Changes in medicine have eliminated the need for millions of blood transfusions, which is good news for patients getting procedures like coronary bypasses and other procedures that once required a lot of blood.
But the trend is wreaking havoc in the blood bank business, forcing a wave of mergers and job cutbacks unlike anything the industry, which became large scale after World War II, has ever seen.
Nothing like that is happening at the Kentucky Blood Center, based in Lexington, although the center is feeling the effects of the new trend toward fewer blood transfusions.
Denise Fields, marketing and communications director for the Lexington center, said transfusions of red blood cells from the center have declined about 6 percent during the past year or so.
Of greater concern, she said, was a recent decline in donations of red cells at the blood center.
According to Fields, donations of red cells to the Lexington center are down by roughly 1,000 donations since the fiscal year started July 1.
"From July 1 to Aug. 24 of this year, we had 10,201 red-cell donations, and last year we had 11,396," she said. "That puts us a little over 1,000 short. Our biggest concern right now is the decline in donations."
Nationwide, blood transfusions are down almost one-third during the past five years, to about 11 million units last year from about 15 million units, according to the American Red Cross, which has about 40 percent of the market.
With "minimally invasive" techniques such as laparoscopic surgery and other shifts in medicine, demand for blood continues to drop despite population growth and a soaring number of people older than 65, who have the most surgeries requiring blood.
Blood bank revenue is falling and might reach $1.5 billion this year from a high of $5 billion in 2008.
Fields, the Kentucky Blood Center spokeswoman, said several things might have reduced donations there in recent months.
"We had the horrible winter; schools had to extend their year; families started re-arranging vacations; then everybody went back to school early," she said. "Summer is always a tough time in the blood banking business, but this summer was especially tough for us."
The Kentucky Blood Center has been able to keep area hospitals supplied, she said, but officials imported almost 400 units of blood from other centers to help meet the need.
Center officials hope the level of donations will return to normal soon, now that summer vacations are over and schools are in session, she said.
"Once school is in session and we start blood drives in high schools and on college campuses, we hope it will come back," Fields said. "Plus, we're always trying to touch base with donors and get them to come in."
One reason for declining demand is that recent studies have found many transfusions unnecessary, so patients no longer are getting expensive services that did them no good. The Society of Thoracic Surgeons, for example, changed the guidelines for transfusions after coronary artery bypass grafts beginning in April 2012. A normal hemoglobin count is 12 to 16 grams per deciliter of blood, depending on gender. Some doctors automatically ordered a transfusion after surgery; others did so only if the patient's hemoglobin level fell to 10. Under the new guidelines, transfusion is not recommended until the level falls to 7.
"There's overwhelming evidence to suggest that blood transfusion is a dual-edged sword," said Dr. Victor A. Ferraris, a heart surgeon at the University of Kentucky who was chairman of a committee that wrote the new guidelines. "Some people need it and it saves their lives; other people are harmed by it."
In another approach, new guidelines emphasize treating patients for anemia in the weeks before surgery to minimize the need for transfusions. Cancer therapies also have changed in a way that reduces transfusion needs. So has surgery: In a total hip replacement, loss of 750 milliliters of blood, about 0.8 pint, was considered standard; now it is 200 milliliters.
Doctors might be adopting the new guidelines faster because of the recent computerization of medical records, which allows a physician to order transfusions from a computer screen. The computer, though, knows the guidelines, and it will alert a doctor if the order falls outside the norm. The same system can collect data on which surgeons routinely exceed the guidelines.
Insurance plans also discourage transfusions. Some, including Medicaid, pay hospitals a flat fee for a procedure, whether it involves the transfusion of one unit, two, three or none.
And blood is expensive. Nonprofit organizations collect whole blood from unpaid donors, but hospitals might pay $225 to $240 a unit, according to executives in the business, which covers a variety of costs, including testing. If the unit is billed to the patient, the price can be $1,000 or more. Part of the expense is for storage, management and inventory losses; around 1 million units a year are discarded, mostly because they are not used soon enough.
"Blood is not a pharmaceutical that can sit on the shelf for 12 months or 18 months," said Miriam A. Markowitz, chief executive of the American Association of Blood Banks. Red cells have a life of 42 days; platelets last five days. And hospitals must stock a variety of blood types and try very hard not to run out of any category.
The reduction comes at a fortunate time because the list of reasons for excluding blood donors seems to get longer, reducing the pool of possible donors.
Because of the reduced demand for blood, potential donors might see emergency appeals less frequently, but the blood banks still issue them, during snowstorms, for example, and when donors are less likely to give, like during summer vacations and the December holidays. Even at reduced levels of demand, the blood banks need tens of thousands of donors a day.
The trend has not played itself out, Markowitz said. "We still anticipate some pretty significant declines," she said. "Certainly it will stabilize, certainly it will plateau," she said, although she added that a lot of people would like to know when that will happen.
In the meantime, the industry is going through a wave of mergers and acquisitions. America's Blood Centers, an association of independent blood banks, said its membership had fallen to 68 from 87 five years ago.
In July, the Institute for Transfusion Medicine, in Pittsburgh, said it would merge with OneBlood of Orlando, Fla. The new organization expects to distribute almost 2 million units of blood a year, making it one of the largest blood banks in the country.
Some experts in the blood industry who spoke at a meeting in June 2013 of the Department of Health and Human Service's Advisory Committee on Blood and Tissue Safety and Availability predicted that most of the collection agencies, which have established relationships with donors, would survive as independent entities. But they also predicted that behind-the-scenes operations such as stockpiling, testing and distribution would merge to achieve efficiencies. Already, blood banks are turning to consolidated lab companies for testing, instead of maintaining their own labs.