CMA brief offers suggestions as federal commission studies country's blood-gathering system

Canadian Medical Association Journal 1995; 153: 655-656

[résumé]

Abstract

As prescribers of blood and blood products, physicians must be assured that Canada's system for collecting, processing, storing and disseminating blood and its byproducts is the best and most secure that Canadians can afford within the current health care system, the CMA told the federal Commission of Inquiry on the Blood System in a brief submitted in late July.

"The blood supply we once relied on and the safety of which we took for granted has been seriously affected by the HIV/AIDS epidemic and hepatitis C," the association said in a brief prepared in response to the commission's interim report. The CMA said it hopes the inquiry, chaired by Mr. Justice Horace Krever, "will restore faith in a system that is essential for the health and safety of all Canadians."

"The Krever Commission acknowledged that public confidence in the blood system is low and the CMA stressed the need to restore that confidence," said Dr. Carole Guzmán, the CMA's associate secretary general. "Blood and blood products are necessary in many cases, and patients who need to receive blood should not be unduly alarmed."

The CMA was encouraged by a preliminary finding in the Krever Commission's interim report that Canadians who need blood or blood products need not worry that they might be less safe than people in other developed countries, she added.

While supporting much of the direction provided in the interim report, the CMA warned that it made little reference to the cost, cost effectiveness and affordability of the commission's recommendations. Some recommendations appear to have significant cost implications for the health care system, but the CMA emphasized that "any decision to do one thing is a decision not to do something else."

More specifically, the CMA recommended that:

• Rather than have all hospitals contact people who received blood transfusions in a given period to find patients who might have been infected by HIV or hepatitis C, the commission should pilot trace-back programs in a variety of practice settings to determine the relative cost benefit or cost effectiveness of such programs.
• Current donation programs for autologous blood should not be expanded until their relative cost benefit is determined. Recent data indicate that while there is little expected health benefit from the substitution of autologous for allogeneic blood, there are significant additional costs because of blood that is unused or discarded and the more labour-intensive donation process. Autologous donations should also be subject to the same strict standards and scrutiny as allogeneic donations, which may have further cost implications.
• The Krever Commission should consider revising its statements with respect to risk reduction to include consideration of marginal costs and diminishing returns, and the restraints imposed on the system by limited financial resources. The CMA said the optimum blood system cited in the interim report, which strives to eliminate all known risks even though complete elimination of risk is impossible, fails to take into account the cost implications of the goal. "Physicians accept that medical practice coexists with uncertainty and risk to the patient and to society as a whole," said the CMA. "It must be acknowledged that the therapeutic use of blood in patient care involves degrees of uncertainty and risk similar to other elements of medical practice."
• The commission should not make a special case for blood and blood products when making recommendations about informed decision making by patients. "It is important to emphasize that all [patient-physician] discussions should occur within the context of the overall plan of treatment, and information should be presented in a way that does not unduly alarm a patient. Placing particular emphasis on the receipt of blood and blood products may not be appropriate given the relative severity of a number of other material risks" associated with a medical procedure, said the brief. CMA policy requires disclosure of material risks, including the potential receipt of blood or blood products, but the brief said if it is determined that physicians are failing to make information available to patients, the situation should be redressed by continuous quality improvement, not a regulatory approach.
• In order for physicians to provide accurate information to patients about risks posed by blood and blood products, an expert advisory committee to the federal minister of health, similar to the one that deals with vaccines and immunization, should be established. Physicians must receive regular reports on the safety of the blood supply and it must be established who will be responsible for providing this vital information.
• There should be clear and centralized authority to address major issues of public health at the national level.

However, the CMA cautioned that the complexity of the process required to produce reasonable evidence on which to base change and the challenge of translating complex scientific evidence in order to make the information widely available should not be underestimated.