Red blood cell transfusion practices in patients undergoing orthopedic surgery: a multi-institutional analysis.

This retrospective review analyzed and compared transfusion practices in patients undergoing orthopedic surgery in five Massachusetts hospitals with current practice guidelines; opportunities for improvement were identified. Patient-specific clinical information and data about transfusion practices were obtained from the medical records of 384 Medicare patients undergoing orthopedic surgery between January 1992 and December 1993. The number of patients who donated autologous blood preoperatively differed significantly among hospitals as did the number of autologous units that were unused. The number of blood units transfused at each transfusion event also differed significantly; some surgeons transfused > or =2 units in the majority of their patients, while others transfused 1 unit at a time. This variation in practice was not explained by differences in patients' clinical status. The mean pretransfusion hematocrit was higher for autologous versus allogeneic blood, suggesting more liberal criteria to transfuse autologous blood. Nearly half of all transfusion events were determined to have been potentially avoidable. Avoidable transfusions were also three to seven times more likely with autologous than with allogeneic blood. Significant inter-hospital differences existed in the number of elective surgery patients exposed to allogeneic blood. The major determinant of allogeneic blood use in these patients was the availability of autologous blood. Each additional autologous blood unit available decreased the odds of allogeneic blood exposure twofold. Differences in intraoperative and postoperative blood salvage use also were noted. These findings indicate that significant variations in practice exist. Comparative data enabled hospitals to identify and target specific areas for improvement.

Practices in the Prevention of Venous Thromboembolism.

Objective: The objective of this study was to determine the proportion of Massachusetts Medicare patients who received prophylaxis for venous thromboembolism following colectomy, hysterectomy, or total hip arthroplasty. Sample frame: All 90 Massachusetts acute care hospitals. Time frame: 1 April through 30 September, 1994. Target population: Patients discharged with an International Classification of Disease (ICD-9-CM) discharge diagnostic code (recorded in the Massachusetts Medicare Claims Database) for colectomy, hysterectomy, or total hip arthroplasty were used to identify the target patient population. Sample population: 1,397 patients randomly selected from the target population, including 467 total hip arthroplasties, 474 colectomies, and 456 hysterectomies. Data extraction: Medical records were reviewed by trained nurse abstractors who collected information on the use of prophylaxis for venous thromboembolism. Results: Prophylaxis for venous thromboembolism was employed by surgeons practicing in Massachusetts hospitals in 93% of total hip arthroplasty cases (regional variation 85-98%), 84% of colectomies (regional variation 57-93%), 66% of hysterectomies (regional variation 35-71%), and in 87% of the subset of 111 hysterectomies with malignancy (regional variation 25-100%). Conclusions: The results of this statewide study demonstrated significant regional and hospital-to-hospital variation in the use of prophylaxis for venous thromboembolism following major surgery. A lower rate of prophylaxis use was observed in hospitals with fewer than 200 beds and in hospitals that did not have teaching programs. Hospitals with below-average rates of prophylaxis were targeted for intensive quality improvement interventions.

Improving the appropriateness of red blood cell transfusions in patients undergoing orthopedic surgery.

Orthopedic surgery is a common procedure among the elderly, and patients are at risk of receiving unnecessary blood transfusions. The goals of this project were to analyze current transfusion practices, identify opportunities for improvement, implement hospital-based quality improvement programs, and measure their impact on transfusion practices. Our aims were to decrease unnecessary transfusions and overall exposure to blood products. Data were abstracted from medical records, at baseline and postintervention. The results demonstrated significant improvements: a 55% decrease in avoidable transfusion events (from 42% to 19%, p < .001) and a decrease in the pre-transfusion hematocrit from a baseline of 29% to 26.9% in the postintervention period (p < .01). The percentage of single unit transfusion events increased from 71.9% to 77.2% (p = .05). These results suggest that the interventions had a significant impact on the use of blood. In the long term, these results should translate into cost savings and improved patient outcomes.

The prevention of venous thromboembolism: a statewide evaluation of practices in Massachusetts.

The objective of this study was to determine the proportion of Massachusetts Medicare patients who received prophylaxis for venous thromboembolism following colectomy, hysterectomy or total hip arthroplasty. The sample frame was all 90 Massachusetts acute care hospitals, and the time frame was 1 April to 30 September 1994. The patients discharged with an International Classification of Disease (ICD-9-CM) discharge diagnostic code (recorded in the Massachusetts Medicare Claims Database) for colectomy, hysterectomy or total hip arthroplasty were used to identify the target patient population. The sample population comprised 1397 patients randomly selected from the target population, including 467 total hip arthroplasties, 474 colectomies, and 456 hysterectomies. Medical records were reviewed by trained nurse abstractors who collected information on the use of prophylaxis for venous thromboembolism. Prophylaxis for venous thromboembolism was employed by surgeons practicing in Massachusetts hospitals in 93 per cent of total hip arthroplasty cases (regional variation 85-98 per cent), 84 per cent of colectomies (regional variation 57-93 per cent), 66 per cent of hysterectomies (regional variation 35-71 per cent), and in 87 per cent of the subset of 111 hysterectomies with malignancy (regional variation 25-100 per cent). The results of this statewide study demonstrated significant regional and hospital-to-hospital variation in use of prophylaxis for venous thromboembolism following major surgery. A lower rate of prophylaxis use was observed in hospitals with fewer than 200 beds and in hospitals that did not have teaching programmes. Hospitals with below-average rates of prophylaxis were targeted for intensive quality improvement interventions.

Physician practices in the prevention of deep vein thrombosis: the MassPRO DVT Study.

Numerous well-designed clinical trials have demonstrated that prophylaxis reduces the incidence of acute deep vein thrombosis (DVT) in high-risk surgical patients by two-thirds, with a corresponding reduction in mortality from pulmonary embolism. However, studies of clinical practices suggest that DVT prophylaxis is underused-for example, only 39% of high-risk surgical patients in 16 central Massachusetts hospitals were administered DVT prophylaxis in 1986. Subsequently, an intensive educational initiative was launched to improve utilization of DVT prophylaxis. Although some improvement was reported, the level of use was not optimal. The Massachusetts Peer Review Organization (MassPRO) DVT study was designed to gather data on recent practice patterns among Massachusetts surgeons and determine the need for additional educational and quality assurance efforts. The results indicate that there is broad compliance among orthopedic surgeons with consensus recommendations for the use of DVT prophylaxis. Nearly all patients who undergo total hip replacement in Massachusetts are protected from DVT by one or more methods of prophylaxis. These data suggest that the ongoing efforts to improve the use of DVT prophylaxis in Massachusetts since 1986 have come to fruition, at least with respect to total hip replacement.

Evaluating the appropriateness of red blood cell transfusions: the limitations of retrospective medical record reviews.

OBJECTIVE: Several studies have looked at the appropriateness of red blood cell transfusions, using retrospective chart reviews to assess compliance with guidelines. The goal of this study was to determine the quality of medical chart documentation, and assess the validity and the feasibility of using retrospective chart review data as part of a quality improvement (QI) program, to evaluate the appropriateness of peri-operative transfusions. DESIGN: The charts of 188 patients admitted for elective orthopedic surgery were reviewed. Both intra-operative and post-operative transfusion events (n = 353) were analyzed. RESULTS: Only 68% of post-operative transfusion events on the day of surgery and 35% of transfusion events on days after surgery were accompanied by documentation of blood loss and/or change in vital signs. Symptoms were recorded in only 10% of post-operative transfusion events. The rationale for transfusion was recorded in only 16% of post-operative transfusion events on the day of surgery, in 27% on post-operative days and in 95% of intra-operative transfusions. The documentation of rationale was not different for transfusion events involving autologous blood (31%) or allogeneic blood (32%). This study provided information on transfusion practices. Single unit transfusions occurred in only 47 and 34% of patients receiving autologous and allogeneic blood, respectively. Only 19% of patients transfused with more than one allogeneic blood units, were clinically reassessed between blood units, compared to 34% of patients receiving more than one autologous blood unit. We conclude that retrospective chart reviews are limited by inadequate documentation and may not be the optimal source of information to determine the appropriateness of a transfusion. Improved methods (e.g. prospective reviews, or other system-level data collection methods) are needed for QI programs to influence practice. Despite its limitations, the information obtained suggests that current practice could be improved.

Transfusion-associated circulatory overload in orthopedic surgery patients: a multi-institutional study.

Although recognized as a serious complication of hemotherapy, few data are available on the incidence of transfusion-associated circulatory overload (TACO). Detailed demographic and clinical information was obtained from records of 382 Medicare patients undergoing total hip or knee replacements (and receiving transfusions) from January 1992 to December 1993 at five Massachusetts hospitals. Seventy-eight percent of the patients were women with a mean age of 77 years. Thirty-two percent had co-morbidities including myocardial or coronary disease. Transfusion-related complications and comorbidities were identified and reviewed by transfusion experts. Patients were excluded from consideration if non-transfusion factors such as myocardial disease could have contributed to the development of acute pulmonary edema. Four (3 females, 1 male) patients (1.05%) developed TACO postoperatively. Mean age of these patients was 84 years (range, 75-101) versus 77 years for non-TACO. The mean intraoperative estimated blood loss was 375 mL. Each patient received only 1-2 units of red blood cells prior to onset of TACO, and in two cases only autologous blood was used. The mean positive fluid balance was 2,480 mL. The mean pretransfusion hematocrit prior to circulatory overload (CO) was 26.0 percent. Symptoms were reversed with diuretics. Length of stay was significantly prolonged by these incidents. TACO is a frequent and serious event in an orthopedic surgical setting. It is associated with advanced age, increased health care costs, and may occur in the setting of modest transfusion volumes. The utilization of conservative transfusion criteria and fluid management in the perioperative setting may decrease the incidence of this complication in this population.

Physician practices in the prevention of deep vein thrombosis: the masspro dvt study.

ABSTRACTNumerous well-designed clinical trials have demonstrated that prophylaxis reduces the incidence of acute deep vein thrombosis (DVT) in high-risk surgical patients by two-thirds, with a corresponding reduction in mortality from pulmonary embolism. However, studies of clinical practices suggest that DVT prophylaxis is underused - for example, only 39% of high-risk surgical patients in 16 central Massachusetts hospitals were administered DVT prophylaxis in 1986. Subsequently, an intensive educational initiative was launched to improve utilization of DVT prophylaxis. Although some improvement was reported, the level of use was not optimal. The Massachusetts Peer Review Organization (MassPRO) DVT study was designed to gather data on recent practice patterns among Massachusetts surgeons and determine the need for additional educational and quality assurance efforts. The results indicate that there is broad compliance among orthopedic surgeons with consensus recommendations for the use of DVT prophylaxis. Nearly all patients who undergo total hip replacement in Massachusetts are protected from DVT by one or more methods of prophylaxis. These data suggest that the ongoing efforts to improve the use of DVT prophylaxis in Massachusetts since 1986 have come to fruition, at least with respect to total hip replacement.

The Uniform Clinical Data Set: an evaluation of the proposed national database for Medicare's quality review program.

The accuracy, reliability, and validity of the Medicare Peer Review Organization (PRO) review process have all been questioned. Evidence concerning the PRO program's effect on cost and quality of care remains lacking. The Health Care Financing Administration has thus committed itself to reform, and the Uniform Clinical Data Set (UCDS) has been proposed as the national database for Medicare's quality review program. The UCDS is an automated, computerized data set designed to standardize the evaluation of quality. It should allow an objective, consistent, and efficient process for peer review, based on explicit decision criteria and on aggregated information about patterns of care and quality. But is this truly so? We review the existing evidence on the UCDS and compare it with the current PRO reviews of quality, concluding that although the UCDS can potentially improve the accuracy and the reliability of data abstraction and the validity of reviews, this remains to be shown. Preliminary data on the UCDS suggest that work is needed before it can meet appropriate expectations for a national database for quality assessments. We also propose a model for reviews of quality in which we show that reviews of care done in the context of internal quality improvement programs will differ in goals and intensity from reviews of care done at the national level. We suggest that the UCDS has a unique, but limited role--that of national surveillance of practice patterns. Detailed assessments of quality are more appropriately done at local or institutional levels.

Chlorination, chlorination by-products, and cancer: a meta-analysis.

OBJECTIVES: Individual epidemiological investigations into the association between chlorination by-products in drinking water and cancer have been suggestive but inconclusive. Enough studies exist to provide the basis for a meaningful meta-analysis. METHODS: An extensive literature search was performed to identify pertinent case-control studies and cohort studies. Consumption of chlorinated water, surface water, or water with high levels of chloroform was used as a surrogate for exposure to chlorination by-products. Relative risk estimates were abstracted from the individual studies and pooled. RESULTS: A simple meta-analysis of all cancer sites yielded a relative risk estimate for exposure to chlorination by-products of 1.15 (95% CI: 1.09, 1.20). Pooled relative risk estimates for organ-specific neoplasms were 1.21 (95% CI: 1.09, 1.34) for bladder cancer and 1.38 (95% CI: 1.01, 1.87) for rectal cancer. When studies that adjusted for potential confounders were pooled separately, estimates of relative risks did not change substantially. CONCLUSIONS: The results of this meta-analysis suggest a positive association between consumption of chlorination by-products in drinking water and bladder and rectal cancer in humans.

Screening for HBsAg in pregnant women: a cost analysis of the universal screening policy in the province of Quebec.

We carried out a cost analysis of a universal prenatal screening policy for hepatitis B virus infection in pregnant women. A universal screening policy in the province of Quebec (87,000 births per year) would cost about $473,000 per year and the prevention of one chronic carrier, $8,915. The cost varied greatly according to the ethnic origin of the mother and the cost of the serologic test. Strategies to reduce the cost of the serologic test could greatly reduce the cost of this screening policy.

[Evaluation of quality of care in the United States]. / L'évaluation de la qualité des soins aux Etats-Unis.

Quality assessment in the USA has been undertaken during the past twenty years by different institutions sponsored by the Congress, the government and professional associations. The evaluation tools which were developed reflect both the diversity of the American medical scene fashions in health care management. They evolved from norms to incentives, but each step in this evolution left its marks in the form of regulations, financial incentives and traditions.

Medical practice guidelines: current activities and future directions.

OBJECTIVE: To examine the state of the art in the field of medical practice guidelines, to identify limitations, and to suggest future directions. DESIGN: Informal descriptive survey using a questionnaire administered by telephone, supplemented by comments, by opinions, and by examples solicited from the participating organizations. PARTICIPANTS: Eight prominent organizations representing prototypic approaches to guideline development; these organizations included three medical societies, two health care organizations, two insurers, and one private health benefits management company. RESULTS: Improving the quality of medical care was a stated goal of all eight surveyed organizations. However, their objectives have not been stated in operational terms, reflecting the lesser emphasis placed on methods and means for both implementing guidelines and evaluating their impact on health practices and outcomes. In contrast, several systematic methods for developing guidelines exist. They differ in the stress placed on formal literature reviews, reliance on local as opposed to national experts, and formal methods of group judgment, but no evidence exists on which approaches produce sounder and more usable guidelines. CONCLUSIONS: Guidelines are being vigorously promoted as a means to improve the effectiveness of the health care system. Current initiatives show both strengths and weaknesses. In particular, the attention now paid to the development of guidelines needs to be matched by attention to implementation strategies and to the scientific evaluation of their effectiveness in real clinical settings. Also, more agreement is needed on acceptable methods for developing guidelines, assessing their content, and evaluating their impact on professional behavior, patient outcomes, and health care costs. Fortunately, several initiatives to bring greater order and quality to this field are under way.