Paid platelet donors: Points to consider

Is there a case that there are medically urgent, periodic platelet shortages, and will they increase in the future? Does overall platelet demand exceed supply and how is this managed? Should it be a surprise that periodic shortages occur for a 5-day dated blood component, most vulnerable to bacterial contamination and resulting sepsis, which requires a regular commitment on the part of highly dedicated donors to supply? Will the demand for platelets increase as our population ages, and without new strategies, will blood providers be able to keep up with demand? A recent article in Transfusion1 suggests that the platelet supply is constrained and argues that paying younger donors would increase platelet availability. Here, we discuss this suggestion in the context of recent unpublished data on donor motivation and hospital perceptions about paid platelet donors. We also discuss other options for stabilizing the availability of platelets. We suggest that there is currently insufficient information to support the wide-scale implementation of a paid apheresis platelet program in the context of many decades of maintaining a volunteer blood system. The American Red Cross (ARC) conducted six focus groups of platelet donors in three unique markets (Tulsa OK-rural; Boston MA-urban; Portland OR-suburban), and also surveyed 8000 current and potential platelet donors to understand their experience and motivations for donating during a 5-month period in 2018–2019. The results indicate that the reasons for donating are fundamentally altruistic and personal. A total of 91% of platelet donor respondents stated they continue to donate as a way to give back to the community and 71% continue to donate because it is something special that not everyone can do. Overall, platelet donor motivations do not differ from those of whole blood donors. They share a desire to help their community or specific patient populations (e.g., cancer patients). However, donor motivation was not a predictor of donation frequency. And, only 21% of surveyed current donors indicated incentives were important or very important to their donor experience, 18% of potential platelet donor respondents said incentives would lead them to donate platelets, and fewer than 15% of lapsed donors (absence of donation within the prior 24 months) indicated incentives would motivate them to donate again. Instead, donors prefer social forms of recognition (e.g., certificates, annual recognition, “wall of fame”). Comfort and convenience were identified as more important drivers than recognition for ongoing donation. Our studies indicate that donor retention and frequency are more closely tied to the overall donation experience than incentives. Donors supported enhancement of the donor experience including improved convenience in hours of operations and locations, professionalism of the staff and increased appreciation of the donor. In short, our survey findings determined platelet donors are motivated by altruism and convenience and not financial rewards. The ARC also conducted a survey and sought the opinions of hospitals regarding the use of paid donor apheresis platelets. This survey was conducted May–July 2019 and included 104 urban/suburban and rural hospital decision makers, 30 of whom were interviewed in greater detail. Overall, most participants did not see a need to change current practice, although it was recognized that demand in some instances exceeds supply. Approximately 40% of respondents indicated they routinely confront platelet supply challenges; however, they indicated this rarely involves delayed or withdrawn care. Further, those that often struggle with platelet fulfillment state they also have trouble with an adequate supply of other blood products. Only 21% indicated they would readily accept paid donor platelets without any conditions. One-quarter of respondents opposed the use of paid donor platelets, citing safety reasons, impact on volunteer donors, and increases in price with 23% specifically stating they would not accept paid donor apheresis products for routine needs. Additionally, 24% believed there were clinical differences between platelets from paid and volunteer donors. The majority (78%) stated they would require pathogen reduction before using paid donor platelets; only 9% would use platelets from paid donors without pathogen reduction. Paid donor platelets would be used as a “last option” by 53% of respondents, while 32% believed the potential benefits of a more stable supply outweigh the risks. Some suggested options for suppliers to try prior to resorting to paid donor apheresis platelets including different donor recruitment efforts (e.g., making donors aware of specifically how their donation was used). Experience has shown that platelet supply can be grown independent of paid donors. Platelet transfusions increased 16% between 2017 and 2019 and blood collectors were able to keep pace.2 Blood collectors have adjusted by adding new collections sites, expanding hours of operation and collection devices to existing donor centers, optimizing platelet split rates, reducing outdates, and dedicating marketing efforts to recruit platelet donors. Our donor base grew by 14% from December 2019 to December 2020. Importantly, the 20–54 year–old age group constituted greater than 60% of our donor base and of that, the under 35-year old donor segment constituted approximately 39% of our donor base. As a result, the ARC has grown platelet production by 23% since 2016; each month adding 4000 new platelet donors and reactivating 800 lapsed donors (internal ARC data); from this we conclude that the potential donor base is not yet used to its capacity. Furthermore, the ARC has increased donation frequency by 6.4% over the 3 years ending September 2019. As a result of the COVID-19 pandemic and associated convalenscent plasma programs, the ARC and other blood collectors have seen an influx of new platelet donors. Overall, the volunteer platelet donor base is strong, with return donor retention of 46% and conversion of first-time whole blood donors to repeat platelet donors of approximately 30%, with potential for further growth especially among younger donors. Stubbs et al.1 acknowledge evidence is lacking suggesting that compensating donors may result in lower recruitment costs and increased efficiencies for blood collectors. However, the safeguards inherent to a paid donor program needed to ensure both donor and patient safety cannot be underestimated. The donor management standards for qualifying applicant donors including but not limited to ensuring community-based residency and cross-donation management require substantial investment and coordination. Ample evaluation of the feasibility and investment is required before any assessment on financial impact is given. In addition, if a paid platelet donation program is implemented, particularly if just on a portion of platelet donations, ethical and legal considerations would be required to determine if patients would need to be notified of a paid source as part of the informed consent process. We consider that the fundamental challenge to maintaining adequate platelet supply across the country is not a lack of donors, but rather their short shelf life, normally only 5 days. This problem is exacerbated by the need for bacterial testing of all but pathogen-reduced platelets, shortening shelf life further to 3.5 days. Extension of dating to 7 days will not have a dramatic impact considering that much of the additional dating is consumed during the required process of bacterial testing.3 As noted by Stubbs et al.,1 there are other factors affecting platelet availability which could be considered, such as changes to platelet dose, or increased use of random donor platelets, but pathways to resolution of these issues are unclear. Additionally, the impact of payment for some donations may have consequences upon the non-remunerated aspects of blood collection. We briefly address some of these considerations below. Given platelet's short shelf life, there is the inevitable issue of product outdates which contributes to shortages. Most hospitals want the freshest platelets available for their scheduled orders. This expectation remains even during periods of low inventory, resulting in platelets with 1–1.5 days of dating not being transfused. In 2017, the NCBUS reported that 165,000 (7.1%) apheresis platelet units outdated within blood centers, and within hospital inventories, 179,000 (9.7%) outdated.2 Although the outdate rate has dropped in recent years due to improved inventory management, outdates remain a significant contributor to platelet shortages. Managing outdates is particularly challenging for smaller, rural hospitals. Extension of platelet shelf life to 7 days can help mitigate platelet expiration, but again, much of the benefit is consumed during bacterial testing.3 In addition, currently not all platelets may be qualified for 7 days (e.g., those in platelet additive solution and pathogen-reduced platelets); thus, outdates will remain a significant challenge.3 The variability of requirements for platelets is a major issue. Not only do hospital needs vary daily, but in addition platelets are segmented by ABO blood type and by other attributes such as irradiation and CMV seronegativity. With the upcoming implementation of safety mitigations required by the FDA's final guidance on bacterial safety of platelets,3 the majority of blood collectors will have at least two types of platelets in inventory, those that have been tested by large volume delayed sampling and pathogen reduced. Maintaining more than one product in inventory increases costs and outdates. Some hospitals are not yet set up to accept both products, creating perceived shortages. However, it should be noted that the currently FDA-licensed pathogen reduction system obviates the need for CMV seronegative and irradiated platelets, thus facilitating improved inventory management. Exacerbating the difficulties of changing requirements is the intention to use paid donor platelets when volunteer donor platelets cannot be obtained. If products derived from paid donors are indeed relegated to be used mostly under significant supply constraints, their benefit may be diminished. Blood collectors would be challenged in terms of production planning, predicting demand for paid products and managing a discreet inventory for emergency needs. This would increase complexity, wastage and costs, and may limit any improvement to overall platelet supply. Stubbs et al.1 consider that cold-stored platelets (CSP) may help to resolve at least some of the problems of availability. In some locations, such as rural areas, a supply of CSP might help bleeding patients, but CSP cannot be used prophylactically which represents a significant if not the majority of platelet needs. Thus, implementation of CSP would result in additional inventory challenges associated with attendant complexities for hospitals and blood centers. Compounding the ambiguity of paying platelet donors is the fact that more than 11.7 million red blood cells were collected in the US in 20172 via non-remunerated blood donations. Financially incentivizing donors may be negatively perceived and potentially cannibalize our many decades of maintaining a volunteer blood system as well as possibly resulting in the loss of altruistic donors. However, Stubbs et al. suggest that this is not the case1 based on data from paid plasma donors,4 which may not be applicable to the coexistence of a volunteer and paid platelet donor program. The demographics of paid donors will vary from our volunteer donors including a subset of volunteer donors that may see payment as an incentive with potentially negative consequences. There is also the question of compatibility with the blood center and the World Health Organization ethos around volunteer donors; paying donors runs counter to the philosophy of blood product collection in this country. Indeed, a recent, comprehensive review by Chell et al. clearly shows that there are no consistent data to establish the efficacy of donor payment, especially cash payments, in an environment such as that of the US.5 Nor are there any data of the effects of cash payments on donor motivation over a long period of time. This review does, however, report that financial compensation of donors might impact the selflessness that drives US blood donations. The key recommendation of Chell et al. is that there is a need for controlled trials to determine the usefulness of financial incentives to promote blood donation. Notably, there are no data to establish the financial impact of introducing a payment for platelet donation. Comprehensive validation is required prior to an extensive input of resources into such a program that potentially could compromise the attitudes of, and willingness of our current donors to give, and confidence from our hospitals. Carefully designed surveys could be conducted by the major blood providers, as academic or operational studies, either self-funded or with appropriate contract or grant support. As suggested by Chell et al.,5 donor research would benefit from examining opinions from current donors, potential donors, and the broader community on a variety of incentives with the additional need to define appropriate reward schedules that encourage repeat donation and establish blood donation as a habit. Our contention, based on survey data from hospitals and blood donors and subsequent analysis, is that there is no evidence that paying platelet donors would result in a meaningful, stable platelet supply. Financial incentives do not contribute to a loyal, repeating platelet donor base. Further, paying donors does nothing to address the other contributors to shortages (i.e., short shelf life and product segmentation). For an industry long struggling to achieve financial solvency, the costs associated with compensating donors, and implementing the necessary program safeguards, would need to be recovered and may result in increased fees. In summary, we have found that donors donate as an altruistic act to help their community where retention is based most importantly on the donation experience rather than incentives. Over half of those surveyed viewed paid donor platelets as a last option with nearly a quarter of those surveyed refusing to use them. Internal ARC data indicate that growth to platelet programs is realistic using a number of mechanisms, but clearly additional research is needed to examine all aspects of incentives and changes to behavior enabling a strong and stable platelet donor program moving forward. The unknown impact to the altruism of blood donations in a paid program is troubling in that it could compromise the willingness of volunteer donors to donate, create hospital concern about the safety of the platelet supply, and result in increased costs for blood collectors and hospitals. We suggest that, along with studies on donor motivation by payment, analyses, and evaluation of optimization of platelet availability are needed prior to consideration of paid platelet donation. PY serves on the medical advisory board of Fresenius Kabi. and Creative Testing Solutions. SLS serves on the Scientific Advisory Board of Hema-Quebec and Creative Testing Solutions. RYD serves on the Scientific and Research Advisory Committee of the Canadian Blood Services.

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