Musings on the blood business

Several recent papers got me to focus once again on transfusion medicine as a business instead of as a branch of medicine. Some musings:

1. The first paper is an editorial in the 25 Sept. issue of the Canadian Medical Association Journal featuring a systematic review in the same issue on the use of erythropoietin in critically ill patients.

• Hebert PC, Stanbrook M. Indication creep: physician beware. (editorial) CMAJ 2007;177(7): 697. (full free text:)

One finding of the review was that when the treatment (costing ~$400/dose) is used off-label for critically ill patients, it typically saves less than one unit of blood, does not improve clinical outcomes, and potentially results in more thrombotic complications.

The editorial authors note that, in the USA, erythropoietin manufacturers have aggressively promoted the drug via direct-to-consumer advertising and incentive payments to physicians. The editorial mentions that, while off-label use may lead to treatment innovations, they also create a loophole for drug manufacturers to bypass regulatory oversight designed to protect patients.

2. The second paper is in the November issue of Transfusion:

• Constantine MM, Thomas W, Whitman L, Kahwash E, Dolan ES, Smith S, Caudle CJ, Burton E, Anderson DR. Intravenous immunoglobulin utilization in the Canadian Atlantic provinces: a report of the Atlantic Collaborative Intravenous Immune Globulin Utilization Working Group. Transfusion 2007; 47 (11), 2072–80.

The authors present as background these facts:

• Since its introduction in the 1980s IVIG use has steadily increased (since 1990 at an average annual rate of 12.5 %).
• Off-label uses have grown significantly.
• In Canada there is no direct charge for individual patients or hospitals for IVIG: provincial governments are billed annually by Canada's two blood suppliers (CBS and H-Q) for blood products used the previous year.
• CBS convened a national conference in 2000 on IVIG utilization: a key recommendations was for provinces to develop utilization boards.
• BC was the first to develop a utilization board and their report on IVIG utilization suggested that approximately 50 percent of IVIG use was for off-label indications. Also see

• IVIG utilization management handbook. Vancouver: British Columbia Provincial Blood Coordinating Office; 2002.

3. The last of the recent articles is from the 25 Sept. issue of CMAJ. The title says it all, but the humorous piece is about an attempt to develop and market a drug for premature ejaculation; the sub-theme is disease mongering:

• Cassels A. W is for Wilbert's wee willy (which tends to go off prematurely). CMAJ 2007;177(7): 816. (full free text)

All of which harkens back to two other humourous yet serious articles featured earlier on TraQ (both are full free text):

• Sackett DL, Oxman AD. HARLOT, plc. An amalgamation of the world's two oldest professions. A new niche company specializing in How to Achieve positive Results without actually Lying to Overcome the Truth. Br Med J 2003; 327:1442-5.

• Oxman AD, Sackett DL, Chalmers I, Prescott TE. A surrealistic mega-analysis of redisorganization theories. J R Soc Med 2005 Dec; 98(12):563-8.

Hope you enjoy the articles and their underlying messages to us as health providers.

Cheers, Pat

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