Disclosure of physician-specific behavior improves blood utilization protocol adherence in cardiac surgery

Background: Evidence indicates that a transfusion (Tx) trigger hemoglobin (Hgb) value of 8 gm/dL may be safer than a more liberal Tx trigger in cardiac surgery (CS) patients. We hypothesized that weekly physician feedback would improve adherence to such a protocol, but that the public identification of individual physician behavior would have an additive effect.

Methods: We concurrently reviewed all adult CS patients at our institution from December 1, 2010 to May 27, 2011. We matched any cardiac surgery intensive care unit Tx event (red blood cells) with the Hgb value immediately before Tx. Patients requiring massive transfusions (>10 units/24 hours) were excluded. After all providers agreed upon a Hgb of 8 as the Tx trigger, we studied 3 consecutive time periods: no feedback, weekly feedback of group Tx behavior, and weekly feedback with identification of individual surgeon Tx behavior.

Results: Of the 512 patients who underwent cardiac operations, 144 patients underwent 510 Tx events. Compared with period 1, the unadjusted odds of receiving a Tx above 8 gm/dL decreased by 48% in study period 2(odds ratio: 0.52, p < 0.01), and 63% in study period 3(odds ratio: 0.37, p <0.001). Single unit transfusion rates increased from 77% to greater than 90% (p < 0.001). In-hospital mortality also fell from period 1 to period 3 (7.0% to 1.5%, p = 0.02) with the observed to expected mortality ratio decreasing from 2.19 to 0.51.

Conclusions: Blood transfusion protocol adherence improves when weekly feedback is provided. Identifying individual surgeon behavior improves adherence to a greater degree. Routine presentation of quality metrics with identification of individual physician-specific behavior may be the most effective way to accomplish performance improvement.