Abstract

Auditing and feedback are frequently used to improve patient care. However, it remains unclear how to optimize feedback effectiveness for the appropriate use of treatments such as blood transfusion, a common but costly procedure that is more often overused than underused. To evaluate 2 theoretically informed feedback interventions to improve the appropriate use of blood transfusions. Two sequential, linked 2 × 2 cluster randomized trials were performed in hospitals in the UK participating in national audits of transfusion for perioperative anemia and management of hematological disorders. Data were collected for a surgical trial from October 1, 2014, to October 31, 2016, with follow-up completed on October 31, 2016. Data were collected for a hematological trial through follow-up from July 1, 2015, to June 30, 2017. Trial data were analyzed from November 1, 2016, to June 1, 2019. Hospitals were randomized to standard content or enhanced content to improve feedback clarity and usability and to standard support or enhanced support for staff to act on feedback. The primary end point was appropriateness of transfusions audited at 12 months. Secondary end points included volume of transfusions (aiming for reductions at patient and cluster levels) and transfusion-related adverse events and reactions. One hundred thirty-five of 152 eligible clusters participated in the surgical audit (2714 patients; mean [SD] age, 74.9 [14.0] years; 1809 women [66.7%]), and 134 of 141 participated in the hematological audit (4439 patients; median age, 72.0 [IQR, 64.0-80.0] years; 2641 men [59.5%]). Fifty-seven of 69 clusters (82.6%) in the surgical audit randomized to enhanced content downloaded reports compared with 52 of 66 clusters (78.8%) randomized to standard reports. Fifty-nine of 68 clusters (86.8%) randomized to enhanced support logged onto the toolkit. The proportion of patients with appropriate transfusions was 0.184 for standard content and 0.176 for enhanced content (adjusted odds ratio [OR], 0.91 [97.5% CI, 0.61-1.36]) and 0.181 for standard support and 0.180 for enhanced support (adjusted OR, 1.05 [97.5% CI, 0.68-1.61]). For the hematological audit, 53 of 66 clusters (80.3%) randomized to enhanced content downloaded the reports compared with 53 of 68 clusters (77.9%) randomized to standard content. Forty-nine of 67 clusters sites (73.1%) assigned to enhanced support logged into the toolkit at least once. The proportion of patients with appropriate transfusions was 0.744 for standard content and 0.714 for enhanced content (adjusted OR, 0.81 [97.5% CI, 0.56-1.12]), and 0.739 for standard support and 0.721 for enhanced support (adjusted OR, 0.96 [97.5% CI, 0.67-1.38]). This comparison of cluster randomized trials found that interventions to improve feedback usability and guide local action were no more effective than standard feedback in increasing the appropriate use of blood transfusions. Auditing and feedback delivered at scale is a complex and costly program; therefore, effective responses may depend on developing robust local quality improvement arrangements, which can be evaluated using rigorous experimental designs embedded within national programs. isrctn.org Identifier: ISRCTN15490813.

Highlights

  • Blood for transfusion is a finite and costly resource that has known risks.[1]

  • The proportion of patients with appropriate transfusions was 0.184 for standard content and 0.176 for enhanced content and 0.181 for standard support and 0.180 for enhanced support

  • odds ratio (OR), 0.81 [97.5% CI, 0.56-1.12]), and 0.739 for standard support and 0.721 for enhanced support. This comparison of cluster randomized trials found that interventions to improve feedback usability and guide local action were no more effective than standard feedback in increasing the appropriate use of blood transfusions

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Summary

Introduction

Blood for transfusion is a finite and costly resource that has known risks.[1] Research advocates restrictive transfusion practice.[2] In England, the National Comparative Audit of Blood Transfusion (NCABT) assesses the appropriateness of transfusions and provides comparative performance feedback in a rolling program across different clinical specialties. The AFFINITIE (Audit and Feedback Interventions to Increase Evidence-Based Transfusion Practice) program aimed to design and evaluate enhanced feedback interventions within the NCABT and thereby increase appropriate use of blood components.[4] We followed guidance on complex interventions[5] in designing 2 feedback interventions to address specific weaknesses in feedback cycles identified in prior qualitative research.[3,6,7,8,9,10,11] We evaluated these enhanced content and enhanced support interventions for 2 transfusion topics: perioperative anemia management (surgical trial) and red blood cell and platelet use in patients with hematological malignant disease (hematological trial).[12]

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