Clinical Decision Support Reduces Overuse of Red Blood Cell Transfusions: Interrupted Time Series Analysis

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Abstract

Background: Red blood cell transfusion is the most common procedure in hospitalized patients in the US. Growing evidence suggests that a sizeable percentage of these transfusions are inappropriate, putting patients at significant risk and increasing costs to the health care system. Methods: We performed a retrospective quasi-experimental study from November 2008 until November 2014 in a 576-bed tertiary care hospital. The intervention consisted of an interruptive clinical decision support alert shown to a provider when a red blood cell transfusion was ordered in a patient whose most recent hematocrit was ≥21%. We used interrupted time series analysis to determine whether our primary outcome of interest, rate of red blood cell transfusion in patients with hematocrit ≥21% per 100 patient (pt) days, was reduced by the implementation of the clinical decision support tool. The rate of platelet transfusions was used as a nonequivalent dependent control variable. Results: A total of 143,000 hospital admissions were included in our analysis. Red blood cell transfusions decreased from 9.4 to 7.8 per 100 pt days after the clinical decision support intervention was implemented. Interrupted time series analysis showed that significant decline of 0.05 (95% confidence interval [CI], 0.03-0.07; P <.001) units of red blood cells transfused per 100 pt days per month was already underway in the preintervention period. This trend accelerated to 0.1 (95% CI, 0.09-0.12; P <.001) units of red blood cells transfused per 100 pt days per month following the implementation of the clinical decision support tool. There was no statistical change in the rate of platelet transfusion resulting from the intervention. Conclusions: The implementation of an evidence-based clinical decision support tool was associated with a significant decline in the overuse of red blood cell transfusion. We believe this intervention could be easily replicated in other hospitals using commercial electronic health records and a similar reduction in overuse of red blood cell transfusions achieved.

Original languageEnglish (US)
JournalAmerican Journal of Medicine
DOIs
StateAccepted/In press - 2016

Fingerprint

Clinical Decision Support Systems
Erythrocyte Transfusion
Platelet Transfusion
Hematocrit
Erythrocytes
Confidence Intervals
Interrupted Time Series Analysis
Electronic Health Records
Tertiary Healthcare
Tertiary Care Centers
Delivery of Health Care
Costs and Cost Analysis

Keywords

  • Alert
  • Anemia
  • Choosing Wisely
  • Clinical decision support
  • Electronic health record
  • Electronic medical record
  • Interrupted time series analysis
  • Overuse
  • Quality
  • Red blood cell transfusion
  • Transfusion

ASJC Scopus subject areas

  • Medicine(all)

Cite this

@article{91224a10ea9d409cacd6693ce0293b5d,
title = "Clinical Decision Support Reduces Overuse of Red Blood Cell Transfusions: Interrupted Time Series Analysis",
abstract = "Background: Red blood cell transfusion is the most common procedure in hospitalized patients in the US. Growing evidence suggests that a sizeable percentage of these transfusions are inappropriate, putting patients at significant risk and increasing costs to the health care system. Methods: We performed a retrospective quasi-experimental study from November 2008 until November 2014 in a 576-bed tertiary care hospital. The intervention consisted of an interruptive clinical decision support alert shown to a provider when a red blood cell transfusion was ordered in a patient whose most recent hematocrit was ≥21{\%}. We used interrupted time series analysis to determine whether our primary outcome of interest, rate of red blood cell transfusion in patients with hematocrit ≥21{\%} per 100 patient (pt) days, was reduced by the implementation of the clinical decision support tool. The rate of platelet transfusions was used as a nonequivalent dependent control variable. Results: A total of 143,000 hospital admissions were included in our analysis. Red blood cell transfusions decreased from 9.4 to 7.8 per 100 pt days after the clinical decision support intervention was implemented. Interrupted time series analysis showed that significant decline of 0.05 (95{\%} confidence interval [CI], 0.03-0.07; P <.001) units of red blood cells transfused per 100 pt days per month was already underway in the preintervention period. This trend accelerated to 0.1 (95{\%} CI, 0.09-0.12; P <.001) units of red blood cells transfused per 100 pt days per month following the implementation of the clinical decision support tool. There was no statistical change in the rate of platelet transfusion resulting from the intervention. Conclusions: The implementation of an evidence-based clinical decision support tool was associated with a significant decline in the overuse of red blood cell transfusion. We believe this intervention could be easily replicated in other hospitals using commercial electronic health records and a similar reduction in overuse of red blood cell transfusions achieved.",
keywords = "Alert, Anemia, Choosing Wisely, Clinical decision support, Electronic health record, Electronic medical record, Interrupted time series analysis, Overuse, Quality, Red blood cell transfusion, Transfusion",
author = "Steven Kassakian and Thomas Yackel and Thomas Deloughery and David Dorr",
year = "2016",
doi = "10.1016/j.amjmed.2016.01.024",
language = "English (US)",
journal = "American Journal of Medicine",
issn = "0002-9343",
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TY - JOUR

T1 - Clinical Decision Support Reduces Overuse of Red Blood Cell Transfusions

T2 - Interrupted Time Series Analysis

AU - Kassakian, Steven

AU - Yackel, Thomas

AU - Deloughery, Thomas

AU - Dorr, David

PY - 2016

Y1 - 2016

N2 - Background: Red blood cell transfusion is the most common procedure in hospitalized patients in the US. Growing evidence suggests that a sizeable percentage of these transfusions are inappropriate, putting patients at significant risk and increasing costs to the health care system. Methods: We performed a retrospective quasi-experimental study from November 2008 until November 2014 in a 576-bed tertiary care hospital. The intervention consisted of an interruptive clinical decision support alert shown to a provider when a red blood cell transfusion was ordered in a patient whose most recent hematocrit was ≥21%. We used interrupted time series analysis to determine whether our primary outcome of interest, rate of red blood cell transfusion in patients with hematocrit ≥21% per 100 patient (pt) days, was reduced by the implementation of the clinical decision support tool. The rate of platelet transfusions was used as a nonequivalent dependent control variable. Results: A total of 143,000 hospital admissions were included in our analysis. Red blood cell transfusions decreased from 9.4 to 7.8 per 100 pt days after the clinical decision support intervention was implemented. Interrupted time series analysis showed that significant decline of 0.05 (95% confidence interval [CI], 0.03-0.07; P <.001) units of red blood cells transfused per 100 pt days per month was already underway in the preintervention period. This trend accelerated to 0.1 (95% CI, 0.09-0.12; P <.001) units of red blood cells transfused per 100 pt days per month following the implementation of the clinical decision support tool. There was no statistical change in the rate of platelet transfusion resulting from the intervention. Conclusions: The implementation of an evidence-based clinical decision support tool was associated with a significant decline in the overuse of red blood cell transfusion. We believe this intervention could be easily replicated in other hospitals using commercial electronic health records and a similar reduction in overuse of red blood cell transfusions achieved.

AB - Background: Red blood cell transfusion is the most common procedure in hospitalized patients in the US. Growing evidence suggests that a sizeable percentage of these transfusions are inappropriate, putting patients at significant risk and increasing costs to the health care system. Methods: We performed a retrospective quasi-experimental study from November 2008 until November 2014 in a 576-bed tertiary care hospital. The intervention consisted of an interruptive clinical decision support alert shown to a provider when a red blood cell transfusion was ordered in a patient whose most recent hematocrit was ≥21%. We used interrupted time series analysis to determine whether our primary outcome of interest, rate of red blood cell transfusion in patients with hematocrit ≥21% per 100 patient (pt) days, was reduced by the implementation of the clinical decision support tool. The rate of platelet transfusions was used as a nonequivalent dependent control variable. Results: A total of 143,000 hospital admissions were included in our analysis. Red blood cell transfusions decreased from 9.4 to 7.8 per 100 pt days after the clinical decision support intervention was implemented. Interrupted time series analysis showed that significant decline of 0.05 (95% confidence interval [CI], 0.03-0.07; P <.001) units of red blood cells transfused per 100 pt days per month was already underway in the preintervention period. This trend accelerated to 0.1 (95% CI, 0.09-0.12; P <.001) units of red blood cells transfused per 100 pt days per month following the implementation of the clinical decision support tool. There was no statistical change in the rate of platelet transfusion resulting from the intervention. Conclusions: The implementation of an evidence-based clinical decision support tool was associated with a significant decline in the overuse of red blood cell transfusion. We believe this intervention could be easily replicated in other hospitals using commercial electronic health records and a similar reduction in overuse of red blood cell transfusions achieved.

KW - Alert

KW - Anemia

KW - Choosing Wisely

KW - Clinical decision support

KW - Electronic health record

KW - Electronic medical record

KW - Interrupted time series analysis

KW - Overuse

KW - Quality

KW - Red blood cell transfusion

KW - Transfusion

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