Data were collected on a total of 200 THA and 242 TKA primary and revision procedures between 2009 and 2015 that met inclusion criteria. The number of revisions are detailed in Table 2 for each sample and make up the minority of the data. Statistical analysis was performed using Statistica 6.0 (Statsoft Inc) using an ANOVA multivariate analysis for baseline characteristics and Pearson Chi-squared test for transfusion analysis. The level of significance for all statistical tests was set at 0.05.
The mean age for THA males and females was 65.6±11.4 yr and 69.3±12.6 yr, respectively. The mean age for TKA males and females was 67.7±8.6 yr and 67.3±8.8 yr, respectively. Significant age difference was found in the THA sample, showing older patients in 2009 compared with other samples (F (2, 149)=4.76, P<0.05). As expected, in both THA and TKA, males had a significantly greater preoperative hemoglobin (mean 14.1±1.5 for THA; and 14.4±1.5 for TKA, P<0.05) compared with females (mean 13.0±1.3 for THA; and 13.1±1.1 for TKA, P<0.05). The proportion of primary and revision cases within each sample was not statistically different between sample groups.
Chi square analysis showed significant reduction in transfusion rates from 2009 to 2015 in both THA (38.5%; 24.4%; 8.5%; and 12.5% for 2009; 2012; 2014; and 2015; χ2=17.9, P<0.05), and TKA (12.4%; 6.1%; 7.8%; and 2.1% for 2009; 2012; 2014; and 2015; χ2=4.2, P<0.05). This coincided with an increased adherence to give the blood transfusion in line with national guidelines in both THA and TKA (χ2=7.19, P=0.027) (Table 2 and Figure 3). Importantly, the TXA protocol was implemented after sampling in 2009. After its introduction, the most significant reductions in transfusions occurred when compared to baseline in both THA (38.5% to 24.4%) and TKA (12.4% to 6.1%), with these numbers continuing to drop in subsequent years once further initiatives were introduced.
Our study demonstrated the effectiveness of implementing several patient blood management strategies, including educational packages, a TXA protocol, and preoperative anemia optimization protocol. We found a stepwise reduction of allogenic transfusion rates, which coincided with an increased adherence in appropriateness to give a blood transfusion with national clinical practice guidelines at our institution. Previous studies have looked at the adherence of certain aspects of their respective national guidelines and a relationship to transfusion from a ‘before and after’ perspective. To our knowledge, however, this is the first study to implement multiple strategies and collect data across several years as the patient blood management landscape changed within Australia from an orthopaedic perspective. Recently, Norgaard et al.28 undertook a large patient blood management study in Denmark, which included both medical and surgical patients. They implemented a patient blood management program from their evidence-based guidelines and demonstrated significant reductions in transfusions and an overall increase in compliance with their national guidelines. Within Australia, Kopanidis et al.29 performed a before and after study that aimed to define an optimal strategy for blood management in the setting of major orthopaedic joint surgery using both preoperative and intraoperative measures. The authors compared usual care (no preoperative anemia optimization, no intraoperative TXA use) with an intervention (preoperative anemia optimization and intraoperative TXA). They found a reduction in incidence of preoperative anemia and a lower incidence of allogenic blood transfusions. Other authors have analyzed the effect of instituting a blood management program that included the use of preoperative iron transfusions with erythropoietin and intraoperative TXA with cell salvage devices.30 This program significantly reduced the rate of allogenic blood transfusions and length of stay.
There are several limitations to this study. First, the numbers in each cohort were small, and the incidence of transfusion within each cohort was small, therefore small differences can appear larger when expressed as a percentage. Second, the most significant reduction in transfusion rates were demonstrated after the 2009 sample. Our data suggested that patients in the 2009 cohort were statistically older than those in subsequent groups, raising the possibility that a younger demographic in cohorts following the 2009 sample may have contributed to these cohorts receiving fewer transfusions. It does not, however, explain the ongoing reduction in transfusion for subsequent years, nor does it explain the increase in adherence with national guidelines. Third, because of the progressive nature of implementing interventions across time, we recognize that there are many confounders to the trend in the data. We are not able to determine, which intervention(s), or which combination of interventions is most significant in causing a change in transfusion practice nor if an improvement in surgical technique may have contributed to a reduction in transfusion rates. This, however, was not the aim of the study because it was not intended to be a true ‘before and after’ study. The aim of the study was to simply outline a real-life example of implementing patient blood management strategies over time within a large network. Finally, the generalizability of our results to other hospitals is limited, since we collected data and implemented internal guidelines, despite these being based on national guidelines.
In conclusion, the introduction of several patient blood management strategies reduced the number of allogenic blood transfusions administered to patients undergoing THA and TKA at our institution. The reduction coincided with an increase in adherence to national blood transfusion guidelines. A multimodal and individualized approach is the most effective way to achieve this in a large health service and outlines how in reality these approaches and strategies are implemented over time.
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