What factors contribute to hospital variation in obstetric transfusion rates?

Trends in postpartum hemorrhage and manual removal of the placenta and the association with childbirth interventions: A Dutch nationwide cohort study

BACKGROUND

Because the cause of increasing rates of postpartum hemorrhage (PPH) and manual placental removal (MROP) is still unknown, we described trends in PPH, MROP, and childbirth interventions and examined factors associated with changes in rates of PPH and MROP.

METHODS

This nationwide cohort study used national perinatal registry data from 2000 to 2014 (n = 2,332,005). We included births of women who gave birth to a term singleton child in obstetrician-led care or midwife-led care. Multivariable logistic regression analyses were used to examine associations between characteristics and interventions, and PPH ≥ 1000 mL and MROP.

RESULTS

PPH rates increased from 4.3% to 6.6% in obstetrician-led care and from 2.5% to 4.8% in midwife-led care. MROP rates increased from 2.4% to 3.4% and from 1.0% to 1.4%, respectively. A rising trend was found for rates of induction and augmentation of labor, pain medication, and cesarean section, while rates of episiotomy and assisted vaginal birth declined. Adjustments for characteristics and childbirth interventions did not result in large changes in the trends of PPH and MROP. After adjustments for childbirth interventions, in obstetrician-led care, the odds ratio (OR) of PPH in 2014 compared with the reference year 2000 changed from 1.66 (95% CI 1.57-1.76) to 1.64 (1.55-1.73) among nulliparous women and from 1.56 (1.47-1.66) to 1.52 (1.44-1.62) among multiparous women. For MROP, the ORs changed from 1.51 (1.38-1.64) to 1.36 (1.25-1.49) and from 1.56 (1.42-1.71) to 1.45 (1.33-1.59), respectively.

CONCLUSIONS

Rising PPH trends were not associated with changes in population characteristics and rising childbirth intervention rates. The rising MROP was to some extent associated with rising intervention rates.

Predicting risk of peripartum blood transfusion during vaginal and cesarean delivery: A risk prediction model

OBJECTIVE

The objective of this study is to develop a model that will help predict the risk of blood transfusion using information available prior to delivery.

STUDY DESIGN

The study is a secondary analysis of the Consortium on Safe Labor registry. Women who had a delivery from 2002 to 2008 were included. Pre-delivery variables that had significant associations with transfusion were included in a multivariable logistic regression model predicting transfusion. The prediction model was internally validated using randomly selected samples from the same population of women.

RESULTS

Of 156,572 deliveries, 5,463 deliveries (3.5%) required transfusion. Women who had deliveries requiring transfusion were more likely to have a number of comorbidities such as preeclampsia (6.3% versus 4.1%, OR 1.21, 95% CI 1.08-1.36), placenta previa (1.8% versus 0.4%, OR 4.11, 95% CI 3.25-5.21) and anemia (10.6% versus 5.4%, OR 1.30, 95% CI 1.21-1.41). Transfusion was least likely to occur in university teaching hospitals compared to community hospitals. The c statistic was 0.71 (95% CI 0.70-0.72) in the derivation sample. The most salient predictors of transfusion included type of hospital, placenta previa, multiple gestations, diabetes mellitus, anemia, asthma, previous births, preeclampsia, type of insurance, age, gestational age, and vertex presentation. The model was well-calibrated and showed strong internal validation.

CONCLUSION

The model identified independent risk factors that can help predict the risk of transfusion prior to delivery. If externally validated in another dataset, this model can assist health care professionals counsel patients and prepare facilities/resources to reduce maternal morbidity.

Optimizing systems to manage postpartum hemorrhage

Systems to optimize the management of postpartum hemorrhage must ensure timely diagnosis, rapid hemodynamic and hemostatic resuscitation, and prompt interventions to control the source of bleeding. None of these objectives can be effectively completed by a single clinician, and the management of postpartum hemorrhage requires a carefully coordinated interprofessional team. This article reviews systems designed to standardize hemorrhage diagnosis and response.

Hospital-level variation in rates of postpartum hemorrhage in California

BACKGROUND

To examine the extent of hospital-level variation in risk-adjusted rates of postpartum hemorrhage (PPH).

STUDY DESIGN AND METHODS

We performed a cross-sectional study examining live births in 257 California hospitals between 2011 and 2015 using linked birth certificate and maternal discharge data. PPH was measured using International Classification of Diseases Codes version 9. Mixed-effects logistic regression models were used to examine the presence and extent of hospital-level variation in PPH before and after adjustment for patient-level risk factors and select hospital characteristics (teaching status and annual delivery volume). Risk-adjusted rates of PPH were estimated for each hospital. The extent of hospital variation was evaluated using the median odds ratio (MOR) and intraclass correlation coefficient (ICC).

RESULTS

Our study cohort comprised 1,904,479 women who had a live birth delivery hospitalization at 247 hospitals. The median, lowest, and highest hospital-specific rates of PPH were 3.48%, 0.54%, and 12.0%, respectively. Similar rates were observed after adjustment for patient and hospital factors (3.44%, 0.60%, and 11.48%). After adjustment, the proportion of the total variation in PPH rates attributable to the hospital was low, with a MOR of 2.02 (95% confidence interval [CI]: 1.89-2.15) and ICC of 14.3% (95% CI: 11.9%-16.3%).

DISCUSSION

Wide variability exists in the rate of PPH across hospitals in California, not attributable to patient factors, hospital teaching status, and hospital annual delivery volume. Determining whether differences in hospital quality of care explain the unaccounted-for variation in hospital-level PPH rates should be a public health priority.

Obstetric red cell transfusion in a high-volume tertiary hospital: a retrospective cohort study

Introduction

Red cell transfusion is expensive and not without risks. Despite the availability of transfusion guidelines, studies report a wide interhospital variation in transfusion rates. This retrospective cohort study was conducted to define the incidence of red cell transfusion in a multi-ethnic obstetric population and to evaluate current transfusion practice with regard to indications and appropriateness.

Methods

All parturients who delivered a live or stillbirth in the period 2014-2015 and who received allogeneic blood transfusion during pregnancy and up to six weeks postnatally were identified. Their medical records were reviewed to extract the relevant demographic, obstetric and transfusion data. Descriptive analysis of data was performed using IBM SPSS Statistics software.

Results

Out of 23,456 parturients who delivered in the study period, 760 were administered red cell transfusion, resulting in a transfusion rate of 3.2% or 32 in 1,000 maternities. A total of 1,675 red cell units were utilised in 863 transfusion episodes. Major indications for transfusion were anaemia in pregnancy (49.2%) and postpartum haemorrhage secondary to an atonic uterus. Transfusion was more frequently associated with caesarean than vaginal births (4.9% vs. 2.4%). About 14% of transfusions were initiated with pre-transfusion haemoglobin (Hb) ≥ 8.0 g/dL, whereas 37% of transfusions resulted in post-transfusion Hb > 9.0 g/dL.

Conclusion

The incidence of red cell transfusion was 3.2% in a multiethnic obstetric population. Patient blood management strategies should focus on optimising antenatal anaemia, reducing blood loss during delivery and eliminating inappropriate transfusion.

The effect of clinician education on blood transfusion practice in obstetrics: completing the audit cycle

BACKGROUND

With blood products being a limited and expensive resource within the healthcare system, there is an ever-increasing emphasis on judicial and appropriate use.

AIMS

To evaluate whether implementing contemporary society recommendations on restrictive transfusion policies would reduce inappropriate use of red blood cell transfusions, by evaluating the effect of a staff educational campaign.

METHODS

An audit of peri-partum red cell concentrate (RCC) transfusion practice within a tertiary obstetric unit was undertaken, covering a 1-year period (2015), examining data related to transfusion prescribing practices. Subsequently, an educational programme was held for clinical and laboratory staff which aimed to bring practice in line with society guidelines. A repeat audit covering another 1-year period (2018) was undertaken.

RESULTS

The number of RCC units of transfused reduced by 49% between 2015 and 2018 (426 to 218). The number of patients receiving transfusion dropped from 166 in 2018 (1.8% of births) to 119 in 2015 (1.5% of births). Among stable patients who were transfused, the proportion receiving a single unit increased from 6.9 to 53.9%. (p < 0.001). Haematological reassessment between units rose from 13.8 to 80.4% (p < 0.001). Written consent documentation improved (68% in 2018 vs. 38% in 2015) (p < 0.001).

CONCLUSIONS

The implementation of guidelines has resulted in substantial reduction in RCC transfusions between 2015 and 2018. Fewer women received a blood transfusion, and those who did received fewer units. There is a higher proportion of patients being reassessed between units and receiving single unit transfusions. Recording of consent has improved.

Patterns of red-cell transfusion use in obstetric practice in sweden 2003-2017: A nationwide study

BACKGROUND

There is a paucity of data on patterns of red-cell transfusions in obstetrical care, but some studies have suggested an increase in transfusion rates during the last decade. The purpose of this study was to investigate maternal characteristics, temporal trends and hospital variations in red-cell use in a large contemporary obstetric cohort in Sweden.

STUDY DESIGN AND METHODS

Nationwide observational cohort study of maternal red-cell transfusions for all deliveries in Sweden between 2003 and 2017.

RESULTS

The proportion of deliveries that received red-cell transfusions was stable during the study period, although the number of red-cell units administered per delivery declined. Among transfused women, most received a low-volume transfusion of 1 or 2 units. Red-cell transfusion was more common among the nulliparous, for instrumental and caesarean deliveries, and with increased maternal age. We saw large variations in transfusion rates between hospitals in Sweden, despite adjusting for age and parity.

CONCLUSIONS

In comparison to other high-resource countries we see a high proportion of deliveries with maternal red-cell transfusions. However, we do not see an increase in red-cell use over time.

Inter-hospital variation in use of obstetrical blood transfusion: a population-based cohort study

OBJECTIVE

To identify the extent of hospital-to-hospital variation in use of obstetrical blood transfusion.

DESIGN

Population-based cohort study linking provincial perinatal and blood transfusion registries.

SETTING

British Columbia, Canada, 2004-2015.

POPULATION

All pregnant women delivering at or beyond 20 weeks' gestation at any British Columbia hospital.

METHODS

Mixed-effects regression models were used to estimate hospital-specific transfusion rates after sequentially accounting for (1) the role of random variation, (2) maternal medical and obstetrical characteristics (i.e. patient case mix) and (3) institutional and delivery factors (such as use of instrumental or caesarean delivery).

MAIN OUTCOME MEASURES

Hospital-specific use of obstetrical red blood cell transfusion.

RESULTS

Among 44 hospitals, crude institutional transfusion rates across the study period ranged from 3.7 to 23.6 per 1000, with an average of 8.3 per 1000. After adjusting for maternal characteristics, institution and delivery risk factors, a nearly three-fold difference in rates between the 10th and 90th percentile remained (5.4-14.5 per 1000). Twelve sites had rates significantly higher or lower than the provincial average. Women residing in remote areas were 2.5-fold (95% CI 1.8-3.5] more likely to receive a blood transfusion than were women residing in metropolitan areas.

CONCLUSIONS

Meaningful variation between hospitals in use of blood transfusion during pregnancy was not explained by differences in patient case-mix or institutional factors, suggesting that over- or under-utilisation of this resource may be occurring in obstetrical care.

TWEETABLE ABSTRACT

Use of blood transfusion in pregnant women varied broadly between hospitals in British Columbia, Canada.

Assessing the effect of risk factors on rates of obstetric transfusion over time using two methodological approaches

Background

While red blood cell transfusion rates have declined in most Australian medical specialties, obstetric transfusion rates have instead been increasing. Obstetric transfusions are mostly linked to postpartum haemorrhage, the rates of which have also increased over time. This study used two methodological approaches to investigate recent trends in obstetric transfusion in New South Wales (NSW) and the extent to which this was influenced by changing maternal and pregnancy characteristics.

Methods

Linked birth and hospital records were used to examine rates of red blood cell transfusion in the postpartum period for mothers giving birth in NSW hospitals from 2005 to 2015. Logistic regression models were run to examine the contribution of maternal and pregnancy risk factors to changing rates of transfusion. Risk factors were divided into “pre-pregnancy” and “pregnancy related”. Crude and adjusted estimates of the effect of year of birth on obstetric transfusion rates were compared to assess the effect of risk factors on rates over time using two approaches. The first compared actual and predicted odds ratios of transfusion for each year. The second compared the observed increase in transfusion rate with that predicted after controlling for the risk factors.

Results

Among 935,659 births, the rate of obstetric transfusion rose from 13 per 1000 births in 2005 to 17 in 2011, and remained stable until 2015. From 2005 to 2015, postpartum haemorrhage increased from 74 to 114 per 1000 births. Compared with the rate in 2005, the available maternal and pregnancy characteristics only partially explained the change in rate of transfusion by 2015 (Method 1, crude odds ratio 1.39 (95% CI 1.25, 1.56); adjusted odds ratio 1.29 (95% CI 1.15, 1.45)). After adjustment for maternal and pregnancy characteristics, obstetric transfusion incidence was predicted to increase by 10.3%, but a 38.7% increase was observed (Method 2).

Conclusion

Rates of obstetric transfusion have stabilised after a period of increase. The trend could not be fully explained by measured maternal and pregnancy characteristics with either of the two approaches. Further investigation of rates and maternal and clinical risk factors will help to inform and improve obstetric blood product use.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0595-6) contains supplementary material, which is available to authorized users.

The clinical and economic consequences of practice style variations in common surgical interventions: A protocol for systematic review

BACKGROUND

Surgical intervention is one of the common therapeutic interventions applied to a vast class of diseases. Unwarranted variation in practice style in different locations is considered as practice style variations (PSVs), which cause undesirable effects on patient health status and economic consequences. The magnitude of the variations in surgical interventions and its effects on clinical outcomes of patients and also utilization of resources have been investigated in recent years. But the findings show considerable heterogeneities in magnitude and consequences. We develop a protocol to systematically review the current literature of PSV to explain the magnitude of PSV and its clinical and economic consequences.

METHOD

This systematic review will include observational and experimental studies to investigate magnitude and consequences of PSV in common surgical interventions, cardiovascular disease, urological, and ophthalmological diseases. Source of information is scientific databases, theses, clinical trials registrations website, and grey literature. A comprehensive electronic search will be conducted through PubMed, Web of Science, EBSCO, EMBASE, and Scopus databases. Studies are assessed systematically by 2 investigators. Methodological quality of the included studies is evaluated by the STROBE and CONSORT checklists. In case of data availability, we will pool findings of included studies by meta-analysis techniques in the CMA software. Subgroup analyses are based on the type of the interventions and selected diseases.

RESULTS

This study has ethical approval from ethical committee of Iran University of Medical Sciences, ethic code: IR.IUMS.REC1395.9221504203. The results will be published in a peer-reviewed journal.

CONCLUSION

A systematic review is considered as an appropriate scientific method for reaching a consensus on magnitude as well as consequences of PSV. Results of this study will help clinical experts to attain more knowledge about PSV and encourage them to use some tools such as clinical guidelines and shared decision making to alleviate its consequences.

Outcomes of subsequent pregnancy following obstetric transfusion in a first birth

Background

Increasing rates of postpartum haemorrhage and obstetric transfusion mean that more women are entering subsequent pregnancies with a history of blood transfusion. This study investigates subsequent pregnancy outcomes of women with a prior obstetric red cell transfusion, compared to women without a transfusion.

Methods

All women with a first pregnancy resulting in a liveborn singleton infant of at least 20 weeks gestation delivering in hospitals in New South Wales, Australia, between 2003 and 2012 were included in the study, with followup for second births until June 2015. Linked hospital and births data were used to identify women with a transfusion and/or postpartum haemorrhage in their first birth, time to second pregnancy and adverse birth outcomes (including transfusion, postpartum haemorrhage and severe morbidity) in their subsequent birth.

Results

There were 358,384 singleton births to primiparous women, with 1.4% receiving an obstetric blood transfusion. Sixty-three percent of women had at least one subsequent birth. The relative risk (RR) of requiring a transfusion in a second birth was 4.9 (95% CI 4.1,6.1) for women with a previous transfusion compared with women without. The risk (RR) of severe morbidity in a second birth was 4.1 times higher (95% CI 2.2,7.4) for those receiving a transfusion without haemorrhage in their first birth compared with women with neither haemorrhage nor transfusion.

Conclusion

It is important to consider a woman’s history of transfusion and/or haemorrhage as part of her obstetric history to ensure management in a manner that minimises risk in subsequent pregnancies.

National and International Guidelines for Patient Blood Management in Obstetrics: A Qualitative Review

In developed countries, rates of postpartum hemorrhage (PPH) requiring transfusion have been increasing. As a result, anesthesiologists are being increasingly called upon to assist with the management of patients with severe PPH. First responders, including anesthesiologists, may adopt Patient Blood Management (PBM) recommendations of national societies or other agencies. However, it is unclear whether national and international obstetric societies' PPH guidelines account for contemporary PBM practices. We performed a qualitative review of PBM recommendations published by the following national obstetric societies and international groups: the American College of Obstetricians and Gynecologists; The Royal College of Obstetricians and Gynecologists, United Kingdom; The Royal Australian and New Zealand College of Obstetricians and Gynecologists; The Society of Obstetricians and Gynecologists of Canada; an interdisciplinary group of experts from Austria, Germany, and Switzerland, an international multidisciplinary consensus group, and the French College of Gynaecologists and Obstetricians. We also reviewed a PPH bundle, published by The National Partnership for Maternal Safety. On the basis of our review, we identified important differences in national and international societies' recommendations for transfusion and PBM. In the light of PBM advances in the nonobstetric setting, obstetric societies should determine the applicability of these recommendations in the obstetric setting. Partnerships among medical, obstetric, and anesthetic societies may also help standardize transfusion and PBM guidelines in obstetrics.

Intravenous iron: barriers and facilitators to its use at nine maternity hospitals in New South Wales, Australia

BACKGROUND

Anaemia in pregnancy is mostly due to iron deficiency, and the use of intravenous (IV) iron is gaining acceptance as a treatment option. Recently released obstetric transfusion guidelines recommend IV iron for obstetric patients in certain situations, including when oral formulations are poorly tolerated, unlikely to be well absorbed, or when rapid restoration of iron stores is required.

AIMS

To identify barriers and facilitators to the use of IV iron in pregnancy among nine maternity hospitals in New South Wales, Australia.

MATERIALS & METHODS

A qualitative research study was undertaken using semi-structured interviews. Nine maternity units were chosen to cover a range of clinical settings and obstetric blood transfusion rates. Interviews were conducted with haematologists, obstetricians and midwives, and included questions about the use of IV iron in each institution. Interviews were transcribed and coded, and NVivo software was used to develop themes.

RESULTS

A total of 125 interviews were conducted: 61 with doctors. The use of IV iron differed between hospitals and individual doctors. There were hospital/pharmaceutical, clinician and patient factors which acted as either barriers or facilitators to the use of IV iron. Where perceived barriers outweighed facilitators in a particular hospital, doctors were less likely to use IV iron.

DISCUSSION

The use of IV iron, as perceived by doctors, differed across hospitals. There are some potentially modifiable barriers to the use of IV iron that may need to be addressed for IV iron to be available to obstetric patients not tolerating oral formulations or requiring rapid restoration of iron stores.