Designing a strategy to implement cost-effective blood transfusion management in elective hip and knee arthroplasties: A study protocol

Abstract

Background Total hip and knee arthroplasties are two of the most commonly performed procedures in orthopedic surgery. Different blood-saving measures (BSMs) are used to reduce the often-needed allogenic blood transfusions in these procedures. A recent large randomized controlled trial showed it is not cost effective to use the BSMs of erythropoietin and perioperative autologous blood salvage in elective primary hip and knee arthroplasties. Despite dissemination of these study results, medical professionals keep using these BSMs. To actually change practice, an implementation strategy is needed that is based on a good understanding of target groups and settings and the psychological constructs that predict behavior of medical professionals. However, detailed insight into these issuses is lacking. Therefore, this study aims to explore which groups of professionals should be targeted at which settings, as well as relevant barriers and facilitators that should be taken into acount in the strategy to implement evidence-based, cost-effective blood transfusion management and to de-implement BSMs. Methods The study consists of three phases. First, a questionnaire survey among all Dutch orthopedic hospital departments and independent treatment centers (n = 99) will be conducted to analyze current blood management practice. Second, semistructured interviews will be held among 10 orthopedic surgeons and 10 anesthesiologists to identify barriers and facilitators that are relevant for the uptake of cost-effective blood transfusion management. Interview questions will be based on the Theoretical Domains Interview framework. The interviews will be followed by a questionnaire survey among 800 medical professionals in orthopedics and anesthesiology (400 professionals per discipline) in which the identified barriers and facilitators will be ranked by frequency and importance. Finally, an implementation strategy will be developed based on the results from the previous phases, using principles of intervention mapping and an expert panel. Discussion The developed strategy for cost-effective blood transfusion management by de-implementing BSMs is likely to reduce costs for elective hip and knee arthroplasties. In addition, this study will lead to generalized knowledge regarding relevant factors for the de-implementation of non-cost-effective interventions and insight in the differences between implementation and de-implementation strategies.

Implementation and de-implementation: two sides of the same coin?

“…We use empirical data here from two previously published studies, which are performed at different moments in time: one involving implementation28 29 and one involving de-implementation30 31 among Dutch orthopaedic surgeons. The implementation study aimed to identify factors influencing the implementation of a step-wise strategy of non-surgical therapy for patients with hip and knee osteoarthritis (OA) (including medication and referral guidelines) before undertaking surgical therapy 14.…”

Frequent use of blood-saving measures in elective orthopaedic surgery: a 2012 Dutch blood management survey

“…The conclusion of this study was thus that these three BSMs were not cost-effective in elective primary TKA and THA [12]. Annually, TKA are performed in about 20.000 patients and THA in about 26.000 patients [13], so that cost savings might be considerable if BSMs are de-implemented [14]. …”

Towards a systematic approach for (de)implementation of patient blood management strategies

“…Blood salvage includes two modalities: first; intraoperative cell salvage, which is used during surgery in which a patients' blood is collected, washed, concentrated and then re-infused, and second, a device that postoperatively collects, filters and re-infuses autologous wound blood by means of a wound drainage and re-infusion system (So-Osman et al, 2014b). Nowadays, the postoperative wound drainage system is used more commonly in primary arthroplasties opposed to intraoperative cell salvage, which is retained for more complex surgery such as revision arthroplasties (Voorn et al, 2013;Struijk-Mulder et al, 2014;Sikorski et al, 2017). In a recent multicentre RCT, it was concluded that blood salvage was not effective to prevent exposure to allogeneic transfusion or to reduce the number of allogeneic red blood cell units transfused in primary elective THA and TKA and therefore could be considered low-value care (So-Osman et al, 2014a,b).…”

“…Step 2: The analysis of current care, target group and setting (problem analysis) In this step, the extent of the de-implementation problem is mapped: how often and in what setting low-value care is used, the persons and patients involved in the PBM elements and the relevant barriers and facilitators that are involved in abandoning the PBM elements (Voorn et al, 2012). The problem analysis of the LISBOA study consisted of two parts.…”

“…The problem analysis of the LISBOA study consisted of two parts. Current use was assessed with a survey sent to all the heads of Dutch orthopaedic departments (Voorn et al, 2013). The survey demonstrated that 68% of the responders used ESAs on a regularly basis, intra-operative cell salvage was used by 31% of responders, and postoperative drainage and re-infusion was frequently used by 69% of the responders (response rate of the survey: 82%).…”