Soril Lesley J J, Noseworthy Thomas W, Dowsett Laura E, Memedovich Katherine, Holitzki Hannah M, Lorenzetti Diane L, Stelfox Henry Thomas, Zygun David A, Clement Fiona M
Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada.
BMJ Open. 2018 May 18;8(5):e019912. doi: 10.1136/bmjopen-2017-019912.
To assess the impact of behaviour modification interventions to promote restrictive red blood cell (RBC) transfusion practices.
Systematic review and meta-analysis.
SETTING, PARTICIPANTS, INTERVENTIONS: Seven electronic databases were searched to January 2018. Published randomised controlled trials (RCTs) or non-randomised studies examining an intervention to modify healthcare providers' RBC transfusion practice in any healthcare setting were included.
The primary outcome was the proportion of patients transfused. Secondary outcomes included the proportion of inappropriate transfusions, RBC units transfused per patient, in-hospital mortality, length of stay (LOS), pretransfusion haemoglobin and healthcare costs. Meta-analysis was conducted using a random-effects model and meta-regression was performed in cases of heterogeneity. Publication bias was assessed by Begg's funnel plot.
Eighty-four low to moderate quality studies were included: 3 were RCTs and 81 were non-randomised studies. Thirty-one studies evaluated a single intervention, 44 examined a multimodal intervention. The comparator in all studies was standard of care or historical control. In 33 non-randomised studies, use of an intervention was associated with reduced odds of transfusion (OR 0.63 (95% CI 0.56 to 0.71)), odds of inappropriate transfusion (OR 0.46 (95% CI 0.36 to 0.59)), RBC units/patient weighted mean difference (WMD: -0.50 units (95% CI -0.85 to -0.16)), LOS (WMD: -1.14 days (95% CI -2.12 to -0.16)) and pretransfusion haemoglobin (-0.28 g/dL (95% CI -0.48 to -0.08)). There was no difference in odds of mortality (OR 0.90 (95% CI 0.80 to 1.02)). Protocol/algorithm and multimodal interventions were associated with the greatest decreases in the primary outcome. There was high heterogeneity among estimates and evidence for publication bias.
The literature examining the impact of interventions on RBC transfusions is extensive, although most studies are non-randomised. Despite this, pooled analysis of 33 studies revealed improvement in the primary outcome. Future work needs to shift from asking, 'does it work?' to 'what works best and at what cost?'
CRD42015024757.
评估行为改变干预措施对促进限制性红细胞（RBC）输血实践的影响。
系统评价和荟萃分析。
设置、参与者、干预措施：检索了7个电子数据库至2018年1月。纳入已发表的随机对照试验（RCT）或非随机研究，这些研究在任何医疗环境中检验了一种干预措施以改变医疗服务提供者的RBC输血实践。
主要结局是接受输血的患者比例。次要结局包括不适当输血的比例、每位患者输注的RBC单位数、住院死亡率、住院时间（LOS）、输血前血红蛋白水平和医疗费用。使用随机效应模型进行荟萃分析，在存在异质性的情况下进行荟萃回归。通过Begg漏斗图评估发表偏倚。
纳入了84项低至中等质量的研究：3项为RCT，81项为非随机研究。31项研究评估了单一干预措施，44项研究检验了多模式干预措施。所有研究中的对照为标准治疗或历史对照。在33项非随机研究中，使用干预措施与输血几率降低（比值比[OR]0.63[95%置信区间（CI）0.56至0.71]）、不适当输血几率降低（OR0.46[95%CI0.36至0.59]）、每位患者输注的RBC单位数加权平均差（WMD：-0.50单位[95%CI-0.85至-0.16]）、住院时间（WMD：-1.14天[95%CI-2.12至-0.16]）和输血前血红蛋白水平降低（-0.28g/dL[95%CI-0.48至-0.08]）相关。死亡率几率无差异（OR0.90[95%CI0.80至1.02]）。方案/算法和多模式干预措施与主要结局的最大降幅相关。估计值之间存在高度异质性且有发表偏倚的证据。
尽管大多数研究是非随机的，但研究干预措施对RBC输血影响的文献很广泛。尽管如此，对33项研究的汇总分析显示主要结局有所改善。未来的工作需要从询问“它有效吗？”转向“什么最有效以及成本是多少？”
PROSPERO注册号：CRD42015024757。
