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Health services research
Research
Hospital variation in allogeneic transfusion and extended length of stay in primary elective hip and knee arthroplasty: a cross-sectional study
  1. Veronique M A Voorn1,
  2. Perla J Marang-van de Mheen1,
  3. Anja van der Hout1,
  4. Cynthia So-Osman2,3,
  5. M Elske van den Akker–van Marle1,
  6. Ankie W M M Koopman–van Gemert4,
  7. Albert Dahan5,
  8. Thea P M Vliet Vlieland6,
  9. Rob G H H Nelissen6,
  10. Leti van Bodegom-Vos1
  11. on behalf of the LISBOA study group
  1. 1 Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
  2. 2 Department of Transfusion Medicine, Sanquin Blood Supply, Leiden, The Netherlands
  3. 3 Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
  4. 4 Department of Anesthesiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
  5. 5 Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
  6. 6 Department of Orthopedics, Leiden University Medical Center, Leiden, The Netherlands
  1. Correspondence to Dr Leti van Bodegom-Vos; l.vanbodegom-vos{at}lumc.nl

Abstract

Objectives Outcomes in total hip and knee arthroplasty (THA and TKA), such as allogeneic transfusions or extended length of stay (LoS), can be used to compare the performance of hospitals. However, there is much variation in these outcomes. This study aims to rank hospitals and to assess hospital differences of two outcomes in THA and TKA: allogeneic transfusions and extended LoS, and to additionally identify factors associated with these differences.

Design Cross-sectional medical record review study.

Setting Data were gathered in 23 Dutch hospitals.

Participants 1163 THA and 986 TKA patient admissions.

Outcomes Hospitals were ranked based on their observed/expected (O/E) ratios regarding allogeneic transfusion and extended LoS percentages (extended LoS was defined by postoperative stay >4 days). To assess the reliability of these rankings, we calculated which percentage of the existing variation was based on differences between hospitals as compared with random variation (after adjustment for variation in patient characteristics). Associations between hospital-specific factors and O/E ratios were used to explore potential sources of differences.

Results The variation in O/E ratios between hospitals ranged from 0 to 4.4 for allogeneic transfusion, and from 0.08 to 2.7 for extended LoS. Variation in transfusion could in 21% be explained by hospital differences in THA and 34% in TKA. For extended LoS this was 71% in THA and 78% in TKA. Better performance (low O/E ratios) in transfusion was associated with more frequent tranexamic acid (TXA) use in TKA (R=−0.43, p=0.04). Better performance in extended LoS was associated with more frequent TXA use in THA (R=−0.45, p=0.03) and TKA (R=−0.65, p<0.001) and local infiltration analgesia (LIA) in TKA (R=−0.60, p=0.002).

Conclusions Ranking hospitals based on allogeneic transfusion is unreliable due to small percentages of variation explained by hospital differences. Ranking based on extended LoS is more reliable. Hospitals using TXA and LIA have relatively fewer patients with transfusions and extended LoS.

  • Change management
  • Hip
  • Knee
  • Orthopaedic and Trauma Surgery

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjopen-2016-014143

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    Footnotes

    • Contributor LISBOA study group: B Boetes, SJM Breugem, GA Haeseker, D Haverkamp, JA Jansen, YE Könst, NP Kort, CALC Kremers-van de Hei, G Meermans, JJ Nieuwenhuis, AA Polak, WJ Rijnberg, WWJ Rosenberg, VAB Scholtes, H Sonneveld, M Stegeman, A Swets, EJ Uitterlinden, SBW Vehmeijer, AMJS Vervest, J Wolkenfelt, AVCM Zeegers, RG Zuurmond.

    • Contributors The study was designed by VV, PM, CS, TV, RN and LB. Data gathering was executed by VV and AH. Interpretation and analysis of data was done by VV, PM, AH, CS, MA, AK, RN, PM and LB. VV drafted the manuscript. All authors critically revised the manuscript and approved the final version.

    • Funding This work was supported by the Netherlands Organisation for Health Research and Development grant number 171203001 and Sanquin Blood Supply grant number PPOC13-010. Funding was obtained from the Netherlands Organisation for Scientific Research (NWO) Incentive fund Open Access publications. The funding sources did not play a role in the investigation.

    • Competing interests None declared.

    • Patient consent The Medical Ethical Committee of the Leiden University Medical Center decided that ethical approval was not required under Dutch National law (CME 13/132). The gathering of patient data is conducted in compliance with the Good Clinical Practices protocol.

    • Ethics approval The Medical Ethical Committee of the Leiden University Medical Center.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The relevant anonymised data are available upon reasonable request from the authors.