Blood transfusion and autologous donation: a survey of post-surgical patients, interest group members and the public.

Before planned surgery, patients may choose autologous donation in order to avoid the small, but potential, risks of receiving an allogeneic blood transfusion. This study examined the perceived risks of allogeneic blood transfusions, preferences and willingness to pay for autologous donation and the desired role in the decision-making process in three populations: post-surgical patients, special interest group members and the general public. Quantitative and qualitative data were collected from 206 respondents with the help of computer-assisted semi-structured telephone interviews. Thirty-three per cent of the sample voiced concerns about receiving allogeneic blood transfusions. The risks of hepatitis C virus, human immunodeficiency virus, variant Creutzfeldt-Jakob disease and a haemolytic reaction were perceived as being low, but were rated as numerically higher than those of other life events that have equal probability. Autologous donation was perceived as removing all the risks associated with transfusion, and respondents were willing to pay a median $976 AUD ($664 US) to use this technique. Over 80% of respondents preferred to be involved in making the decision about whether to use autologous donation. Even though autologous donation is not 'risk-free' and the blood supply is very safe, people overestimate the associated risks and have a preference for their own blood. Decision aids presenting balanced information on the advantages and disadvantages of both allogeneic and autologous blood may be required.

Factors influencing the uptake of technologies to minimize perioperative allogeneic blood transfusion: an interview study of national and institutional stakeholders.

BACKGROUND: Alternatives to allogeneic blood transfusion exist and are being used to varying extents in Australian hospitals. Evidence on effectiveness and cost-effectiveness is generally inconclusive and provides a suboptimal basis for policy development. AIM: To describe the influences on uptake of transfusion technologies as perceived by national and institutional stakeholders. METHODS: Qualitative interview study. Interview transcripts were coded and analysed independently by at least two researchers. Participants had opportunity to comment on their transcript and the manuscript. RESULTS: A total of 71 interviews were conducted with representatives of the media, specialist medical societies, consumer special interest groups, the Australian Red Cross Blood Service (ARCBS), government, private health insurers, technology manufacturers, prominent clinicians in the area and a sample of clinicians drawn from hospitals with variable use of blood-saving technologies. Technical advances and acceptance of lower transfusion triggers were identified as the main influences on the decrease in use of allogeneic blood transfusion in the past decade. Participants indicated that patients were most aware and supportive of autologous predonation. Participants noted that 'enthusiasts' were involved in educating about the need for alternatives, negotiating resourcing and maintaining the use of a technology. Funding mechanisms were seen as main barriers to use of alternatives. A discrepancy was noted in the rigour of evaluation and regulation of pharmaceuticals and devices/procedures. CONCLUSIONS: Uptake of blood transfusion technologies by institutions was dependent mostly on funding arrangements and the presence of an 'enthusiast'. Critical review of the evidence for effectiveness or cost-effectiveness of these technologies was rarely mentioned. Opportunities exist for evidence-based medicine principles to play a greater role in policy decisions in this area.

Use of interventions to minimise perioperative allogeneic blood transfusion in Australia. A survey by the International Study of Perioperative Transfusion (ISPOT) Study Group.

OBJECTIVE: To investigate use of interventions to minimise need for perioperative transfusion of allogeneic blood in surgical units in Australia. DESIGN: Two questionnaire-based surveys of practice. SETTING: All hospitals in Australia, 1996-1997. PARTICIPANTS: Survey 1: all Australian hospitals that have at least 50 beds and undertake surgery; Survey 2: surgical units identified as using the interventions. MAIN OUTCOME MEASURES: Reported rates of use of the various interventions (preoperative autologous donation, acute normovolaemic haemodilution [ANH], cell salvage, and drugs); use of guidelines; and perceptions about the appropriateness of current levels of use. RESULTS: Survey 1 was returned by 349 of 400 hospitals (87%) and Survey 2 by 324 of 578 surgical units (56%). Preoperative autologous donation was most widely used (70% of hospitals), most commonly in units performing orthopaedic or vascular surgery (65% and 37%, respectively). Cell salvage and ANH were used by 27% and 24% of hospitals, respectively, most often in units performing cardiothoracic (40% and 44%, respectively) and vascular surgery (29% and 15%, respectively). These three interventions were used significantly more in private than in public hospitals (P < 0.05). Use of printed guidelines was uncommon. Respondents considered that autologous transfusion techniques should be used more widely because of their perceived efficacy and concerns about safety of allogeneic blood. Perceived barriers to greater use included lack of surgeon or physician interest, uncertain scheduling of surgery in public hospitals and cost (cell salvage). Drugs to minimise blood loss were used by fewer than 10% of hospitals. CONCLUSIONS: Interventions to minimise the need for perioperative allogeneic blood transfusion (apart from drugs) are widely used in Australia. However, enthusiasm for intraoperative techniques of re-infusing autologous blood needs to be assessed against the evidence of their efficacy and cost-effectiveness.

Evaluation of a national and international distance education program in clinical epidemiology (691).

Distance education (DE) has been used as a teaching mode for over 100 years for a variety of academic, vocational and recreational courses. This paper describes a postgraduate clinical epidemiology course conducted by DE for Australian and international health professionals, and compares the educational experiences of three groups of students (on-campus part-time, Australian DE and international DE). The groups were not expected to differ in academic achievement (marks) in eight subjects or in degree completion rates. The marks in each subject were not significantly different and typically were within five marks across all student groups. Approximately 40-50% of Australian DE students complete the graduate diploma coursework requirements in the minimum 2 years study. The completion rate increases to 70-80% as the period of candidature increase. The completion rates of Australian DE students were not significantly different from those of on-campus part-time students. Evaluation of the course by degree completion rates, comparison of academic achievement between off-campus and on-campus students, and qualitative feedback from students demonstrates that DE is as successful as on-campus teaching in providing training in clinical epidemiology at the postgraduate level. The flexibility of this mode of training as a means of providing public health training is discussed.

Colorectal cancer screening: discussions with first degree relatives.

Screening by faecal occult blood test and colonoscopy is recommended for first degree relatives of people with colorectal cancer. While it is known that screening participation among relatives is low, relatives' beliefs and attitudes towards screening have not been explored at an in-depth level. In this study, four focus group discussions with first degree relatives of people with colorectal cancer were held. Discussions were audio-taped, transcribed verbatim and the data were independently coded and analysed by the authors. Three main themes were identified: risk, understanding, and screening. Perceived risk was determined by family history, age and gender. Of concern, there was limited understanding of the asymptomatic nature of screening with most relatives initially 'screened' after consulting a doctor with colorectal symptoms. These findings need to be considered in screening programs.

An 'Academic Detailing' Intervention To Decrease Exposure to HIV Infection among Health-care Workers.

This intervention aimed to decrease health-care workers' experience of automatic pilot (mindless functioning) when performing high risk procedures. An academic detailing visit resulted in a significant increase in compliance with safety guidelines and a decreased incidence of other unsafe practices among 80 health care workers of two hospital units. The effects of mindlessness on health behaviour may be far reaching and the model described in this paper can be used to develop appropriate interventions.

Hospital administrators' tolerance of staff needlestick injuries.

OBJECTIVE: To survey hospital administrators regarding their opinions of an acceptable frequency of staff needlestick injury and the frequency that would prompt additional preventive action. DESIGN: A simple anonymous questionnaire sent to 960 administrators with one reminder. Data were collected regarding hospital size and community role, whether human immunodeficiency virus (HIV)-infected patients had ever been treated, presence of an infection control practitioner, estimation of the proportion of staff vaccinated against hepatitis B, and opinions as to the acceptable frequency of needlestick accidents and the accident frequency, requiring additional action. SETTING: 240 public hospitals in New South Wales, Australia. PARTICIPANTS: The executive officers, directors of medical services, directors of nursing, and safety officers of the hospitals surveyed. RESULTS: The response rate was 50%. Administrators' opinions of acceptable accident frequency increased with hospital size and (independently of size) with experience with HIV-infected patients, and with the presence of a full-time infection control practitioner. Accident frequencies judged to require additional preventive action were higher than injury frequencies regarded as acceptable. CONCLUSIONS: The hospital administrators surveyed accept staff needlestick injuries as inevitable, the more so in hospitals that have treated known HIV-infected patients and that have full-time infection control practitioners.