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

Autor: Thea P. M. Vliet Vlieland, Veronique M. A. Voorn, Rob G H H Nelissen, Stefanie N. Hofstede, Albert Dahan, Ad A. Kaptein, Perla J Marang-van de Mheen, Theo Stijnen, Cynthia So-Osman, Ankie W. M. M. Koopman-van Gemert, Anja van der Hout, Leti van Bodegom-Vos, M. Elske van den Akker-van Marle
Přispěvatelé: Clinical Psychology, APH - Mental Health
Jazyk: angličtina
Rok vydání: 2017
Předmět:
Male
Blood transfusion
Arthroplasty
Replacement
Hip
medicine.medical_treatment
Hip and knee arthroplasty
law.invention
0302 clinical medicine
Randomized controlled trial
Perioperative autologous blood salvage
law
030212 general & internal medicine
Arthroplasty
Replacement
Knee
Netherlands
Aged
80 and over
lcsh:R5-920
030503 health policy & services
Health Policy
Preoperative erythropoietin
General Medicine
Middle Aged
De-implementation
Female
lcsh:Medicine (General)
0305 other medical science
Tranexamic acid
medicine.drug
Adult
medicine.medical_specialty
Blood management
Randomization
Health Informatics
03 medical and health sciences
SDG 3 - Good Health and Well-being
Internal medicine
medicine
Humans
Blood Transfusion
Aged
Operative Blood Salvage
business.industry
Research
Public Health
Environmental and Occupational Health
Multifaceted strategy
Perioperative
Arthroplasty
Low-value care
Surgery
Orthopedic surgery
business
Zdroj: Implementation Science, 12
Voorn, V M A, Marang-van de Mheen, P J, van der Hout, A, Hofstede, S N, So-Osman, C, van den Akker-van Marle, M E, Kaptein, A A, Stijnen, T, Koopman-van Gemert, A W M M, Dahan, A, Vliet Vlieland, T P M M, Nelissen, R G H H & van Bodegom-Vos, L 2017, ' 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 ', Implementation Science, vol. 12, no. 1, 72 . https://doi.org/10.1186/s13012-017-0601-0
Implementation Science, Vol 12, Iss 1, Pp 1-11 (2017)
Implementation Science : IS
Implementation Science, 12(1):72. BioMed Central
ISSN: 1748-5908
Popis: 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.
Databáze: OpenAIRE
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