100% ─8.6% ─8.9% ─1.4% 1.0%

Aphaeresis platelets 100% ─1.6% 2.6% ─3.4% ─13.0%

Plasma 100% ─8.9% ─7.8% ─1.8% ─5.3%

Base index (amount compared to processing)

Erythrocytes 100% ─3.5% ─5.1% ─8.7% ─10.2%

BC platelets 100% ─8.6% ─16.7% ─17.9% ─17.1%

Aphaeresis platelets 100% ─1.6% 1.0% ─2.5% ─15.2%

Plasma 100% ─8.9% ─16.0% ─17.5% ─21.9%

Differences in data submitters should be emphasized – data about processing and issuing is submitted by

blood centres, hospitals submit data about transfusions and this can cause certain differences. For

example, number of issued blood products submitted by blood centres does not equal the number of

blood products received from blood centres submitted by hospitals – the difference is 2─9% by blood

component. According to the data submitted by hospitals on received and used blood components, the

loss of blood components in the transfusion stage is only 1─4% (2010/2011 average).

ANALYSIS OF BLOOD CENTRE EQUIPMENT

Analysis of equipment is based on the lists of equipment provided by blood centres, where the number of

equipment and year of purchase were analyzed.


Number and selection of equipment partially depends on production capacities (e.g. number of freezers),

but mostly on the selection of prepared products. According to the comparison of the lists of equipment,

60% of equipment belongs to PERH, 20% to Tartu, 16% to Pärnu and only 7% to Ida-Viru blood centre.

Different capacities of equipment should also be taken into account – e.g. freezers can be with different

sizes. Tartu blood centre has their own freezing chamber, which decreases their need for freezers. Using

services also affects the number of equipment, e.g. Tartu blood centre uses the services of Tartu

University Hospital laboratory for testing blood, thus some of the equipment is not reflected in the

centre’s equipment list, while PERH blood centre conducts the test at site.

ANALYSIS OF BLOOD CENTRE OPERATING COSTS

Blood centre operating costs were divided into five groups:

staff – salaries and compensations, training and missions;

facilities – amortization and repairs, communal and maintenance costs, rental costs;

equipment – amortization and maintenance;

medical materials – pharmaceutical merchandise and medical materials, purchased medical

services;

other costs – amortization and maintenance of other main assets; bureau costs, communication

costs, IT costs, purchase of non-medical services, economic supplies, work clothing and

maintenance, donor costs (souvenirs, food), other work costs (membership fees, indemnifications

etc), allocations from general costs of hospitals, sales tax.

ASSUMPTIONS MADE IN CALCULATING FINANCIAL IMPACTS OF SCENARIOS OF BLOOD SERVICE

DIVISION OF RESPONSIBILITIES

Scenario 2: consolidated processing and testing

Starting point: number of whole blood donations in PERH blood centre increases 9400 doses (30%); more

resources are needed (vehicles for mobile collections/equipment/staff), if current capacity is insufficient.

Number of mobile collection visits increases from 250 to 459 (84%), mobile collection sites from 99 to

166.

Additional costs resulting from changes in division of responsibilities:

Increase in PERH blood centre staff: +6 positions;

The need for new equipment in PERH blood centre: 2 separators; there is sufficient free capacity

for other equipment;

Increase in PERH blood centre equipment maintenance costs;

Increase in PERH blood centre transportation costs: mobile collection visits to Pärnu and Ida-Viru

districts, daily transportation of collected blood from Pärnu donor point;

Re-arrangement costs: managing changes (project management e.g. planning logistics, recruiting

people, changing contracts etc, covers also other smaller costs) — 3 people in three centres;

redundancy costs of 1 month.


Savings resulting from changes in division of responsibilities:

Decrease in staff costs in Pärnu and Ida-Viru blood centres, total of 17.5 positions: Pärnu keeps 5

positions for blood collection (currently in average 4 donors visit centre per hour);

Decrease in costs on equipment, facilities, maintenance and repairs in Pärnu and Ida-Viru blood

centres;

Decrease in bureau and management costs in Pärnu and Ida-Viru blood centres: costs related to

doubling work by centres (IT costs, office supplies, furniture etc).

Other assumptions:

Transition period 1 year and 3 months, in 1st year necessary equipment is purchased and new

staff is recruited in PERH blood centre, new staff starts working in 2nd year, re-arrangements in

Pärnu and Ida-Viru blood centres end in 2nd quarter of year 2, therefore double costs on staff,

maintenance and management occur for three months.

Redundant equipment in Pärnu and Ida-Viru blood centre is morally aged and has no sales value.

Thus, savings are potentially underestimated. As an exception, purchase costs of freezers for

PERH is not included in calculations as the Pärnu and Ida-Viru freezers can be used.

Costs avoided in the future are not taken into account, e.g. savings from not renewing equipment

and facilities and not developing Pärnu and Ida-Viru blood centres (EVI etc). Thus savings are

potentially underestimated.

Impacts outside of blood service are not taken into account. For example, increase in Pärnu, Ida-

Viru and Narva hospital transportation costs as blood will be ordered from Tallinn. However, the

costs might not be different from current costs, as blood is transported into Tartu for testing and

other hospital blood banks often join blood orders with hospital’s regular transportation

(transporting patients into district hospitals). It may be possible to join orders for Pärnu hospital

with everyday blood transportation to the Tallinn. Secondly, effects on joint laboratory of Tartu

University Hospital are not taken into account - the number of services will decrease, but on the

other hand, savings for blood service increase.

Scenario 4: public centralized blood service

Starting point: the number of whole blood donations in Tallinn blood centre increases 26 000 doses (85%);

more resources are needed (vehicles for mobile collections/equipment/staff), if current capacity is

insufficient.

Additional costs resulting from changes in division of responsibilities:

Increase in Tallinn blood centre staff: +13 positions.

The need for new equipment in Tallinn blood centre: 6 separators, 1 analyzer, 1 vehicle; there is

sufficient free capacity for other equipment. Some work processes can be re-arranged into two

shifts.

Increase in Tallinn blood centre equipment maintenance costs.

Increase in Tallinn blood centre transportation costs: mobile collection visits to Pärnu and Ida-

Viru district, daily transportation of collected blood from Pärnu and Tartu. Re-arrangement costs:

management changes (project management e.g. planning logistics, recruiting people, changing


contracts etc, covers also other smaller costs) — 3 people in Pärnu, Ida-Viru and Tartu, 2 people

in Tallinn; redundancy costs of 1 month.

Savings resulting from changes in division of responsibilities:

Decrease in staff costs in Pärnu, Ida-Viru and Tartu blood centres, total of 26.25 positions: Pärnu

keeps 5 positions for blood collection (currently 4 donors on average visit the centre per hour),

Tartu keeps 21 positions for blood collection (and mobile collection), hospital blood bank and

blood product distribution (currently 5 donors on average visit centre per hour);

Decrease in costs on equipment, facilities, maintenance and repairs in Pärnu, Ida-Viru and Tartu

blood centres;

Decrease in bureau- and management costs in Pärnu, Ida-Viru and Tartu blood centres: costs

related to doubling work by centres (IT costs, office supplies, furniture etc).

Other assumptions:

Transition period 1 year and 9 months, in 1st year necessary equipment is purchased and new

staff is recruited in PERH blood centre, new staff starts working in 2nd year, re-arrangements in

Pärnu, Ida-Viru and Tartu end in 4th quarter of year 2, therefore double costs on staff,

maintenance and management occur for nine months.

Redundant equipment in Pärnu, Ida-Viru and Tartu blood centre is morally aged and has no sales

value. Thus, savings are potentially underestimated. As an exception, purchase costs on freezers

for PERH is not included in calculations as the Pärnu, Ida-Viru and Tartu freezers can be used.

Costs avoided in the future are not taken into account, e.g. savings from not renewing and

developing Pärnu and Ida-Viru blood centres. Thus, savings are potentially underestimated.

Impacts outside of blood service are not taken into account (described at the previous scenario).

the analysis of cost-effectiveness of the optimal system of …...matra project2 was conducted by...

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