Trial of Feedback on Blood Use

Trial of Feedback on Blood Use (TOFU)

Background & Rationale Many studies have demonstrated substantial variability in blood use among both physicians and hospitals, suggesting the need to standardize transfusion practices and reduce unnecessary transfusions.To that end, national regulatory agencies in many countries require that hospitals monitor local blood use. However, the utility of this monitoring is unclear. A small number of prospective studies aimed at improving physician transfusion behavior have been published, but well-supported, generalizable findings are currently lacking. The proposed study will test the hypothesis that providing feedback of individual blood use data to transfusing physicians will reduce unnecessary RBC transfusions. A limited number of studies conducted in a range of settings have examined whether audit and feedback can improve physician practice and clinical outcomes. Results have been mixed. The proposed study would represent the first attempt to rigorously assess the impact of audit/feedback on changing transfusion practice.

The recently completed FOCUS trial presents a unique opportunity in that it provides high-quality data on which to base transfusion practice recommendations for a specific patient population. In the FOCUS trial, 2016 adult patients with a history of or risk factors for cardiovascular disease undergoing surgical hip fracture repair were randomized to be transfused with RBCs for a Hgb <10 g/dL (liberal group) or for symptoms of anemia and/or a Hgb <8 g/dL (restrictive group). The primary end point was the ability to ambulate independently at 60 days, and key secondary endpoints included 30-day and long-term mortality, myocardial infarction, and stroke. No significant difference was observed in any end point, demonstrating that -- as in the earlier TRICC trial -- a restrictive strategy was as safe as a liberal transfusion strategy. An earlier multicenter RCT similarly showed no difference in the rate of silent myocardial ischemia among 260 knee and hip surgery patients randomized to be transfused for a Hgb <8 g/dL or <10g/dL. With no demonstrable benefit of transfusing at a higher Hgb, and given the high costs and multiple risks of transfusion, adoption of the lower (8 g/dL) transfusion trigger in hip surgery patients seems logical. A small preliminary study was conducted at 9 BEST institutions. Each participating institution contributed data on a minimum of 10 consecutive patients who underwent total hip replacement surgery during 2010-11. Out of 186 patients, 63 (34%) were transfused postoperatively. 41/122 (34%) of the postoperative RBC units were transfused at a pretransfusion hemoglobin of > 8 g/dL, suggesting that a practice improvement opportunity exists.

Research Question In orthopedic surgeons performing adult elective hip surgery, does providing individual feedback data on transfusion practice in the context of the FOCUS trial data reduce postoperative RBC utilization compared with providing no feedback?

Primary Hypothesis Providing individual feedback on transfusion practice to orthopedic surgeons performing adult hip arthroplasty will reduce elective RBC transfusions in the postoperative period.