Choosing Wisely: Decreasing the incidence of perioperative blood transfusions in gynecologic oncology

doi:10.1016/j.ygyno.2019.03.008

Gynecologic Oncology

Volume 153, Issue 3, June 2019, Pages 597-603

https://doi.org/10.1016/j.ygyno.2019.03.008 Get rights and content

Highlights

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Implementation of a transfusion reduction program is associated with a reduction in transfusion in gynecologic surgery.
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Transfusion reduction is associated with a significant institutional cost savings.
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Transfusion reduction is not associated with increased morbidity or mortality.

Abstract

Objective

To evaluate the efficacy and economic impact of a transfusion reduction initiative for patients undergoing gynecologic surgery.

Methods

We conducted a prospective healthcare improvement study to align transfusion practices with the American Society of Hematology's Choosing Wisely® campaign. Baseline transfusion rates were determined retrospectively for all major gynecologic surgical cases from 3/1/14 to 6/30/14. Data for the post-intervention period from 5/15/15 to 5/16/16 were captured prospectively. The primary outcome was transfusion within 72 h of surgery. Secondary outcomes included perioperative morbidity, mortality, number of units ordered per transfusion episode and cost.

Results

We identified 1281 surgical cases, 334 in the baseline and 947 in the post-implementation cohort. The baseline cohort was noted to have a higher median estimated blood loss (100 v. 75 mL, P < 0.01). Otherwise, there were no differences in clinical or perioperative characteristics between the two cohorts. The perioperative transfusion rate decreased from 24% to 11% (adjusted OR 0.27, 95% CI 0.16 to 0.45; P < 0.001). The perioperative laparotomy transfusion rate decreased from 48% to 23% (adjusted OR 0.21, 95% CI 0.12, 0.37; P < 0.001). The number of occurrences in which more than one unit of blood was ordered at a time decreased from 65% to 23%, P < 0.001. The incidence of surgical site infections declined in the post-intervention group, otherwise there were no differences in 30-day mortality, cardiac, venous thromboembolism or readmission rates between the groups. The projected cost savings was $161,112 over the 12-month intervention period.

Conclusions

Implementation of an educational based transfusion reduction program was associated with substantial reductions in perioperative transfusions and cost without significant changes in morbidity or mortality.

Introduction

Choosing Wisely® is an initiative developed by the American Board of Internal Medicine to identify tests or procedures that are often over-utilized [1]. The Choosing Wisely® campaign has been adopted by many subspecialty societies to promote awareness of waste and potential harm through unnecessary testing. In 2013, the American Society of Hematology identified transfusions as one of their Choosing Wisely® targets. The society recommended against transfusing more than the minimal number of red blood cells necessary to alleviate symptoms of anemia or return a patient to a safe hemoglobin (hgb) range of 7 to 8 g/dL as well as to transfuse one unit of packed red blood cells (PRBCs) at a time in lieu of the traditional two units [2].

Patients with gynecologic cancer are at high risk of perioperative blood transfusions with reported rates as high as 41 to 77% [3,4]. Previous studies have demonstrated that blood transfusions are associated with increased perioperative morbidity and mortality [[5], [6], [7], [8]]. Despite the relative frequency of perioperative blood transfusions in gynecologic oncology, there is limited published support on development of transfusion reduction initiatives and their efficacy.

Review of our transfusion data in the Department of Gynecologic Oncology and Reproductive Medicine at The University of Texas MD Anderson Cancer Center (MD Anderson) revealed that our perioperative transfusion rate of 24% was significantly above the national average rate of 13.8% and that we were non-compliant with national blood utilization recommendations [5,9,10]. We therefore designed and implemented a healthcare improvement initiative to decrease our perioperative transfusion rates and align practices with current evidence-based guidelines. The primary aim of our health care improvement initiative was to decrease our perioperative transfusion rates by 25% for patients undergoing gynecologic surgery. Our primary endpoint was receipt of transfusion within 72 h of surgery. Secondary endpoints included compliance with guidelines, perioperative morbidity, 30-day mortality, projected blood savings, and estimated cost savings.

Section snippets

Materials and methods

This study was approved by the MD Anderson Quality Improvement Assessment Board and this manuscript has been prepared in accordance to the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines [11]. We utilized the Six Sigma Define, Measure, Analyze, Improve and Control model to design our intervention.

Results

We identified 1281 surgical cases, 334 in the baseline cohort and 947 in the post-implementation cohort. Patient demographic and clinical characteristics are listed in Table 1. Perioperative characteristics and surgical procedures performed are listed in Table 2. There were no differences between the two cohorts with regards to age, body mass index (BMI), preoperative chemotherapy, preoperative radiation, ASA class, race/ethnicity, presence of malignancy, cancer type, surgical approach or

Discussion

Perioperative transfusions in gynecologic surgery significantly decreased after implementation of an educational based transfusion reduction program in adherence with Choosing Wisely®. The pattern of transfusion reduction was observed across several subgroups and maintained over a 12-month period. Our intervention was associated with decreased variability in transfusion practices. We successfully transformed our practice from a high outlier to below the national average. This change in

Conclusion

We demonstrated an education-based transfusion reduction initiative is effective at decreasing perioperative blood utilization in gynecologic oncology. Transfusion reduction is a high-impact patient-centered health-care initiative with potential significant economic impact. There is an opportunity for continuous improvement, further transfusion reduction and expansion to other clinical settings.

Conflicts of interest

Dr. Meyers reports research funding from AstraZeneca for unrelated research. The others report no other conflicts of interest.

Acknowledgements and financial support

This research was supported in part by the National Institutes of Health (NIH) through MD Anderson Cancer Center Support Grant CA016672. Dr. Prescott's work on this project was supported by a NIH T32 grant, Training of Academic Gynecologic Oncologists, from the National Cancer Institute (5T32-CA101642). Dr. Meyers work on this project was supported by a NIH/NCI k07CA20103. The funding source had neither direct role in preparing or reviewing this study nor this manuscript. The authors thank M.

Authors' contributions

Lauren S. Prescott: (1) Involved in conception and design of the project, acquisition of data, analysis and interpretation of data (2) Participated in drafting the article and revising it critically for important intellectual content (3) Approved the final manuscript.

Jolyn Taylor: (1) Involved in acquisition of data (2) Participated in revising the article critically for important intellectual content (3) Approved the final manuscript.

Ahmed Enbaya: (1) Involved in acquisition of data (2)

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This retrospective study used data from children’s hospitals participating in the Pediatric Health Information System database. Children aged 17 years and younger who underwent umbilical hernia repair from July 2017 to August 2022 were eligible for inclusion. Children with recurrent hernias, an emergency, or urgent presentation were excluded. An interrupted time series using segmented multivariable logistic regression estimated the association of guideline publication in November 2019 with the odds of guideline-adherent repair (age ≥4) after adjusting for sociodemographic characteristics and hospital-level random effects.
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Guideline publication was associated with greater odds of guideline-adherent repair, yet public insurance coverage and Midwest location remain significant predictors of early repair against recommendations.
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To compare the venous thromboembolism (VTE) rate in patients with ovarian cancer undergoing neoadjuvant chemotherapy before and after implementing routine thromboprophylaxis.
This is a quasi-experimental pre-post study evaluating the VTE rate in patients with ovarian cancer who received neoadjuvant chemotherapy following a quality improvement initiative of routine thromboprophylaxis within a single healthcare system that started in January 2017. Patients were excluded if VTE was diagnosed before initiating chemotherapy. Patient factors and perioperative variables of interest were investigated for their association with VTE through univariate and multivariate models.
Of the 136 patients in the pre-implementation group, 3.7% (n = 5) received thromboprophylaxis. Of the 154 patients in the post-implementation group, 65.6% (n = 101) received thromboprophylaxis. Provider compliance varied from 51% in 2019 to 79.3% in 2021. The overall rate of VTE, from the start of chemotherapy to the end of treatment, was 21.3% (n = 29) pre- and 8.4% (n = 13) in the post-implementation group (p < 0.01). There was no difference in major bleeding events between groups (0% vs. 0.68%, p = 0.63). On univariate analysis, thromboprophylaxis (OR 0.19; 95% CI 0.07–0.52) and post-implementation period (OR 0.34; 95% CI 0.17–0.69) were associated with a decreased risk of any VTE during primary treatment. On multivariate analysis, only thromboprophylaxis remained significantly associated with reduced VTE rates (aOR 0.19; 95% CI 0.07–0.53).
Routine thromboprophylaxis during neoadjuvant chemotherapy is associated with reduced risk of VTE throughout primary treatment and is not associated with increased bleeding events.
Efficacy and safety of a restrictive blood transfusion protocol in gynecologic surgical patients
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Citation Excerpt :
A different study of a gynecologic oncology population showed a reduction in superficial and deep surgical site infections after the implementation of a restrictive transfusion protocol, though the authors comment on the concomitant implementation of a surgical site infection task force introduced during that time (Mark et al., 2019). In a study similarly modeled to this one that compared the administration of blood products before and after the initiation of a restrictive blood transfusion protocol as well as postoperative adverse events, Prescott et al. demonstrated a decrease in surgical site infection and no difference in 30-day mortality, VTE or cardiac rates between groups (Prescott et al., 2019). Our data expands on these findings to include analysis of reoperation on day of admission, reintubation, renal insufficiency, delirium, and readmissions.
This study sought to compare differences in blood transfusion and surgical complication rates before and after the implementation of a restrictive blood transfusion protocol.
On July 1, 2018, our institution implemented a restrictive blood transfusion protocol utilizing a hemoglobin trigger of less than 7 g/dL. Retrospective chart review was completed to review patients undergoing major abdominal surgery by the gynecology and gynecologic oncology services 18 months before, and after initiation of the transfusion protocol. Outcomes included number of patients, units transfused and postoperative complication rates. Complications included reoperation on the day of admission, surgical site infections, wound disruptions, pulmonary, renal, central nervous system, and cardiovascular complications, as well as deep venous thromboses, readmissions, and 30-day mortality.
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Risk factors of major intraoperative blood loss at primary debulking surgery for ovarian cancer
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Moreover, besides the risk of infection, blood transfusions will also reduce the survival time of patients with ovarian cancer. American Society of Hematology opposed transfusing more red blood cells (RBCs) than were necessary to relieve symptoms of anemia or return a patient to a safe level of hemoglobin5. Thus, it is important to assess the volume of intraoperative blood loss ahead of time.
The goal of this study was to find the risk factors for major intraoperative blood loss (MBL) of primary debulking surgery (PDS) for ovarian cancer.
Patients with ovarian cancer who underwent PDS in our hospital, from 2010 to 2017, were enrolled. The association between risk factors and MBL was modeled with the use of logistic regression. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive value of the logistic regression model.
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Citation Excerpt :
Initially, focusing on surgical settings, an international network of multidisciplinary clinicians and researchers developed patient blood management (PBM) as a holistic approach to optimizing the patient’s own blood by modifying the risk factors of anemia, minimizing blood loss, and harnessing and optimizing the patient’s physiological tolerance of anemia (Fig. A.1) [23]. Substantial evidence from large multicentric observational studies and randomized controlled trials shows that PBM programs [24–26] or single PBM treatment modalities [27–29] significantly improve patient outcomes and reduce resource utilization. Although PBM is endorsed in the World Health Organization (WHO) Assembly resolution WHA63.12 [30], comprehensive practice of PBM in oncology is under-recognized and underutilized.
There is accumulating evidence that anemia and iron deficiency, thrombocytopenia, blood loss and coagulopathy are independent risk factors for adverse patient outcomes in oncology and other settings. Patient blood management (PBM) aims to address these factors by managing and preserving a patient’s blood. PBM improves patient health, but also reduces resource utilization, including use of allogeneic blood components, which is another risk factor for adverse outcomes. Supported by the World Health Organization and endorsed in WHA63.12, PBM is recommended by an increasing number of health authorities and is about to become a new standard of care. In support of the Russian National Long-Term Oncology Strategy 2030 to improve quality of oncological care, and with support from the National Association of Specialists in PBM, the PBM Oncology Working Group of the Russian Federation was created. In July 2020, this Group met to discuss the rationale and need for PBM in Russian oncology care. The Group recommended to include PBM as an integral part of standard oncology treatment pathways and developed a national resolution as a call to action on this matter, which was adopted in August 2020. This article details the rationale behind the resolution, delineates the action required from facilitating stakeholders (government; healthcare providers; educational facilities; research entities/institutions; funders; patient representatives/advocates), and proposes a roadmap for implementation. The generation of local health-economic and outcome data and the development of educational programs will be important in the implementation of PBM to help alleviate the health, social and economic burden of cancer.
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However, minimizing the extent of remaining disease does not come free as the introduction of cytoreductive surgery results in complex procedures that often require resection of multiple viscera [6]. Perioperative blood transfusion in complex gynecologic oncology procedures is estimated to range from 15 to 50 % of cases and is often associated with increased post-operative morbidity, including increased risk of surgical site infection, sepsis and composite morbidity [7,8]. In the long term, perioperative transfusion seems to affect survival rates of cancer patients [9,10] and this effect is believed to be exerted through the process of transfusion-related immunomodulation which refers to the transient depression of the immune system [11].
The negative impact of perioperative blood transfusion on survival outcomes has been reported in several cancer types. The purpose of the present study is to summarize existing evidence in ovarian cancer patients. We searched the Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases for observational and randomized trials that assessed the impact of perioperative blood transfusion on the disease-free survival (DFS) and overall survival (OS) of ovarian cancer patients that undergone debulking surgery were selected for inclusion. The methodological quality of the included studies was assessed by using the Newcastle-Ottawa Scale. Statistical meta-analysis was performed with the RevMan 5.3 software using the Der-Simonian Laird random effects model. Seven studies were identified which included 2341 ovarian cancer patients. Meta-analyses that were based on univariate and multivariate reporting revealed that perioperative blood transfusion had a significant negative impact on the patient`s OS rates (OR 1.78, 95 %CI 1.16, 2.74 and OR 1.31, 95 %CI 1.00, 1.71 respectively). Disease free survival rates were also influenced according to the results of the univariate analysis (OR 1.58, 95 %CI 1.14, 2.19), however, the effect was not significant in the multivariate analysis. The analysis that was based on propensity score matched populations did not reveal differences among transfused and non-transfused. Concluding, the findings of our meta-analysis suggest that transfusion of blood products during the perioperative period is not an independent factor that may affect survival outcomes of ovarian cancer patients. Nevertheless, it should be noted that patients that receive transfusion have several potential confounders that may affect their survival outcomes.

View all citing articles on Scopus

¹: Present Address: Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville TN 37212, USA.

²: Present Address: School of Medicine, Temple University, Philadelphia, PA 19102, USA.

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Choosing Wisely: Decreasing the incidence of perioperative blood transfusions in gynecologic oncology

Highlights

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Conflicts of interest

Acknowledgements and financial support

Authors' contributions

Gynecol. Oncol.

Can. J. Diabetes

J. Biomed. Inform.

Cancer Treat. Rev.

Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the choosing wisely campaign

Acad. Med.

The AABB recommendations for the Choosing Wisely campaign of the American Board of Internal Medicine

Transfusion

The impact of perioperative packed red blood cell transfusion on survival in epithelial ovarian cancer

Int. J. Gynecol. Cancer

Optimizing blood transfusion practices through bundled intervention implementation in patients with gynecologic cancer undergoing laparotomy

Obstet. Gynecol.

Blood transfusions in colorectal cancer surgery: incidence, outcomes, and predictive factors: an American College of Surgeons National Surgical Quality Improvement Program analysis

Am. J. Surg.

Effects of allogeneic red blood cell transfusions on clinical outcomes in patients undergoing colorectal cancer surgery: a systematic review and meta-analysis

Ann. Surg.

Perioperative blood transfusion adversely affects prognosis after resection of lung cancer: a systematic review and a meta-analysis

BMC Surg.

Red blood cell transfusion: a clinical practice guideline from the AABB*

Ann. Intern. Med.

A new perspective on best transfusion practices

Blood Transfus.