October 18, 2021
The need to produce more with less is the unfortunate reality for many health care providers. A thoughtful 2021 Annual Meeting session, “Transfusion Medicine Access in Resource-Constrained Areas,” reviewed some of the challenges with providing transfusion medicine services and products in resource-poor areas. Though commonly associated with low- and lower-middle-income countries (LMICs), resource constraints also affect many areas in the United States.
Tina Ipe, MD, MPH, from the University of Arkansas for Medical Sciences, works in a state that ranks fifth in the US for poverty. She has encountered many challenges with providing health care, especially specialized health care in a resource-constrained setting.
According to the US Census Bureau, most of the US (72%) is considered rural or non-metropolitan and 19% of the US population lives in rural areas. Despite this, rural health care is a frequently overlooked area of clinical practice — a fact which adversely affects millions of Americans.
Factors that impact health care access in rural US areas include:
Those same factors also impact health care access in low and LMICs, defined as countries that have a gross national income per capita of less than $4,000. There are 82 countries in this group and not only do they represent the majority of the world’s population but they also suffer from the most burden of disease. Approximately 90% of disease burden is shouldered by low and LMICs. They face additional factors that include:
There are many challenges to the provision of transfusion medicine (TM) services in resource-constrained areas in the US. These include insufficient staff, particularly a lack of TM-trained positions or blood banking specialists; inadequate resources and staff training, such as inadequate staff training for generalists who cover blood banking duties; incomplete standard operating procedures that fail to address CAP or AABB standards; a lack of quality assurance programs; and a lack of data on how to improve access to TM care.
Research is an integral, empowering, innovating part of clinical care; however, conducting research in resource-constrained areas is difficult because there are competing priorities, such as the provision of clean water in developing countries. Other barriers to conducting research include complex, often confusing regulatory processes with lengthy approval times; institutional barriers driven by a lack of administrative support and no or few incentives for doing research; unreliable or nonexistent internet access; untrained personnel who have not learned research methodology and lack mentors to guide them in this area; and high out-of-pocket expenses that force researchers to fund their own research. Additionally, because of cultural taboos, patients may refuse to participate in research.
Ipe mentioned potential solutions that might help to alleviate health care barriers:
Ipe described the Arkansas Initiative for Convalescent Plasma, a statewide effort to ensure convalescent plasma (CPP) for every Arkansan. By understanding the local infrastructure and knowing who the key players were, they were able to coordinate the collection and provision of CCP during the pandemic. They did this by working alongside the Department of Health and local blood collectors and hospitals to not only educate them but also review and manage resources appropriately. They were able to provide at least two units of CCP for every Arkansan between April and July 2020.
Pampee Young, MD, PhD, also from the University of Arkansas for Medical Sciences, discussed the state of blood demand and production, as well as supply chain considerations, related to rural hospitals and the unique challenges tied to new blood products, such as CPP, and rural access.
Her data, largely drawn from the American Red Cross (ARC), showed that product collection and manufacturing is on the rise, even during the pandemic, but likely would have been higher without the pandemic.
However, the vast majority of hospitals they serve are within 100 miles of a distribution site. Those outside the range of distribution sites are rural. About 5.4% of customers are not within a 3-hour drive from a distribution point; some rural sites are almost 8 hours away from the nearest distribution site. This longer transport time and geographic disparity help to explain published reports showing that rural trauma victims have a higher risk of death than their urban counterparts.
When Young’s facility was setting up a CCP program in late March 2020, the supply was very constrained and the issues of access were a major challenge. Getting donors registered was not an issue; 58,965 registered between March 27-July 15.
Issues that did arise were:
Young noted that during pandemic times, close attention should be paid to where cases are occurring and shifting care trends.
Session attendees remarked in the chat box that the topics covered in this session were important and deserved attention.