The 2009 National Blood Collection and Utilization Survey Report

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The 2009 National Blood Collection andUtilization Survey Report

ISBN 978-1-56395-328-6



THE 2009 NATIONAL BLOOD COLLECTION AND UTILIZATION SURVEY REPORT

Table of Contents

List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

1. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Important Trends in the US Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Blood Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Blood Transfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Biovigilance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2. Key Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

New Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Interesting But Statistically Unchanged Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

3. Blood Collected and Processed in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Trends in Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Total WB/RBC Collections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Whole Blood Collections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6RBC Apheresis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Non-RBC Components Produced . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Platelets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Plasma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Cryoprecipitate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Granulocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

4. Blood Transfused in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Whole Blood and Red Blood Cells Transfused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Pediatric Transfusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Transfusion Recipients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Non-RBC Components Transfused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Platelet Dosage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Outdated Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ii Table of Contents




5. Component Modification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Leukocyte Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Transfusion of Modified Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

6. Current Issues in Blood Collection and Screening . . . . . . . . . . . . . . . . . . . . . . . . . .24

Donors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Donor Hemovigilance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

7. Current Issues in Blood Transfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

US Population Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Trends in Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Blood Inventories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Blood Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Bacterial Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Biovigilance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Crossmatch Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Red Cell Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Platelet Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

8. Component Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Red Blood Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Plasma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Whole-Blood-Derived Platelets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Apheresis Platelets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Cryoprecipitate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

9. Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

10. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

11. Appendix: Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Survey Instrument . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Sampling Frame. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Sample Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Data Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Response Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Sampling Weights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Variance Estimation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Imputation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Characterization of Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Limitations of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Table of Contents iii








1. Executive Summary

The Assistant Secretary forHealth, along with theDepartment of Health andHuman Services (DHHS)operating divisions [Centers for Disease Control andPrevention (CDC), Centersfor Medicare and MedicaidServices (CMS), Food andDrug Administration (FDA),and the National Institutesof Health (NIH)] sponsoredthe 2009 National BloodCollection and UtilizationSurvey (NBCUS), whichwas conducted under contract to AABB.

The DHHS 2009 NBCUScontinues to be the majormechanism for assessingblood collections and utilization in the United Statesand follows previousnational blood surveys conducted in 2007, 2005,2002, 2000, and 1998 forthe survey years 2008 (current), 2006, 2004, 2001,

1999, and 1997. Data fromearlier assessments conducted by the NationalHeart, Lung, and BloodInstitute and the Center forBlood Research are included where they are comparable to recent questions.

The objectives of the surveywere to generate nationalestimates for blood collection and utilization activities in the United States in2008; provide comparisonswith previous years; provide data for national biovigilance safety monitoring;and characterize businesspractices in the blood collection, transfusion medicine, and cellular therapiescommunities.

The facilities surveyedincluded all non-hospitalbased blood collection cen

ters (blood centers), a sample of hospitals from theAmerican Hospital Association (AHA) database, AABBmember hospitals not in theAHA database, and a sample of cord blood banks.Hospitals reporting fewerthan 100 inpatient surgeriesper year were not included.Hospitals with annual surgi

cal volumes between 100and 999 were stratified andrandomly sampled at a rateof 33.3%, while all hospitals reporting 1,000 or moresurgeries were included inthe sample.

The overall response ratefor the 2009 NBCUS was53.1% (1,660/3,129). Forblood centers the responserate was 93.3% (126/135);for hospitals, 51.5% (1,529/ 2,970); and for cord bloodbanks 20.8% (5/24). Statistical procedures were used toverify that the sample wasrepresentative of the studyuniverse and to developsample weights to producenational estimates. Resultsfrom the cellular therapiessurvey are presented in asupplement to this report.

Important Trends in theUS Blood Supply

The supply of availableWhole Blood (WB) and RedBlood Cell (RBC) units afteraccounting for infectiousdisease testing was17,159,000. This numberexceeds transfusions of

allogeneic WB/RBCs(14,855,000) by a margin of 2,304,000 units—13% of available supply. Thesehigh numbers of availablenon-transfused units indicate the beginning of a

Executive Summary 1




blood surplus, which maybe of a local nature, as13.2% of hospitals havereported some challengesto supply.

The blood supply was provided by 10,877,000 allogeneic donors whosuccessfully gave blood—3,165,000 (29%) of whomwere first-time donors and7,640,000 (71%) of whomwere donors who haddonated previously. Repeatdonors, as defined by the

reporting facility, provideda total of 11,461,000 donations, the equivalent of 1.5donations per donor. Theallogeneic blood collectionrate was 85.2 units perthousand population of donor age (16-64) in 2008compared to 84.1 units perthousand (donor age 18-64)in 2006. Donors aged 16

24 contributed 19% of theunits collected in 2008. Therate of donations in thepopulation aged 16-24 was84.8 units per thousandpersons in 2008, nearly ashigh as the rate for the eligible population overall.

The US WB/RBC allogeneictransfusion rate in 2008 was48.8 units per thousandpersons in the overall USpopulation; this was not asignificant change from the48.3 units per thousandpersons in 2006.

Blood Collection

The 2009 NBCUS estimatesthat a total of 17,286,000units were collected, an

increase of 6.9% over 2006total collections. Blood centers were responsible for thecollection of 16,212,000units or 93.8% of the supply; hospitals collected1,074,000 units or 6.2%.

RBC apheresis collections(allogeneic, includingdirected, and autologous,combined) accounted for1,926,000 units collected.This was an increase of 18.9% over RBC apheresiscollections in 2006 (Figure11).

Blood Transfusion

The total number of WB/ RBCs transfused in 2008equaled 15,014,000 units.This was not statistically different from overall utilization in 2006. However,there were significantlymore non-directed allogeneic units transfused,including pediatric transfusions expressed as adult

equivalents (p<0.05). Significantly fewer directedunits (intended for a specific patient) were transfused (73,000 unitscompared with 126,000units in 2006; p<0.05).

The total number of platelets transfused in 2008was 2,021,000 apheresisequivalent units, a statistically significant increase

of 16.7% (p<0.001). In achange from previousreports, platelets arereported as apheresisequivalent units [one apheresis platelet = five whole-blood-derived (WBD) platelet concentrates], reflectingthe predominant source of platelets in 2008. Apheresis platelets represent the

bulk of the increase (16.2%,p<0.001), while transfusion of WBD platelets alsoincreased but not significantly.

Biovigilance

The 2009 NBCUS alloweda second opportunity for an

evaluation of the baselineof adverse events associated with blood collectionand transfusion (both donorand recipient hemovigilance) in the United States.At the time data were collected for this survey, preparations were beingconcluded to pilot theHemovigilance Module of

the National HealthcareSafety Network (NHSN)and the Donor Hemovigilance System was beingdeveloped.

2 Executive Summary



0

3000

6000

9000

12000

15000

18000

2008

T h o u s a n d s o f U n i t s

0.9%

1.9% 5.6% 10.2%

11.3%

1999 2001 2004 2006 TraditionalAllogeneicCollections RBCApheresisCollections

Figure 11. Use of RBC apheresis technology.


An estimated total of adverse reaction rate procedures, a significant60,000 transfusion-related (events/total components increase (p<0.05) in theadverse reactions were transfused) was 0.25% reported adverse reactionreported for 2008, not sig compared to 0.26% in rates among donors fromnificantly different than 2006. 2006 (11,000 reactions;reported in 2006.* The 0.07% of procedures). This

increase may be an artifactApproximately 16,000of better reporting due tosevere adverse donor reac

*See text box on page 35 for enhanced focus on biovigitions were reported byexplanation of change in 2006 lance, rather than an actualblood collectors in 2008, adata. increase.rate of 0.09% of collection

Executive Summary 3




2. Key Findings

The results of the 2009 • The donation rate for pools of five or fewerNBCUS provide an update repeat donors was 1.5 concentrates.of US blood collection and donations per donor in • The transfusion of transfusion services and 2008, compared with apheresis plateletsrelated activities in the 1.7 donations per repeat increased significantly2008 survey year to the donor in 2006. in 2008 by 16%analyses made by the five • The rate of severe donor (p<0.001). The number

previous nationwide sur- reactions was 0.09% of WBD platelet con-veys conducted in 2007, (p<0.05). centrates transfused did2005, 2002, 2000, and • The WB/RBC collection not change when com-1998 (see references, page rate per thousand US pared with 2006 figures.47). Notable findings from donor population (aged • The total number of allthe 2009 NBCUS and com- 16-64) was 85.2 units components transfusedparisons with the 2007 sur- per thousand in 2008. in 2008 was 23,668,000,vey results are listed below. based on the use of an

apheresis platelet as theTransfusion basis for counting plate-

New Findings lets instead of the plate-• Allogeneic (non-

let concentratedirected) WB/RBC trans- equivalent used forCollection fusions increased signifi- counting platelets in

cantly by 5.8% (p = 2006 and previous There was a surplus of 0.023) in 2008 to 14.8 reports.2,043,000 available, million units; however, • Compared to 2006,test-negative, alloge- the total number of WB/ preparation of leuko-neic WB/RBC units col- RBC transfusions (15.0 cyte-reduced (LR) com-lected over those million units) remained ponents increased bytransfused in the United statistically unchanged. 9.2%.States in 2008 (12%). • The number of transfu- • The total number of This is a 67% increase

sions that were from transfused componentsover the surplus collections directed that were irradiatedreported in 2006 to a specific person increased by 14.8%(1,227,000). decreased significantly while the number of • Autologous collections to 73,000 units (p = transfused componentsdeclined significantly by 0.032; –42%). that were leukocyte24.5% to 253,000 units • WBD platelets were reduced increased by(p<0.001). transfused most often in 20.1%.

4 Key Findings




• A total of 62 hospitals(4.4%) reported postponing elective surgeryfor one or more daysdue to blood inventory

shortages. Comparisonof weighted data showsthat this affected 325patients nationwide,compared to 721 in2006 (p<0.001).

• The mean age of RBCunits at transfusion was18.2 days.

• The mean age of WBDplatelet units was 3.7

days at transfusion vs3.2 days for apheresisplatelet units, compared with 2.1 and 3.2days, respectively,reported in 2006.

• The average hospitalcost of a unit of leukocyte-reduced RBCsincreased significantlyby 5.5% to $223.09

between 2006 and2008. CMS covers

approximately 83% of this cost.

Interesting But

Statistically UnchangedFindings

Collection

• Total WB/RBC collections in 2008 increasedfrom 2006 by 6.9% to17.3 million units, butthe difference was notstatistically significant.

• Allogeneic collectionsremained statisticallythe same at 17.0 millionunits.

• The number of RBCapheresis units collectedwas 1.9 million.

• Of the 10,877,000 allogeneic donors who successfully gave blood in

2008, 29% were first-time donors and 71%were repeat donors;

0.6% were directeddonors.

• Test losses declined15.9% to 127,000 unitsfrom the 151,000 units

reported in 2006.

Transfusion

• The rate of adversetransfusion reactionsreported to hospitaltransfusion services was0.25%, the same as thecorrected rate from2006.*

• The rate of allogeneicWB/RBC transfusionsremained nearly thesame at 48.8 units perthousand overall USpopulation, comparedto 48.3 units per thousand persons in 2006.

*See text box on page 35 for explanation of change in 2006data.

Key Findings 5




3. Blood Collected and Processed

in the United States

Trends in Collection

Whole blood and RBC collections for the survey years1989 through 2008 are

illustrated in Figure 31.Total collections, whichdropped to a low of 12.6million units in 1997,reached a high of 17.3 million units reported in the2009 NBCUS for the year2008. New questionsaimed at better accountingfor RBC apheresis collections helped to add preci

sion to these collectionelements.

Autologous donations, Fig-ure 32, continue to declinesignificantly from 2006 to2008. Autologous collections included 253,000manual WB collections and8,000 RBC apheresis col

lections (included in theRBC apheresis totals), or1.5% of total collections.The practice of donating forthe use of a designatedpatient has also continuedto decline to a small frac

tion of overall collections,only 61,000 units in 2008.

Total WB/RBC

Collections

The total WBD and apheresis RBCs collected in theUnited States in 2008 were17,286,000 (±1,890,000)units, before laboratory testing (Table 31). Blood centers collected 16,212,000units, or 93.8% of the total.The remaining 1,074,000 ±243,000 units (6.2%) werecollected by hospitals.Compared to total collections from 2006, 2008 collections increased 6.9%.

The increase can be attributed to an 18.9% increasein RBC apheresis and a6.3% increase in manual

WB allogeneic (excludingdirected) collections, whichcollectively accounted for98.2% of total blood collections for 2008. The totalunits rejected on testingdecreased by 15.9% in2008 compared to 2006.

There were 17,159,000usable (available) units,99.3% of units collected.

Whole Blood Collections

Donations of WB in 2008totaled 15,361,000. Thesecollections, reportedaccording to the type of donation, are shown inTable 31. Communitydonations, excludingdirected donations,accounted for 98% of total

WB collections; directeddonations totaled 0.4%;and autologous donationscontributed 1.6%.

Allogeneic donations (nondirected) totaled15,047,000 (±1,659,000) of which 93.8% were collected by blood centers and

6.2% by hospitals. The percentage increase in allogeneic donations (nondirected) between 2006and 2008 was 6.3%, whichwas not statistically significant. Also not significantwas the 12.8% decline in

6 Blood Collected and Processed in the United States




20

18

6

4

2

1989 1992 1994 1997 1999 2001

Survey Year

2004 2006 2008

8

10

12

14

16

M i l l i o n s o f U n i t s

Total

Allogeneic

Autologous

0

Figure 31. Allogeneic, autologous, and total whole blood and red cell collections, 19892008.

Figure 32. Autologous and directed whole blood and red cell collections, 19892008.

0 200 400 600 800 1000 1200 1400 1600

1800 2000

1989 1992 1994 1997 1999 2001 2004 2006 2008

U n i t s i n

T h o u s a n d s

Autologous Directed

Blood Collected and Processed in the United States 7



8

B l o o d C o l l e c t e d a

n d P r o c e s s e d i n t h e U n i t e d S t a t e s

Table 3-1. Estimated 2008 Collection and Transfusion by US (50 States and DC) Blood Centers anBlood (WB) and Red Blood Cells (RBCs) (expressed in thousands of units)

Hospitals

ActivityBlood

Centers Total ±95% CI

2008CombinedTotal

% of TotalCollections/ Transfusions

Collections

WB Allogeneic (excluding directed) 14,120 927 224 15,047 87.0

WB Autologous 172 81 13 253* 1.5

WB Directed (fewer collected thantransfused)

35 26 8 61* 0.4

RBC Apheresis 1,884 41 22 1,926 11.1

Total Supply 16,212 1,074 243 17,286 100.0

Rejected on Testing 116 11 3 127 0.7

Available Supply 16,096 1,063 240 17,159 99.3

Transfusions

Allogeneic (excluding directed) 654 14,127 404 14,782*† 98.4

Autologous 5 154 25 159 1.1

Directed (to designated patient) 0 73 36 73* 0.5

Total Transfusions 660 14,355 411 15,014 100.0

Outdated WB/RBCs 219 228 20 447 2.7

*Significantly different from 2006 data.†Total includes pediatric transfusions.




directed allogeneic donations to 61,000 (±16,000)units. Of these, 36.9% wereeventually used as part of the community supply.

Autologous, or self-directedunits totaled 253,000(±41,000), a decrease of 24.5% compared to 2006(p<0.001). Hospitals collected 32% of all autologous units.

RBC Apheresis

In addition to WB collections, 1,926,000(±328,000) RBC units werecollected by apheresis.Most apheresis RBC collections yielded a double volume (ie, 2 units) of RBCs.RBC apheresis collectionsin 2008 increased by18.9%, which was not statistically significant in comparison to 2006, when1,619,000 RBC units werecollected. There were1,022,000 RBC apheresiscollection procedures.RBCs collected by apheresis constituted 11.3% of thetotal WB/RBC supply in2008 (Figure 11).

While 99.5% of the RBCapheresis collections wereallogeneic, non-directedunits, a small number of units collected by RBC apheresis were either for autologous use (8,000 units) or

directed for the use of aspecific patient (2,000units).

The growth of reported RBC

apheresis collectionsoccurred largely in bloodcenters that accounted for97.8% of such units. In2006, 118 blood centersand 33 hospitals reportedRBC apheresis collections.In 2008, 115 blood centersreported employing thistechnology, and 46 hospitals reported collecting

RBCs by apheresis. Amongthe institutions that reportedRBC apheresis collections(unweighted data), themean number of units collected by blood centers was15,188 (vs 12,419 in 2006)and by hospitals was 529(vs 284 in 2006). The minimum number of units collected by any facility

reporting apheresis collections was 4 and the maximum was 83,111.

Non-RBC ComponentsProduced

Non-RBC component unitscollected or processed

include apheresis platelets,plasma, and granulocytesas well as platelets, cryoprecipitate, and granulocytes from whole blood.The total number of non-RBC components produced for transfusion in

2008 was 11,152,000(WBD platelets counted asindividual concentrates, notas apheresis-equivalentunits).

Platelets

An estimated 1,352,000plateletpheresis procedureswere completed, yielding2,024,000 apheresis platelet components for an overall split rate of 1.5. Thenumber of products

increased 11% from 2006(Table 32). Blood centerscollected 94.1% of apheresis platelets while hospitalswere responsible for 5.9%.

Platelet concentrates werederived from 1,964,000units of WB, a decrease of 18% (p = 0.21) from the2006 volume (2,396,000units). Platelets were prepared from 13.9% of allallogeneic WB collected,down from the 16.9% (NS)from total whole blood collections in 2006. Bloodcenters produced1,789,000 units (91.1%)while hospitals produced175,000 (8.9%).

In 2008 the most commonnumber of platelet concentrates reported to be pooledtogether for transfusion was5 units. This is a changefrom past surveys (2006,2004, and 2001) where the

Blood Collected and Processed in the United States 9



1 0

B l o o d C o l l e c t e d

a n d P r o c e s s e d i n t h e U n i t e d S t a t e s

Table 3-2. Estimated 2008 Collection and Transfusion by US (50 States and DC) Blood Centers andBlood Cell (non-RBC) Components (expressed in thousands of units)

Activity Blood Centers

Hospitals

2008 Total 200Total ±95% CI

Components Collected/Produced

Apheresis Platelets 1,906 119 34 2,024 1,82

WBD Platelet Concentrates† 358 35 13 393 (1,964) 39

Total Platelets 2,263 154 37 2,417 2,22

Plasma‡ 5,305 395 85 5,700 5,68

Cryoprecipitate 1,425 37 18 1,462 1,19

Components Transfused

Apheresis Platelets 60 1,701 93 1,761* 1,51

WBD Platelet Concentrates† 38 222 46 260 (1,300) 21

Total Platelets 98 1,923 116 2,021* 1,73

Plasma‡ 222 4,263 231 4,484* 4,01

Cryoprecipitate 42 1,068 131 1,109 99

Non-WB/RBC Components Outdated 385 514 54 900 87

*Significantly different from 2006 data.†Apheresisequivalent units; numbers in parenthesis represent individual platelet concentrates produced from whole blood collections.‡Plasma for transfusion including apheresis and pediatric plasma.

WBD = wholebloodderived.






4. Blood Transfused in the United States

Whole Blood and RedBlood Cells Transfused

Transfusions of WB andRBCs of all donation typesincluding pediatric transfusions totaled 15,014,000

units. The number of allogeneic, non-directed unitstransfused was significantlygreater than that reportedin 2006 (p = 0.023; Table31). Whole blood transfusions accounted for 0.03%of total transfusions(approximately 5,000units). Allogeneic unitstransfused, includingdirected units and pediatricunits expressed as adult-equivalent units, accountedfor 98.9% of units transfused or 14,855,000 units.Of the available allogeneicunits, 87.9% were used inallogeneic transfusions,compared with 93.4% and95.5% in 2006 and 2004,respectively, suggesting anoversupply.

Autologous transfusionscontinued to decline, as hasbeen the trend in previoussurveys. There were 15.8%fewer units transfused

(159,000 units) than in2006, although this declinewas not statistically significant. The number of autologous units transfusedrepresented 62.9% of the253,000 units donated pre

operatively by patients in2008. Only a very smallnumber, approximately3,000 units (1.4% of theautologous units collected)were reported to have beencrossed over to the community supply in 2008, whilemore than one in threeunits were not used.

Directed donations, thedonation of allogeneicblood for a designatedpatient other than thedonor, accounted for73,000 units transfused; thiswas a significant decreasefrom the 126,000 reportedin 2006 (p = 0.032).Another 17,000 units werereported to have crossed

over to be transfused tonon-designated patients.Although the numberreported to have been collected was only 63,000(manual and apheresis collections combined), manyhospitals reported that they

were unable to retrospectively distinguish betweennon-directed and directedallogeneic units.

Pediatric Transfusions

There was a small increasein pediatric WB/RBC transfusions reported in 2008,7.3% more than in 2006(Table 41). This represents2.6% of all transfusedRBCs. Pediatric transfusions are included in thetotals reported in Table 31.In 2008, hospitals reported

the number of pediatrictransfusions of adult-equivalent units used in whole orin part by component type,for a total of 654,000 unitstransfused to the pediatricpopulation. Pediatric components transfused includedWB/RBCs (58.6%), platelets (26.0%), and plasma(15.4%).

Transfusion Recipients

The 2009 NBCUS capturedthe number of recipients of transfused RBCs of each

12 Blood Transfused in the United States




Table 4-1. Pediatric Transfusions by US (50 States and DC)Blood Centers and Hospitals in 2008 (expressed inthousands of units)

2008 2006 % ChangePediatric Transfusions Total Total 2006-2008

WB/RBCs 383 357 7.3%

Platelets 170 NA NA

Plasma 101 NA NA

NA = Pediatric component transfusions were not reported separately in the 2007

NBCUS.

donation type. Based onunweighted data, the reported number of recipientsof allogeneic RBC units was1,679,000 per 4,379,000units transfused by the 1,018facilities reporting numbersof recipients, or 2.6 unitsper recipient, a decrease

from 3.0 units per recipientper year. This may represent more than one transfusion episode per recipient.Autologous recipientsreceived an average of 1.4units per transfusion (1.6 in2006). Recipients of directedunits received an average of 1.7 units per transfusion in2008. Finally, for recipients

of pediatric RBC units, theratio was 2.0 units perrecipient, a decrease fromthe reported rate of 2.7 perrecipient in 2006.

Extrapolating the ratios of units per recipient popula

tion proportionally to thenumbers of WB/RBCs transfused yields a national estimate of 5.8 million totalWB/RBC recipients in2008. This represents a16% increase in the number of transfusion recipients in comparison with the

estimated 5.0 million recipients of 2006.

Non-RBC ComponentsTransfused

National estimates for non-RBC components transfusedin 2008 (including transfusions to pediatric patients)are presented in Table 32.

An estimated total of 2,021,000 platelet unitswere transfused to USpatients in 2008, anincrease of 16.7% in com

parison with 2006 (p =0.001; Figure 41). Thetransfusion of apheresisplatelets increased by16.2% from 1,515,000 to

1,761,000 units (p<0.001).

In this report, as describedin Chapter 4, platelets arereported using apheresisequivalents. For comparison with the transfusion of apheresis platelets, it isassumed that five WBDplatelet concentrates areequivalent to one unit of

apheresis platelets. Thus,the 1,300,000 units of WBD platelets are reportedas 260,000 apheresisequivalent units.

The decline in the transfusion of WBD platelet concentrates, first observed in1999, was actuallyreversed, albeit not signifi

cantly, between 2006 and2008, increasing 20.3%(p = 0.24), with 260,000apheresis-equivalent unitstransfused in 2008 compared with 216,000 fromthe 2006 survey. Althoughthere was no statistical difference between 2006 and2008 in platelet concentrates transfused, the trendtoward smaller pool size(average size is 5 or fewer)in 2008 allows morepatients to receive platelettransfusions using WBDplatelets than was indicatedby the number of transfused

Blood Transfused in the United States 13




940 1,003

1,2641,391

1,515

1,761

566506

436256

216

260

0

500

1000

1500

2000

2500

1997 1999 2001 2004 2006 2008

*expressed as apheresis doses

U n i t s T r a n s f u s e d ( i n t h o u s a n d s )

Apheresis platelets Whole-blood-derived platelet concentrates*

Figure 41. Trends in platelet transfusion, 19972008.

concentrate units. The ratioof apheresis concentrates toWBD platelet concentratesused has decreased slightlyfrom 2006 (7 apheresisunits: 1 pool of WBD concentrates) to 6.8:1 in 2008.The platelet dose calculation affects this ratio asexpected.

The combined total of WBD plasma and apheresis plasma resulted in4,484,000 units transfused,significantly more(p<0.001) than the numbertransfused in 2006(4,010,000 units). Report

ing institutions indicatedthe amounts of the varioustypes of plasma transfusedas shown in Figure 42. Theresults, for which overlap ispossible, are as follows:

• FFP represented only53.8% of plasma transfused (2,411,000 units).This is a significantly

smaller proportion(p<0.001) of all transfused plasma comparedwith 2006, when 77.2%of the plasma transfused was FFP(3,109,000 units).

• Transfusion of PF24increased significantly(p<0.001) to make up38.8% of the transfusedplasma in 2008,(1,742,000 units), compared with only 15.3%in 2006 (613,000 units).

• Jumbo plasmaaccounted for 1.1%(51,000 units) of plasma

transfused.• Cryoprecipitate-reducedplasma accounted for4.0% of the total plasmatransfused (180,000units), comparable inproportion and amount







Platelet Dosage

Institutions reporting platelet transfusions wererequested to indicate the

number of therapeuticdoses of each type of platelets. Hospitals reported thetransfusion of 1,399,000doses of plateletpheresisproducts and 195,000doses of WBD platelet concentrates (see Figure 43).Blood centers reported thetransfusion of 34,000plateletpheresis doses and

38,000 doses of WBDplatelet concentrates. In2008, the ratio of apheresisplatelet concentrate dosestransfused to WBD dosestransfused was 6.2:1, compared with 4.8:1 in 2006and 3.7:1 in 2004.

Facilities reporting WBDplatelet concentrate dosesindicated the most commondosage used in their institutions (Figure 44; n = 459).As compared to 2006, ahigher percentage of facilities reported five or fewerplatelet concentrates in adose. The use of five orfewer has increased overthe recent surveys. In 2008

this represented the majority of hospitals (47.5%). Thenext largest cohort reportedusing six (38.7%).

WholeͲbloodͲderived plateletdoses

233,000

Apheresis plateletdoses 1,433,000

Figure 43. Therapeutic platelet doses transfused in 2008.

Outdated Units

The national estimate forthe number of WB unitsand all component unitsoutdated by blood centersand hospitals in 2008 was1,346,000 units. Blood centers reported 44.9% of alloutdates. Allogeneic, non-directed RBC outdates weremore commonly reportedby blood centers over hospitals in 2008 (1.5:1), whilehospitals were responsible

autologous outdates (96.4%and 96.2%, respectively).This is reasonable considering that most blood centersdistribute the directed andautologous units to hospitals for specific patients.Most non-RBC components, with the exception of

WBD platelets, were outdated by hospitals. Plasma(FFP or PF24) and cryoprecipitate were least likely tobe outdated by blood centers.

for most of the directed and









DirectedWB/RBCs, 0.7%

AutologousWB/RBCs, 20.9%

Wholeblood (Allogeneic,

nonͲdirected),3.0%

Allogeneic (nonͲdirected) WB/RBCs,75.4%

Figure 45. WB/RBC outdates by collection type.

Outdated plasma totaled103,000 units, only 1.8% of the plasma units processed

for transfusion. The number of outdated cryoprecipitate units was 46,000, 3.1%of the cryoprecipitate processed.

Apheresis platelets, plasma,and cryoprecipitate combined accounted for 31.9%of all outdated units, 6%more than in 2006. Overall,

efficiency of utilization wasvery comparable to thatreported in 2006. The percentage of units processed

OͲnegative OͲpositive 3.0%

5.4%

Other 91.6%

or produced in 2008 thatoutdated (4.7%) was com- Figure 46. Percentage of allogeneic RBC outdates by bloodparable to that of 2006 group and type.(4.6%).

Blood Transfused in the United States 19





Table 5-1. Blood Components* Modified to Achieve Prestorage Leukocyte Reduction in All Facilities

C o m p o n e n t M o d i f i c a t i o n

2 1

2008 20

Blood ComponentLeukocyte-Reduced

Prestorage

Leukocyte-Reduced% of Total Available

ComponentsLeukocyte-Reduced

Prestorage

WB/RBCs

WBD Platelets

Other Component Units*

13,791,000

926,000

74,000

80.4

47.1

1.0

11,312,000

897,000

16,000

*Apheresis platelets not included in totals.WB = Whole Blood; RBCs = Red Blood Cells; WBD = wholebloodderived.

Table 5-2. Change in Number of Blood Components* Modified to Achieve Prestorage Leukocyte Redu2006 to 2008 (expressed in thousands of units)

Blood Centers Hospitals

Modification 2008 2006 % Change 2008 2006 % Change 20

Components leukocyte 14,196 11,906 19.2 595 319 86.5 14,reduced before storage(not at the bedside)

*Red cell/whole blood units, wholebloodderived platelets, other components including plasma, cryoprecipitate included (apheresis platelet






Table 5-4. Total Number of Irradiated and Leukocyte-Reduced Red Blood Cell (RBC) UnitsTransfused in 2008, Compared with RBC Units Transfused in 2006 (expressed in thousands ofunits)

Units

ChangeModification 2008 2006 2008-2006 % Change

Irradiated RBCs 1,502 1,153 349 30.3

Leukocytereduced RBCs, total 10,294 8,076 2,218 27.5

Before or after storage (not at the 10,115 7,886 2,229 28.3bedside)

At the bedside 179 190 –11 –5.8

16000

0

2000

4000

6000

8000

10000

12000

14000

U n i t s i n

T h o u s a n d s

RBCsModifiedbyLR PrestorageLRRBCUnitsTransfused IrradiatedRBCUnitsTransfused Leukofiltered(atBedside)RBCUnitsTransfused

1999 2001 2004 2006 2008

Figure 51. Transfusion of modified red cell components.

Component Modification 23






who do not meet FDAblood hemoglobin levelrequirements for blooddonation. As seen in Figure61, additional categories

for deferral include othermedical reasons for deferral(29.9% of deferrals), high-risk behavior as identifiedon the Donor History Questionnaire (DHQ) deferrals(2.9% of deferrals), anddeferrals for specific foreigntravel (7.9% of deferrals).Deferrals for other medicalreasons may include the

use of medications on themedication deferral list;exposure to human-derivedgrowth hormone, bovine

insulin, hepatitis B immuneglobulin, or unlicensed vaccines; or presentation withphysical conditions orsymptoms incompatible

with blood donation. High-risk behavior deferralsinclude those intended toreduce the risk of transmission of infectious diseases,including human immunodeficiency virus (HIV) andhepatitis viruses.

A total of 127,000 units,from 1.2% of donors (0.7%

of units tested), wererejected for abnormal disease marker test results.

Donor Hemovigilance

This survey provided theopportunity to collect baseline data for donor hemov

igilance, one of fourelements making up biovigilance. The Donor Hemovigilance system wascompleted in 2010 and isdesigned to monitoradverse reactions associated with blood donation.For the purposes of this survey, severe donor adverseevents were defined as

adverse events occurring indonors attributed to thedonation process that

Travel 7.9%

LowHemoglobin 59.3%OtherMedicalReasons

29.9%

HighͲRiskBehavior 2.9%

Figure 61. Categories for deferral.

Current Issues in Blood Collection and Screening 25






7. Current Issues in Blood Transfusion

US Population Trends

Figure 71 illustrates thetrends in the estimated ratesof WB/RBC collection andtransfusion in the UnitedStates from 1980 to 2008.

The rate of collection, theupper line, was calculatedfrom the national estimateof total allogeneic WB andRBCs collected per thousand population (aged 1864 for survey years 19802006; 16-64 for 2008). Therate of transfusion, thelower line, was calculatedfrom the national estimate

of allogeneic WB/RBC unitstransfused per thousandtotal population of all agesfor that year. Population figures were obtained from theUS Bureau of the Census.

Allogeneic blood collection in the US population of age 16 to 64 was 85.2 unitsper thousand persons in2008 compared with 84.1units per thousand personsaged 18 to 64 in 2006. Inmany, if not most, areas of the country, persons asyoung as 16 years of agemay donate and this expan

sion to include the additional population of donorsis reflected in the analysis.Although the actual proportion made up by this agecohort has probablyincreased over the past fewsurvey years, this year thecohort has been included inits entirety to reflect thechange in collection/donation practice. Allogeneicblood collected per thousand total population(including those under 16and over 65) is reflected inthe middle line of Figure 7-1 and shows that the rate of

blood collection in the population only marginallyexceeded the rate of transfusion per person.

Based on the number of donors reported in the 2008survey year, 5.4% of the16- to 64-year-old US population donated in 2008,quite comparable to the

4.8% of the 18- to 64-year-old US population*

*Although 65 is no longer the age limit for donation, <65 years of age was used for consistency with historical analyses.

reported to have donated in2006. The current surveyalso assessed the donationsthat were contributed bydonors of age 16 to 24years of age. The rate of donations in this populationwas 84.8 units per thousand persons in 2008,nearly as high as in the eligible population overalland only slightly lower thanthe rate from persons aged25-64 (85.2 units per thousand persons). Althoughthere has been discussionthat the potential donorbase may be smaller than

previously assumed,* therate of donations per 1,000persons of eligible age(using the slightly reducedage categories imposed bythe US Census) hasremained more or less constant since 2000.

The US WB/RBC transfusion rate in 2008 was 48.8

allogeneic units per thou

* Riley W, Schwei M, McCullough. The United States’ potential blood donor pool: Estimating the prevalent donorexclusion factors on the pool of potential donors.Transfusion 2007;47:11808.

Current Issues in Blood Transfusion 27




20

30

40

50

60

70

80

90

100

1 9 8 0

1 9 8 2

1 9 8 4

1 9 8 6

1 9 8 7

1 9 8 9

1 9 9 2

1 9 9 4

1 9 9 7

1 9 9 9

2 0 0 1

2 0 0 4

2 0 0 6

2 0 0 8

Survey Year

U n i t s / 1 0 0 0 U S

P o p u l a t i o

n

Allogeneic transfusions/1000 pop. (all ages)

Allogeneic Collections/1000 pop. (ages 18-64 through 2006; ages 16-64 in 2008)

Allogeneic Collections by 1000 population (all ages)

Figure 71. Trends in estimated rates of blood collection and transfusion in the United States,19802008.

sand overall population.This rate is not statistically

different from the allogeneic transfusion rate in2006 (48.3/1,000 population), and the trend suggestsa steady state from approximately 2001.

The 2008 transfusion ratedoes not indicate an impactof the recession on the

overall use of blood in theUnited States. It will be of interest to review transfusion rates in future surveysconsidering the nationalinterest in blood management and the reportedimpact of the recession on

the number of elective surgeries.

Note: Allogeneic blood col-lection per thousand total population in 2008 was 55.9. The ageadjusted value of 85.2 was used inFigure 7-1 for consistency with historical analyses.

Trends in Utilization

Figure 72 illustrates therelationship between allogeneic WB/RBC collections and transfusions from1989-2008, as well as themargin between units col

lected and those transfused,which is discussed below.

The rise in the number of collections reported since1997 continues through2008 with 17 million collected, a 6.9% increaseover 2006. Allogeneic collections have increased42% from their low point in1997.

The available supply of both WB/RBCs and non-RBC components was morethan sufficient to meet overall transfusion demands in2008. Shortages discussedin Chapter 8 suggest thatthe few cases of reduced

28 Current Issues in Blood Transfusion




8.0

9.0

10.0

11.0

12.0

13.0

14.0

15.0

16.0

17.0

18.0

1989 1992 1994 1997 1999 2001 2004 2006 2008

Survey Year

M i l l i o n s o f U n i t s

Collections

Transfusions

AvailableCollections:1997-2008

Figure 72. Allogeneic whole blood and red blood cell collections and transfusions, 1989-2008.

availability were local innature.

The margin between allogeneic WB/RBC supply anddemand depicted in Figure72 provides an indicationof the degree of supply sufficiency or oversupply.

In 1989, allogeneic collections totaled 13.6 million,with a margin of 1.9 million, 14% of supply. By1997, the differencebetween units collectedand transfused haddecreased to 862,000 units.

When the available supplyvariable was introduced,this demonstrated thatactual available units, (ie,units that have passed alllaboratory tests and areavailable for transfusion)had decreased to 632,000,only 5.3% of the supply. Inresponse to increasingdemand for RBCs in 1999,

blood centers successfullyincreased allogeneic collections to 13.2 million,increasing the availablemargin to 7.5% in spite of an 8.3% increase in transfusions. Collections increasedsignificantly (p<0.0001) in

2001 due largely to theextraordinary response tothe terrorist events of September 11; however, therewas a concomitant increasein transfusions of the samemagnitude. There werenearly one million excessunits available, or 6.3% of available supply. Since2004, growth in utilization

has increased at a slowerrate than the increase incollection.

In 2008, there was a substantial increase in available allogeneic collectionsto 16.9 million units. With

Current Issues in Blood Transfusion 29



























4 2

C o m p o n e n t C o s t s

Table 8-2. Average Hospital Component Cost ($) by USPHS Region

Mean Dollar Values

USPHSRegion

No. ofHospitals*

RBCsPlasma, frozen

(8hr)Plasma, frozen

(24hr) WBD PlateletsAphPla

Avg p Value Avg p Value Avg p Value Avg p Value Avg

I 74 250.64 <0.0001 56.94 0.8334 55.70 0.4480 73.39 0.0609 514.14

II 134 249.16 <0.0001 58.15 0.7369 59.94 0.0001 89.22 0.0945 601.42

III 152 217.96 0.0028 54.63 0.0810 54.26 0.8347 69.40 0.6490 536.52

IV 259 207.86 <0.0001 52.41 <0.0001 47.46 <0.0001 64.24 0.7741 516.06

V 250 210.79 <0.0001 54.96 0.0541 48.76 0.0009 66.78 0.6012 512.26

VI 169 215.40 <0.0001 58.26 0.6692 54.93 0.6840 48.26 <0.0001 534.80

VII 94 211.68 <0.0001 59.64 0.1776 52.56 0.5990 106.03 0.1501 497.44

VIII 51 223.79 0.8458 73.25 <0.0001 62.18 0.0069 582.67

IX 134 257.14 <0.0001 62.19 0.1253 64.42 0.0361 68.19 0.1127 556.30

X 48 205.46 0.0001 72.61 0.0001 53.22 0.8148 70.09 0.0117 574.67

AllHospitals

1,365 223.09 57.78 53.85 64.98 538.56

*The number of responses for each blood component varies because some hospitals did not provide answers to all questions.RBCs = Red Blood Cells; USPHS = US Public Health Service; WBD = wholebloodderived.




















geted data cleaning wasconducted for sectionswhere follow-on responseswere contingent on the initial question. For example,

if an institution left an introductory “Yes/No” questionblank or answered “No” butthen responded affirmatively to a follow-up question, the lead question wasmade consistent with theinstitutions response(s). All“Don’t Know” responseswere coded similarly and“N/A” and “Not Available”

responses to numeric variables were coded as missing. Frequencies werereviewed and extreme outliers were investigated andcorrected. Finally, the ratioof total transfusions to surgical volume was reviewedfor consistency and potential outliers investigated.

Data Apportionment

During data review,responding institutions thatprovided data for themselves, for additional institutions (question A5), andfor institutions which theyserve (question A6) wereenumerated. A new record

was created for each of theorganizations listed in questions A5 and A6 for whichsurgical volume wasknown. No new recordswere created for 1) institutions for which surgical volume could not be identified

by either the 2006 or the2009 AHA data file(obtained following thefield period of the study) orcould not be ascertained by

AABB or 2) institutions thathad a surgical volume of less than 100.

The new records wereformed by copying the categorical data from theresponding institution’srecords into every record inthe reporting group. Forexample, the responding

institution’s answer to thequestion; “Do you routinelytransfuse plasma (to non-pediatric patients) based onpatient size or unit volume”was given to each institution in the reporting group.

The responding institution’s data that representedcounts were apportioned

among those in the reporting group according to eachinstitution’s surgical volume. However, responsesto questions C8, C10, C12,C15, C16, C17, and C19were not apportionedbecause these questionswere not directly related tosurgical volume. Thesevariables were treated inthe same manner as the categorical variables and copied to each of the newrecords.

Response Rates

Table A2 summarizes theoutcome of the data collection efforts. After eliminat

ing ineligible institutionsthat ceased operations(closed), merged with aninstitution not included onthe sampling frame, or werereported by an affiliate thatwas included in the sampling frame, the combinedsurvey response rate was53.1% (1,660/3,129) representing a decline over the

combined survey responserate of 61.3% for the 2007survey. The response ratefor blood centers was93.3% (126/135). The overall response rate for eligible hospitals was 51.5%(1,529/2,970). Responserates by surgical volumeclasses ranged from 44.5%to 58.3%. Only 20.8% of

the cord blood banksresponded (5/24). The totalnumber of hospitals, bloodcenters, and cord bloodbanks that responded to the2009 survey was 1,660 vs1,849 in 2007. The CTquestionnaire response ratewas 44.3% (89/201). Anadditional 77 institutionsnot on the original sampling

frame completed the CTquestionnaire online, for atotal of 166 (77 + 89)respondents.

For the first time, respondents had the opportunity

Appendix: Methods 51












Table A-6. Average Raking Factor for Hospitals by USPHS Region (50 States and the Districtof Columbia)

USPHSRegion Surgical VolumeControl Total

Surgical Volume

Estimate BeforeRaking Average RakingFactor RespondingSample Size

I 447,397 230,482 1.94 83

II 983,360 590,029 1.67 145

III 1,136,717 687,419 1.65 164

IV 2,217,983 1,162,783 1.91 304

V 1,775,296 916,007 1.94 276

VI 1,287,753 661,332 1.95 193

VII 483,096 252,952 1.91 103

VIII 314,981 154,065 2.04 54

IX 1,257,510 561,251 2.24 150

X 354,932 179,044 1.98 57

TotalFacilities

10,259,025 5,395,369 1.91 1,529

The variance between thereplicate estimates and fullsample estimate is used toestimate the sampling variance. A sufficient numberof replicates is used toensure reasonably preciseestimates of variance formost parameter estimates.

Imputation

Missing values for criticalquestions were imputedusing a model-based regression method. The method

utilizes an iterative procedure that capitalizes oninformation available fromvariables that are highlycorrelated with the variables that have missing values. Imputation modelswere developed separatelyfor blood centers and hospitals and for continuous andcategorical variables. Thisprocedure was used toimpute values for criticalquestions with fewer than20% missing values toensure valid and reliableestimates. Alternatively,information from the 2006

survey was used to“impute” data for two critical questions with greaterthan 20% of the valuesmissing. Specifically, usingthe AHA identificationnumber, hospitals that participated in both surveyswere identified and datawere imported from theprevious year (when available) to fill in the missingvalues. Imputed cases wereflagged to allow the analystto identify which caseswere imputed.

56 Appendix: Methods






mary questionnaire via maildid not have a chance tocomplete the secondaryquestionnaire. Poor representation of cord blood

banks is a limitationbecause the census fromwhich the sample wastaken was not well defined;thus, no meaningful comparisons can be made toprevious years and noextrapolations can be madeto the cord blood bank population.

Finally, unlike previous surveys, the sampling frame forthe 2009 NBCUS included

101 institutions in the USterritories of Guam, PuertoRico, American Samoa, andthe Virgin Islands. However, only 55 of the 101

institutions were found tobe eligible after eliminatinginstitutions that ceasedoperations, merged with aninstitution not included onthe sampling frame, or werereported for by an affiliatethat was included on thesampling frame.

Moreover, only 12 of the 55

responded to the primaryNBCUS questionnaire, for aresponse rate of 22%. This

low response rate may bedue to a number of factors,including language (PuertoRico), lack of recognition of AABB, and/or the voluntary

nature of the survey whereresources may be neededfor patient care.

Because no meaningfulextrapolations to the population can be made fromthe small number of responding institutions, nodata for territories areincluded in this year’s sum

mary report.

58 Appendix: Methods



Documents

The 2009 National Blood Collection and Utilization Survey Report