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van Schie P, van Steenbergen LN, van Bodegom-Vos L, Nelissen RGHH, Marang-van de Mheen PJ. Between-Hospital Variation in Revision Rates After Total Hip and Knee Arthroplasty in the Netherlands: Directing Quality-Improvement Initiatives. J Bone Joint Surg Am 2020; 102:315-324. [PMID: 31658206 DOI: 10.2106/jbjs.19.00312] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Variation in 1-year revision rates between Dutch hospitals after primary total hip and knee arthroplasty (THA and TKA) may direct quality-improvement initiatives if this variation accurately reflects true hospital differences. The aim of the present study was to assess the extent of variation, both overall and for specific indications, as well as the statistical reliability of ranking hospitals. METHODS All primary THAs and TKAs that were performed between January 2014 and December 2016 were included. Observed/expected (O/E) ratios regarding 1-year revision rates were depicted in a funnel plot with 95% control limits to identify outliers based on 1 or 3 years of data, both overall and by specific indication for revision. The expected number was calculated on the basis of patient mix with use of logistic regression models. The statistical reliability of ranking hospitals (rankability) on these outcomes indicates the percentage of total variation that is explained by "true" hospital differences rather than chance. Rankability was evaluated using fixed and random effects models, for overall revisions and specific indications for revision, including 1 versus 3 years of data. RESULTS The present study included 86,468 THAs and 73,077 TKAs from 97 and 98 hospitals, respectively. Thirteen hospitals performing THAs were identified as negative outliers (median O/E ratio, 1.9; interquartile range [IQR], 1.5-2.5), with 5 hospitals as outliers in multiple years. Eight negative outliers were identified for periprosthetic joint infection; 4, for dislocation; and 2, for prosthesis loosening. Seven hospitals performing TKAs were identified as negative outliers (median O/E ratio, 2.3; IQR, 2.2-2.8), with 2 hospitals as outliers in multiple years. Two negative outlier hospitals were identified for periprosthetic joint infection and 1 was identified for technical failures. The rankability for overall revisions was 62% (moderate) for THA and 46% (low) for TKA. CONCLUSIONS There was large between-hospital variation in 1-year revision rates after primary THA and TKA. For most outlier hospitals, a specific indication for revision could be identified as contributing to worse performance, particularly for THA; these findings are starting points for quality-improvement initiatives.
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Affiliation(s)
- Peter van Schie
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
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Schnurr C, Giannakopoulos I, Arbab D, Dargel J, Beckmann J, Eysel P. No benefit of autologous transfusion drains in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2018; 26:1557-1563. [PMID: 28577064 DOI: 10.1007/s00167-017-4585-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 05/23/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE AND HYPOTHESIS Autologous blood transfusion drains are commonly used to reduce allogeneic blood transfusion rate after total knee arthroplasty. There is conflicting evidence as to whether autologous transfusion drains (ABT drains) were effective when restrictive transfusion triggers were used. The aim of our study was to ascertain where, as a part of a blood management protocol, autologous blood transfusion drains reduce the allogeneic blood transfusion rate after total knee arthroplasty. METHODS Two-hundred total knee arthroplasty patients were included in the prospective randomized controlled study. After implantation, a Redon drain without vacuum assistance (control, n = 100) or an autologous blood transfusion drain (ABT group, n = 100) was used. Demographic and operative data were collected. The blood loss, total blood loss, blood values and transfusion rate were documented. RESULTS The blood loss in the drains was significantly increased for the ABT group (409 vs. 297 ml, p < 0.001). There was a non-significant trend towards a higher total blood loss for ABT patients (1844 vs. 1685 ml, n.s.). The allogeneic blood transfusion rate was similar for both groups (8 vs. 9%, n.s.). Similarly, the number of transfused blood units was comparable between both groups (0.2U/patient vs. 0.17U/patient n.s.). CONCLUSION In combination with restrictive blood transfusion triggers, ABT drains had no positive effect on the allogeneic blood transfusion rate. The blood loss in ABT drains was higher. As a consequence, the use of ABT drains was discontinued. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Christoph Schnurr
- Clinic of Orthopedic Surgery, St. Vinzenz Hospital Düsseldorf, Schloßstr. 85, 40477, Düsseldorf, Germany.
| | - Ioannis Giannakopoulos
- Clinic of Orthopedic Surgery, St. Vinzenz Hospital Düsseldorf, Schloßstr. 85, 40477, Düsseldorf, Germany
| | - Dariusch Arbab
- Clinic of Orthopedic Surgery, Klinikum Dortmund, Beurhausstraße 40, 44137, Dortmund, Germany
| | - Jens Dargel
- Clinic for Orthopedic Surgery and Traumatology, University of Cologne, Joseph-Stelzmann-Str. 9, 50924, Cologne, Germany
| | - Johannes Beckmann
- Department for Endoprosthetics Lower Extremity, Sportklinik Stuttgart, Taubenheimstr. 8, 70372, Stuttgart, Germany
| | - Peer Eysel
- Clinic for Orthopedic Surgery and Traumatology, University of Cologne, Joseph-Stelzmann-Str. 9, 50924, Cologne, Germany
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Voorn VMA, van Bodegom-Vos L, So-Osman C. Towards a systematic approach for (de)implementation of patient blood management strategies. Transfus Med 2018; 28:158-167. [PMID: 29508467 DOI: 10.1111/tme.12520] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/26/2018] [Accepted: 02/12/2018] [Indexed: 12/14/2022]
Abstract
Despite the increasing availability of evidence in transfusion medicine literature, this evidence does not automatically find its way into practice. This is also applicable to patient blood management (PBM). It may concern the lack of implementation of effective new techniques or treatments, or it may apply to the (over)use of techniques and treatments (e.g. inappropriate transfusions) that have proven to be of limited benefit for patients (low-value care) and could be abandoned (de-implementation). In PBM literature, the implementation of restrictive transfusion thresholds and the de-implementation of inappropriate transfusions are described. However, most implementation strategies were not preceded by the identification of relevant barriers, and the used strategies were not often supported by literature on behavioural changes. In this article, we describe implementation vs de-implementation, highlight the current situation of (de)implementation in PBM and describe a systematic approach for (de)implementation illustrated by an example of a PBM de-implementation study regarding '(cost-) effective patient blood management in total hip and knee arthroplasty'. The systematic approach used for (de)implementation is based on the implementation model of Grol, which consists of the following five steps: the detection of improvement goals, a problem analysis, the selection of (de)implementation strategies, the execution of the (de)implementation strategy and an evaluation. Based on the description of the current situation and the experiences in our de-implementation study, we can conclude that de-implementation may be more difficult than expected as other factors may play a role in effective de-implementation compared to implementation.
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Affiliation(s)
- V M A Voorn
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands.,Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - L van Bodegom-Vos
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - C So-Osman
- Unit Transfusion Medicine, Sanquin, Leiden, The Netherlands.,Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
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4
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Recent Trends in Blood Utilization After Revision Hip and Knee Arthroplasty. J Arthroplasty 2017; 32:3693-3697. [PMID: 28951054 DOI: 10.1016/j.arth.2017.08.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/25/2017] [Accepted: 08/24/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Blood transfusion guidelines in elective surgery have been implemented over the last decade to minimize risk and cost related to transfusion without sacrificing patient outcomes. Blood utilization in primary total hip (THA) and total knee arthroplasty (TKA) has been extensively studied but there is a paucity of studies evaluating utilization in revision THA and TKA. The purpose of this study is to evaluate current trends in transfusion following revision THA and TKA. METHODS The Humana dataset was reviewed for transfusion trends from 2007 to 2015 for patients undergoing revision THA and TKA. Subgroup analysis was performed to evaluate the impact of age, gender, geographic location, and obesity. RESULTS In total, 9176 and 12,493 revision THA and TKA patients were analyzed with transfusion rates of 19.2% and 11.9%, respectively. Allogeneic packed red blood cells were most commonly transfused (90% and 92%, respectively). Transfusion rates decreased significantly from 24.7% to 10.3% and 15.9% to 4.5%, respectively, over the years 2007-2015. Women had higher transfusion rates (odds ratio [OR] THA:TKA 1.24:1.23), while obesity was associated with lower transfusion rates after revision THA (OR 0.88). Transfusion rates were higher in 2-component revisions compared to primary (OR THA:TKA 1.24:1.24), while 1-component revisions had lower transfusion rates than primary procedures (OR THA:TKA 0.79:0.25). CONCLUSION Transfusion rates after revision THA and TKA have fallen substantially since 2007. In 2016, only 10% and 4% of revision THA and TKA, respectively, required transfusion. The study should provide benchmark data for surgeons to use as comparison to the blood utilization following revision joint replacement at their institutions.
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Voorn VMA, Marang-van de Mheen PJ, van der Hout A, So-Osman C, van den Akker–van Marle ME, Koopman–van Gemert AWMM, Dahan A, Vliet Vlieland TPM, Nelissen RGHH, van Bodegom-Vos L. Hospital variation in allogeneic transfusion and extended length of stay in primary elective hip and knee arthroplasty: a cross-sectional study. BMJ Open 2017; 7:e014143. [PMID: 28729306 PMCID: PMC5541495 DOI: 10.1136/bmjopen-2016-014143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Outcomes in total hip and knee arthroplasty (THA and TKA), such as allogeneic transfusions or extended length of stay (LoS), can be used to compare the performance of hospitals. However, there is much variation in these outcomes. This study aims to rank hospitals and to assess hospital differences of two outcomes in THA and TKA: allogeneic transfusions and extended LoS, and to additionally identify factors associated with these differences. DESIGN Cross-sectional medical record review study. SETTING Data were gathered in 23 Dutch hospitals. PARTICIPANTS 1163 THA and 986 TKA patient admissions. OUTCOMES Hospitals were ranked based on their observed/expected (O/E) ratios regarding allogeneic transfusion and extended LoS percentages (extended LoS was defined by postoperative stay >4 days). To assess the reliability of these rankings, we calculated which percentage of the existing variation was based on differences between hospitals as compared with random variation (after adjustment for variation in patient characteristics). Associations between hospital-specific factors and O/E ratios were used to explore potential sources of differences. RESULTS The variation in O/E ratios between hospitals ranged from 0 to 4.4 for allogeneic transfusion, and from 0.08 to 2.7 for extended LoS. Variation in transfusion could in 21% be explained by hospital differences in THA and 34% in TKA. For extended LoS this was 71% in THA and 78% in TKA. Better performance (low O/E ratios) in transfusion was associated with more frequent tranexamic acid (TXA) use in TKA (R=-0.43, p=0.04). Better performance in extended LoS was associated with more frequent TXA use in THA (R=-0.45, p=0.03) and TKA (R=-0.65, p<0.001) and local infiltration analgesia (LIA) in TKA (R=-0.60, p=0.002). CONCLUSIONS Ranking hospitals based on allogeneic transfusion is unreliable due to small percentages of variation explained by hospital differences. Ranking based on extended LoS is more reliable. Hospitals using TXA and LIA have relatively fewer patients with transfusions and extended LoS.
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Affiliation(s)
- Veronique M A Voorn
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Anja van der Hout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Cynthia So-Osman
- Department of Transfusion Medicine, Sanquin Blood Supply, Leiden, The Netherlands
- Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
| | | | | | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Rob G H H Nelissen
- Department of Orthopedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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6
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Voorn VMA, Marang-van de Mheen PJ, van der Hout A, Hofstede SN, So-Osman C, van den Akker-van Marle ME, Kaptein AA, Stijnen T, Koopman-van Gemert AWMM, Dahan A, Vliet Vlieland TPMM, Nelissen RGHH, van Bodegom-Vos L. The effectiveness of a de-implementation strategy to reduce low-value blood management techniques in primary hip and knee arthroplasty: a pragmatic cluster-randomized controlled trial. Implement Sci 2017; 12:72. [PMID: 28558843 PMCID: PMC5450044 DOI: 10.1186/s13012-017-0601-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 05/16/2017] [Indexed: 01/07/2023] Open
Abstract
Background Perioperative autologous blood salvage and preoperative erythropoietin are not (cost) effective to reduce allogeneic transfusion in primary hip and knee arthroplasty, but are still used. This study aimed to evaluate the effectiveness of a theoretically informed multifaceted strategy to de-implement these low-value blood management techniques. Methods Twenty-one Dutch hospitals participated in this pragmatic cluster-randomized trial. At baseline, data were gathered for 924 patients from 10 intervention and 1040 patients from 11 control hospitals undergoing hip or knee arthroplasty. The intervention included a multifaceted de-implementation strategy which consisted of interactive education, feedback on blood management performance, and a comparison with benchmark hospitals, aimed at orthopedic surgeons and anesthesiologists. After the intervention, data were gathered for 997 patients from the intervention and 1096 patients from the control hospitals. The randomization outcome was revealed after the baseline measurement. Primary outcomes were use of blood salvage and erythropoietin. Secondary outcomes included postoperative hemoglobin, length of stay, allogeneic transfusions, and use of local infiltration analgesia (LIA) and tranexamic acid (TXA). Results The use of blood salvage (OR 0.08, 95% CI 0.02 to 0.30) and erythropoietin (OR 0.30, 95% CI 0.09 to 0.97) reduced significantly over time, but did not differ between intervention and control hospitals (blood salvage OR 1.74 95% CI 0.27 to 11.39, erythropoietin OR 1.33, 95% CI 0.26 to 6.84). Postoperative hemoglobin levels were significantly higher (β 0.21, 95% CI 0.08 to 0.34) and length of stay shorter (β −0.36, 95% CI −0.64 to −0.09) in hospitals receiving the multifaceted strategy, compared with control hospitals and after adjustment for baseline. Transfusions did not differ between the intervention and control hospitals (OR 1.06, 95% CI 0.63 to 1.78). Both LIA (OR 0.0, 95% CI 0.0 to 0.0) and TXA (OR 0.3, 95% CI 0.2 to 0.5) were significantly associated with the reduction in blood salvage over time. Conclusions Blood salvage and erythropoietin use reduced over time, but not differently between intervention and control hospitals. The reduction in blood salvage was associated with increased use of local infiltration analgesia and tranexamic acid, suggesting that de-implementation is assisted by the substitution of techniques. The reduction in blood salvage and erythropoietin did not lead to a deterioration in patient-related secondary outcomes. Trial registration www.trialregister.nl, NTR4044 Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0601-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Veronique M A Voorn
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.,Department of Orthopedic Surgery, Groene Hart Hospital, Bleulandweg 10, 2803, HH, Gouda, The Netherlands
| | - Perla J Marang-van de Mheen
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Anja van der Hout
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.,Department of Clinical Psychology, Vrije Universiteit Amsterdam, Van der Boechorststraat 1-3, 1081, BT, Amsterdam, The Netherlands
| | - Stefanie N Hofstede
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Cynthia So-Osman
- Department of Transfusion Medicine, Sanquin Blood Supply, Plesmanlaan 1a, 2333, BZ, Leiden, The Netherlands.,Department of Internal Medicine, Groene Hart Hospital, Bleulandweg 10, 2803, HH, Gouda, The Netherlands
| | - M Elske van den Akker-van Marle
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Ad A Kaptein
- Department of Medical Psychology, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Theo Stijnen
- Department of Medical Statistics & Bioinformatics, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | | | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Thea P M M Vliet Vlieland
- Department of Orthopedics, Leiden University Medical Center, J11-R, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Rob G H H Nelissen
- Department of Orthopedics, Leiden University Medical Center, J11-R, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
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Bedard NA, Pugely AJ, Lux NR, Liu SS, Gao Y, Callaghan JJ. Recent Trends in Blood Utilization After Primary Hip and Knee Arthroplasty. J Arthroplasty 2017; 32:724-727. [PMID: 27866952 DOI: 10.1016/j.arth.2016.09.026] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 09/14/2016] [Accepted: 09/20/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Blood conservation strategies have evolved greatly over the last 5 years. There is a paucity of large blood utilization studies of total hip arthroplasty (THA) and total knee arthroplasty (TKA) that include recently performed surgery. The purpose of this study was to use a large database to evaluate trends in blood transfusion after THA and TKA, including 2015 data. METHODS The Humana data set was reviewed from 2007 to the third quarter of 2015 for all patients undergoing primary THA and TKA. Rates and type of postoperative blood transfusion were trended through the years of the data set. Further subgroup analysis was performed to evaluate the impact of patients' age, gender, geographic location, and obesity on the incidence of blood transfusion using standard statistical techniques. RESULTS In total, 69,350 THA patients and 139,804 TKA patients were analyzed. Overall transfusion rate was 18.2% and 12.7% after TKA and THA, respectively. The most common type of blood transfused was allogeneic packed red blood cells (88% of all transfusions) followed by perioperative collected autologous blood (12% of all transfusions). There were no transfusions of preoperatively collected autologous blood. Transfusion rates decreased significantly from 21.3%-8.7% and 17.3%-4.4% for THA and TKA, respectively, over the years 2007-2015 (P < .001). CONCLUSION Rates of blood transfusion after primary THA and TKA have fallen precipitously since 2010 and are now down to 9% and 4% for THA and TKA, respectively. Blood management strategies instituted over the last 5 years have had a large impact on transfusion rates after joint arthroplasty.
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Affiliation(s)
- Nicholas A Bedard
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Andrew J Pugely
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Nathan R Lux
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Steve S Liu
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Yubo Gao
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - John J Callaghan
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Lozano M, Cid J. Transfusion medicine as of 2014. F1000PRIME REPORTS 2015; 6:105. [PMID: 25580259 PMCID: PMC4229729 DOI: 10.12703/p6-105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Transfusion of blood components is one of the most common medical treatments, and in spite of the time that has evolved since we started to transfuse blood routinely in the 1930s, there are issues associated with its use that we are still trying to improve. Issues such as when to transfuse and adverse effects associated with the transfusion are fields where new evidence is being generated that ideally should help us to indicate when and what to transfuse to the patients. The recognition that the evidence generated in randomized control trials was not widely applied to guide the indication of the transfusion of blood components has provoked the development of initiatives that try to reduce its unnecessary usage. Those initiatives, grouped under the name of patient blood management, have represented a significant paradigm change, and a growing number of activities in this field are performed in health-care facilities around the world. This article tries to summarize the latest publications in those fields.
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Akute perioperative Hämodilution ohne Verwendung von Hydroxyethylstärke. Anaesthesist 2014; 64:26-32. [DOI: 10.1007/s00101-014-2398-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 10/03/2014] [Accepted: 10/10/2014] [Indexed: 10/24/2022]
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Lorencatto F, Stanworth SJ, Gould NJ. Bridging the research to practice gap in transfusion: the need for a multidisciplinary and evidence-based approach. Transfusion 2014; 54:2588-92. [DOI: 10.1111/trf.12793] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Fabiana Lorencatto
- Division of Health Services Research and Management; City University London; London UK
| | - Simon J. Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Trust; John Radcliffe Hospital
- Radcliffe Department of Medicine; University of Oxford; Oxford UK
| | - Natalie J. Gould
- Division of Health Services Research and Management; City University London; London UK
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Voorn VMA, Marang-van de Mheen PJ, Wentink MM, Kaptein AA, Koopman-van Gemert AWMM, So-Osman C, Vliet Vlieland TPM, Nelissen RGHH, van Bodegom-Vos L. Perceived barriers among physicians for stopping non-cost-effective blood-saving measures in total hip and total knee arthroplasties. Transfusion 2014; 54:2598-607. [PMID: 24797267 DOI: 10.1111/trf.12672] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 02/17/2014] [Accepted: 02/17/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite evidence that the blood-saving measures (BSMs) erythropoietin (EPO) and intra- and postoperative blood salvage are not (cost-)effective in primary elective total hip and knee arthroplasties, they are used frequently in Dutch hospitals. This study aims to assess the impact of barriers associated with the intention of physicians to stop BSMs. STUDY DESIGN AND METHODS A survey among 400 orthopedic surgeons and 400 anesthesiologists within the Netherlands was performed. Multivariate logistic regression was used to identify barriers associated with intention to stop BSMs. RESULTS A total of 153 (40%) orthopedic surgeons and 100 (27%) anesthesiologists responded. Of all responders 67% used EPO, perioperative blood salvage, or a combination. After reading the evidence on non-cost-effective BSMs, 50% of respondents intended to stop EPO and 53% to stop perioperative blood salvage. In general, barriers perceived most frequently were lack of attention for blood management (90% of respondents), department priority to prevent transfusions (88%), and patient characteristics such as comorbidity (81%). Barriers significantly associated with intention to stop EPO were lack of interest to save money and the impact of other involved parties. Barriers significantly associated with intention to stop perioperative blood salvage were concerns about patient safety, lack of alternatives, losing experience with the technique, and lack of interest to save money. CONCLUSION Physicians experience barriers to stop using BSMs, related to their own technical skills, patient safety, current blood management policy, and lack of interest to save money. These barriers should be targeted in strategies to make BSM use cost-effective.
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Affiliation(s)
- Veronique M A Voorn
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
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Voorn VMA, Marang-van de Mheen PJ, So-Osman C, Kaptein AA, van der Hout A, van den Akker-van Marle ME, Koopman-van Gemert AWMM, Dahan A, Nelissen RGHH, Vliet Vlieland TPMM, van Bodegom-Vos L. De-implementation of expensive blood saving measures in hip and knee arthroplasties: study protocol for the LISBOA-II cluster randomized trial. Implement Sci 2014; 9:48. [PMID: 24755214 PMCID: PMC4049434 DOI: 10.1186/1748-5908-9-48] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 04/08/2014] [Indexed: 11/29/2022] Open
Abstract
Background Despite evidence that erythropoietin and intra- and postoperative blood salvage are expensive techniques considered to be non-cost-effective in primary elective total hip and knee arthroplasties in the Netherlands, Dutch medical professionals use them frequently to prevent the need for allogeneic transfusion. To actually change physicians’ practice, a tailored strategy aimed at barriers that hinder physicians in abandoning the use of erythropoietin and perioperative blood salvage was systematically developed. The study aims to examine the effectiveness, feasibility and costs of this tailored de-implementation strategy compared to a control strategy. Methods/Design A cluster randomized controlled trial including an effect, process and economic evaluation will be conducted in a minimum of 20 Dutch hospitals. Randomisation takes place at hospital level. The hospitals in the intervention group will receive a tailored de-implementation strategy that consists of four components: interactive education, feedback in educational outreach visits, electronically sent reports on hospital performance (all aimed at orthopedic surgeons and anesthesiologists), and information letters or emails aimed at other involved professionals within the intervention hospital (transfusion committee, OR-personnel, pharmacists). The hospitals in the control group will receive a control strategy (i.e., passive dissemination of available evidence). Outcomes will be measured at patient level, using retrospective medical record review. This will be done in all hospitals at baseline and after completion of the intervention period. The primary outcome of the effect evaluation is the percentage of patients undergoing primary elective total hip or knee arthroplasty in which erythropoietin or perioperative blood salvage is applied. The actual exposure to the tailored strategy and users’ experiences will be assessed in the process evaluation. In the economic evaluation, the costs of the tailored strategy and the control strategy in relation to the difference in their effectiveness will be compared. Discussion This study will show whether a systematically developed tailored strategy is more effective for de-implementation of non-cost-effective blood saving measures than the control strategy. This knowledge can be used in national and international initiatives to make healthcare more efficient. It also provides more generalized knowledge regarding de-implementation strategies. Trial registration This trial is registered at the Dutch Trial Register NTR4044.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Leti van Bodegom-Vos
- Department of Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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Ten-year follow-up on Dutch orthopaedic blood management (DATA III survey). Arch Orthop Trauma Surg 2014; 134:15-20. [PMID: 24276360 DOI: 10.1007/s00402-013-1893-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. This survey was conducted to assess the current use of perioperative blood-saving measures and to compare it with prior results. MATERIALS AND METHODS All departments of orthopaedic surgery at Dutch hospitals were sent a follow-up survey on perioperative blood-saving measures, and data were compared to the results of two surveys conducted 5 and 10 years earlier. RESULTS The response rate was 94 out of 108 departments (87%). Most departments used erythropoietin prior to hip and knee replacements at the expense of preoperative autologous blood donation. The use of intraoperative autologous retransfusion in revision hip (56 vs. 54%) as well as revision knee arthroplasty (26 vs. 24%), was virtually unchanged. Postoperative autologous retransfusion is still used by the majority of departments after both primary arthroplasty and revision of hip (58/53%) and knee (65/61%). CONCLUSIONS Currently, just as in 2007, the majority of Dutch orthopaedic departments uses erythropoietin, normothermia and postoperative autologous retransfusion with hip and knee arthroplasty. Intraoperative retransfusion is used mainly with hip revision arthroplasty. Other effective blood management modalities such as tranexamic acid have not been widely implemented.
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