Evidence map›Paper›PMID 28558843›Full record

Trial reportImplementation science : IS2017

The effectiveness of a de-implementation strategy to reduce low-value blood management techniques in primary hip and knee arthroplasty: a pragmatic cluster-randomized controlled trial.

Veronique M A Voorn, Perla J Marang-van de Mheen, Anja van der Hout, Stefanie N Hofstede, Cynthia So-Osman, M Elske van den Akker-van Marle, Ad A Kaptein, Theo Stijnen, Ankie W M M Koopman-van Gemert, Albert Dahan and 3 more

Open access · goldAbstract readRandomized Controlled TrialPragmatic Clinical Trial
PubMed Full text at PMC Publisher
In one paragraph

Trial report in Implementation science : IS, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 16 papers, 4 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
16citing papers in PubMed, 4 pooled it
1.9field-weighted citation impact, top 16% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

16 citing papers in PubMed, 4 syntheses or guidelines pooled it, 33 citations in OpenAlex.

  1. Tailored interventions to address determinants of practice.The Cochrane database of systematic reviews · 2026
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  4. Transfusion thresholds for guiding red blood cell transfusion.The Cochrane database of systematic reviews · 2021
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4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

13 authors at 3 institutions in 1 country.

Veronique M A VoornDepartment of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
Perla J Marang-van de MheenDepartment of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
Anja van der HoutDepartment of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
Stefanie N HofstedeDepartment of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
Cynthia So-OsmanDepartment of Transfusion Medicine, Sanquin Blood Supply, Plesmanlaan 1a, 2333, BZ, Leiden, The Netherlands.
M Elske van den Akker-van MarleDepartment of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
Ad A KapteinDepartment of Medical Psychology, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
Theo StijnenDepartment of Medical Statistics & Bioinformatics, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
Ankie W M M Koopman-van GemertDepartment of Anesthesiology, Albert Schweitzer Hospital, P.O. Box 444, 3300, AK, Dordrecht, The Netherlands.
Albert DahanDepartment of Anesthesiology, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
Thea P M M Vliet VlielandDepartment of Orthopedics, Leiden University Medical Center, J11-R, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
Rob G H H NelissenDepartment of Orthopedics, Leiden University Medical Center, J11-R, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
Leti van Bodegom-VosDepartment of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands. l.vanbodegom-vos@lumc.nl.
Leiden University Medical Center · NLGroene Hart Ziekenhuis · NLAlbert Schweitzer Ziekenhuis · NL

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

backgroundPerioperative autologous blood salvage and preoperative erythropoietin are not (cost) effective to reduce allogeneic transfusion in primary hip and knee arthroplasty, but are still used. This study aimed to evaluate the effectiveness of a theoretically informed multifaceted strategy to de-implement these low-value blood management techniques.

methodsTwenty-one Dutch hospitals participated in this pragmatic cluster-randomized trial. At baseline, data were gathered for 924 patients from 10 intervention and 1040 patients from 11 control hospitals undergoing hip or knee arthroplasty. The intervention included a multifaceted de-implementation strategy which consisted of interactive education, feedback on blood management performance, and a comparison with benchmark hospitals, aimed at orthopedic surgeons and anesthesiologists. After the intervention, data were gathered for 997 patients from the intervention and 1096 patients from the control hospitals. The randomization outcome was revealed after the baseline measurement. Primary outcomes were use of blood salvage and erythropoietin. Secondary outcomes included postoperative hemoglobin, length of stay, allogeneic transfusions, and use of local infiltration analgesia (LIA) and tranexamic acid (TXA).

resultsThe use of blood salvage (OR 0.08, 95% CI 0.02 to 0.30) and erythropoietin (OR 0.30, 95% CI 0.09 to 0.97) reduced significantly over time, but did not differ between intervention and control hospitals (blood salvage OR 1.74 95% CI 0.27 to 11.39, erythropoietin OR 1.33, 95% CI 0.26 to 6.84). Postoperative hemoglobin levels were significantly higher (β 0.21, 95% CI 0.08 to 0.34) and length of stay shorter (β -0.36, 95% CI -0.64 to -0.09) in hospitals receiving the multifaceted strategy, compared with control hospitals and after adjustment for baseline. Transfusions did not differ between the intervention and control hospitals (OR 1.06, 95% CI 0.63 to 1.78). Both LIA (OR 0.0, 95% CI 0.0 to 0.0) and TXA (OR 0.3, 95% CI 0.2 to 0.5) were significantly associated with the reduction in blood salvage over time.

conclusionsBlood salvage and erythropoietin use reduced over time, but not differently between intervention and control hospitals. The reduction in blood salvage was associated with increased use of local infiltration analgesia and tranexamic acid, suggesting that de-implementation is assisted by the substitution of techniques. The reduction in blood salvage and erythropoietin did not lead to a deterioration in patient-related secondary outcomes.

trial registrationwww.trialregister.nl, NTR4044.

Indexed as

AdultAgedAged, 80 and overArthroplasty, Replacement, HipArthroplasty, Replacement, KneeBlood TransfusionFemaleHumansMaleMiddle AgedNetherlandsOperative Blood SalvageDe-implementationHip and knee arthroplastyLow-value careMultifaceted strategyPerioperative autologous blood salvagePreoperative erythropoietin

Identifiers

PMID28558843
PMCPMC5450044
OpenAlexW2619812947

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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.