Understanding Intraoperative Transfusion Decision-Making Variability: A Qualitative Study

Abstract

There is evidence of significant intraoperative RBC transfusion variability that cannot be explained by case-mix, and may reflect unwarranted transfusions. The objective was to explore the source of intraoperative red blood cell (RBC) transfusion variability by eliciting the beliefs of anesthesiologists and surgeons that underlie transfusion decisions. Interviews based on the Theoretical Domains Framework were conducted to identify beliefs about intraoperative transfusion. Content analysis was performed to group statements into domains. Relevant domains were selected based on frequency of beliefs, perceived influence on transfusion, and the presence of conflicting beliefs within domains. Of the twenty-eight transfusion experts recruited internationally (sixteen anesthesiologists, twelve surgeons), 24 (86%) were Canadian or American and 11 (39%) identified as female. Eight relevant domains were identified: 1) Knowledge (insufficient evidence to guide intraoperative transfusion), 2) Social/professional role and identity (surgeons/anesthesiologists share responsibility for transfusions), 3) Beliefs about consequences (concerns about morbidity of transfusion/anaemia), 4) Environmental context/resources (transfusions influenced by type of surgery, local blood supply, cost of transfusion), 5) Social influences (institutional culture, judgement by peers, surgeon-anesthesiologist relationship, patient preference influencing transfusion decisions), 6) Behavioural regulation (need for intraoperative transfusion guidelines, usefulness of audits and educational sessions to guide transfusion), 7) Nature of the behaviours (overtransfusion remains commonplace, transfusion practice becoming more restrictive over time), and 8) Memory, attention, and decision processes (various patient and operative characteristics are incorporated into transfusion decisions). This study identified a range of factors underlying intraoperative transfusion decision-making and partly explain the variability in transfusion behaviour. Targeted theory-informed behaviour-change interventions derived from this work could help reduce intraoperative transfusion variability.