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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

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. Department of Clinical Psychology, Vrije Universiteit Amsterdam, Van der Boechorststraat 1-3, 1081, BT, Amsterdam, The Netherlands. Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands. 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. Department of Medical Psychology, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands. Department of Medical Statistics & Bioinformatics, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands. Department of Anesthesiology, Albert Schweitzer Hospital, P.O. Box 444, 3300, AK, Dordrecht, The Netherlands. Department of Anesthesiology, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands. Department of Orthopedics, Leiden University Medical Center, J11-R, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.

Implementation Science : Is. 2017;12((1)):72.
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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 (beta 0.21, 95% CI 0.08 to 0.34) and length of stay shorter (beta -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.
Study details
Language : English
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine