NHS Blood and Transplant, John Radcliffe Hospital, Oxford, United Kingdom.
Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
JAMA Netw Open. 2022 Feb 1;5(2):e220364. doi: 10.1001/jamanetworkopen.2022.0364.
Auditing and feedback are frequently used to improve patient care. However, it remains unclear how to optimize feedback effectiveness for the appropriate use of treatments such as blood transfusion, a common but costly procedure that is more often overused than underused.
To evaluate 2 theoretically informed feedback interventions to improve the appropriate use of blood transfusions.
DESIGN, SETTING, AND PARTICIPANTS: Two sequential, linked 2 × 2 cluster randomized trials were performed in hospitals in the UK participating in national audits of transfusion for perioperative anemia and management of hematological disorders. Data were collected for a surgical trial from October 1, 2014, to October 31, 2016, with follow-up completed on October 31, 2016. Data were collected for a hematological trial through follow-up from July 1, 2015, to June 30, 2017. Trial data were analyzed from November 1, 2016, to June 1, 2019.
Hospitals were randomized to standard content or enhanced content to improve feedback clarity and usability and to standard support or enhanced support for staff to act on feedback.
The primary end point was appropriateness of transfusions audited at 12 months. Secondary end points included volume of transfusions (aiming for reductions at patient and cluster levels) and transfusion-related adverse events and reactions.
One hundred thirty-five of 152 eligible clusters participated in the surgical audit (2714 patients; mean [SD] age, 74.9 [14.0] years; 1809 women [66.7%]), and 134 of 141 participated in the hematological audit (4439 patients; median age, 72.0 [IQR, 64.0-80.0] years; 2641 men [59.5%]). Fifty-seven of 69 clusters (82.6%) in the surgical audit randomized to enhanced content downloaded reports compared with 52 of 66 clusters (78.8%) randomized to standard reports. Fifty-nine of 68 clusters (86.8%) randomized to enhanced support logged onto the toolkit. The proportion of patients with appropriate transfusions was 0.184 for standard content and 0.176 for enhanced content (adjusted odds ratio [OR], 0.91 [97.5% CI, 0.61-1.36]) and 0.181 for standard support and 0.180 for enhanced support (adjusted OR, 1.05 [97.5% CI, 0.68-1.61]). For the hematological audit, 53 of 66 clusters (80.3%) randomized to enhanced content downloaded the reports compared with 53 of 68 clusters (77.9%) randomized to standard content. Forty-nine of 67 clusters sites (73.1%) assigned to enhanced support logged into the toolkit at least once. The proportion of patients with appropriate transfusions was 0.744 for standard content and 0.714 for enhanced content (adjusted OR, 0.81 [97.5% CI, 0.56-1.12]), and 0.739 for standard support and 0.721 for enhanced support (adjusted OR, 0.96 [97.5% CI, 0.67-1.38]).
This comparison of cluster randomized trials found that interventions to improve feedback usability and guide local action were no more effective than standard feedback in increasing the appropriate use of blood transfusions. Auditing and feedback delivered at scale is a complex and costly program; therefore, effective responses may depend on developing robust local quality improvement arrangements, which can be evaluated using rigorous experimental designs embedded within national programs.
isrctn.org Identifier: ISRCTN15490813.
审核和反馈常用于改善患者护理。然而，对于如何优化反馈效果以适当使用输血等常见但昂贵的治疗方法，仍不清楚。输血是一种更常见的过度使用而不是使用不足的治疗方法。
评估 2 种基于理论的反馈干预措施，以改善输血的适当使用。
设计、设置和参与者：在英国参与围手术期贫血和血液系统疾病管理的输血国家审计的医院中进行了 2 项连续、链接的 2×2 聚类随机试验。从 2014 年 10 月 1 日至 2016 年 10 月 31 日收集外科试验的数据，随访于 2016 年 10 月 31 日完成。从 2015 年 7 月 1 日至 2017 年 6 月 30 日收集血液学试验的数据，通过随访完成。试验数据于 2016 年 11 月 1 日至 2019 年 6 月 1 日进行分析。
医院被随机分配到标准内容或增强内容以提高反馈的清晰度和可用性，以及标准支持或增强支持以促使员工采取行动。
主要终点是在 12 个月时进行输血的适当性审核。次要终点包括输血量（旨在降低患者和聚类水平）和输血相关的不良事件和反应。
在 152 个符合条件的聚类中有 135 个参加了外科审计（2714 名患者；平均[SD]年龄 74.9[14.0]岁；1809 名女性[66.7%]），134 个参加了血液学审计（4439 名患者；中位数年龄 72.0[IQR，64.0-80.0]岁；2641 名男性[59.5%]）。在外科审计中，随机分配到增强内容的 69 个聚类中有 57 个（82.6%）下载了报告，而随机分配到标准报告的 66 个聚类中有 52 个（78.8%）。在 68 个随机分配到增强支持的聚类中，有 59 个（86.8%）登录到工具包。标准内容组的适当输血比例为 0.184，增强内容组为 0.176（调整后优势比[OR]，0.91[97.5%CI，0.61-1.36]），标准支持组为 0.181，增强支持组为 0.180（调整后 OR，1.05[97.5%CI，0.68-1.61]）。在血液学审计中，随机分配到增强内容的 66 个聚类中有 53 个（80.3%）下载了报告，而随机分配到标准内容的 68 个聚类中有 53 个（77.9%）。在 67 个被分配到增强支持的聚类站点中，有 49 个（73.1%）至少登录过一次工具包。标准内容组的适当输血比例为 0.744，增强内容组为 0.714（调整后 OR，0.81[97.5%CI，0.56-1.12]），标准支持组为 0.739，增强支持组为 0.721（调整后 OR，0.96[97.5%CI，0.67-1.38]）。
本项聚类随机试验比较发现，改善反馈可用性和指导当地行动的干预措施并不比标准反馈更能增加输血的适当使用。在规模上进行审核和反馈是一个复杂且昂贵的项目；因此，有效的反应可能取决于建立强大的当地质量改进安排，这可以通过在国家计划中嵌入严格的实验设计来评估。
isrctn.org 标识符：ISRCTN8561634。
