Low‐value care threatened the sustainability of healthcare even before the COVID‐19 pandemic with up to 30% of care estimated to be wasteful—meaning it does not add value and may even be harmful to patients. The direct costs of COVID‐19, along with backlogs of delayed care, and staffing shortages, have only intensified fiscal constraints. Now more than ever, healthcare systems must find ways to better utilize finite healthcare resources if they are to be sustainable. It was one decade ago that Choosing Wisely began in the United States to reduce the use of unnecessary medical tests, treatments, and procedures (i.e., low‐value care), and has since spread to over 30 countries. To date, it has been primarily a bottom‐up campaign. The lists by professional societies were a starting point that emphasized many of the “easy wins” to reducing low‐value care, but they are by no means the largest causes of waste in the healthcare system. Most unnecessary care is intertwined with appropriate care and is much more challenging to “de‐implement.” But in some countries, like Canada, Choosing Wisely has moved from an awareness campaign to focus on system re‐design. Not surprisingly, the evidence shows that the campaign has had modest successes in reducing low‐value care, typically at single sites and involving relatively easy‐to‐eliminate tests or treatments. Table 1 lists examples of strategies shown to reduce low‐value care that can be implemented across the hierarchy of intervention effectiveness. This framework is a useful way to conceptualize quality improvement interventions where the lowest ranking is the most feasible but least effective as compared to the higher levels that are increasingly effective yet the hardest to implement. Education and training, which represents the majority of where Choosing Wisely has focused to date, are at the bottom of the hierarchy because although necessary, these are rarely sufficient in order to change longstanding practice patterns, particularly because many drivers of overuse are unrelated to a gap in knowledge. Dedicated stewardship programs are a successful scalable example for reducing unnecessary antimicrobial use because they do not focus on education alone but additionally provide other interventions such as real‐time feedback on prescribing practices. This model can be applied to other targets (e.g., antithrombotic agents, psychoactive drugs in the elderly) but it is not feasible to dedicate personnel to oversee stewardship programs for every overuse problem. Similarly, we cannot burden clinicians with concurrent performance report cards for more than a handful of targets. Overuse is baked into many of our existing processes of care. Simple changes can be implemented at the level of organizational rules and policies, such as revising order sets and other process redesigns to reduce redundant or unnecessary laboratory and radiologic investigations. Yet, the underappreciated distinction between fixed and variable costs means these process changes, often initiated to save money, generate only the illusion of substantial savings. Double‐checks and reminders such as preprocedural screening of patients for appropriateness, for example, prior to knee and hip surgery, are often effective but resource intensive. Addressing regional variations in practice and providing feedback to facilities or health regions may help to inform opportunities but making improvements at this broader system level is unlikely to occur without strong alignment with physician leadership. The results of

Improving healthcare value: Lessons learned from the first decade of Choosing Wisely®

https://onlinelibrary.wiley.com/doi/pdf/10.1111/trf.16265

Adaptations of transfusion systems to the COVID-19 pandemic in British Columbia, Canada: Early experiences of a large tertiary care center and survey of provincial activities.

Background: Unnecessary blood transfusion exposes recipients to potential harms. Aim: The aim of this study was to describe blood transfusion practice and explore doctors’ attitudes towards transfusion. Setting: A hospital providing level 1 and 2 services. Methods: A mixed-methods study design was used. In the cross-sectional descriptive component, a sample was taken from patients transfused over a 2-month period. Blood use was categorised as for medical anaemia or haemorrhage, and appropriate or not. The qualitative component comprised a purposeful sample for focus group and individual semi-structured interviews. Results: Of 239 patients sampled, 62% were transfused for medical anaemia and 38% for haemorrhage. In the medical anaemia group, compliance with age-appropriate transfusion thresholds was 69%. In medical anaemia and haemorrhage, 114 (77%) and 85 (93.4%) of recipients had orders for ≥ 2 red blood cell (RBC) units, respectively. In adults ≥ 18 years old with medical anaemia, 47.1% of orders would have resulted in a haemoglobin (Hb) > 8 g/dL. Six doctors participated in focus group and eleven in individual interviews. There was a lack of awareness of institutional transfusion guidelines, disagreement on appropriate RBC transfusion thresholds and comments that more than one RBC unit should always be transfused. Factors informing decisions to transfuse included advice from senior colleagues, relieving symptoms of anaemia and high product costs. Conclusion: Most orders were for two or more units. In medical anaemia, doctors’ compliance with RBC transfusion thresholds was reasonable; however, almost half of the orders would have resulted in overtransfusion. The attitudes of doctors sampled suggest that their transfusion practice is influenced more by institutional values than formal guidelines.

/pdf/doctors-practice-and-attitudes-towards-red-blood-cell-15d1nj6lja.pdf

Doctors' practice and attitudes towards red blood cell transfusion at Mthatha Regional Hospital, Eastern Cape, South Africa: A mixed methods study.

In hemodynamically stable patients, both anemia and red blood cell (RBC) transfusion may be detrimental to patients; hence, a decision regarding RBC transfusion should be based on thorough risk–benefit assessment. According to hematology and transfusion medicine organizations, RBC transfusion is indicated when recommended hemoglobin (Hb) triggers are met, and symptoms of anemia are present. The aim of our study was to examine the appropriateness of RBC transfusions in non-bleeding patients at our institution. We performed a retrospective analysis of all RBC transfusions performed between January 2022 and July 2022. The appropriateness of RBC transfusion was based on the most recent Association for the Advancement of Blood and Biotherapies (AABB) guidelines and some additional criteria. The overall incidence of RBC transfusions at our institution was 10.2 per 1000 patient-days. There were 216 (26.1%) RBC units appropriately transfused and 612 (73.9%) RBC units that were transfused with no clear indications. The incidence of appropriate and inappropriate RBC transfusions were 2.6 and 7.5 per 1000 patient-days, respectively. The most frequent clinical situations when RBC transfusion was classified as appropriate were: Hb &lt; 70 g/L plus cognitive problems/headache/dizziness (10.1%), Hb &lt; 60 g/L (5.4%), and Hb &lt; 70 g/L plus dyspnea despite oxygen therapy (4.3%). The most frequent causes of inappropriate RBC transfusions were: no Hb determination pre-RBC transfusion (n = 317) and, among these, RBC transfused as a second unit in a single-transfusion episode (n = 260); absence of anemia sings/symptoms pre-transfusion (n = 179); and Hb concentration ≥80 g/L (n = 80). Although the incidence of RBC transfusions in non-bleeding inpatients in our study was generally low, the majority of RBC transfusions were performed outside recommended indications. Red blood cell transfusions were evaluated as inappropriate mainly due to multiple-unit transfusion episodes, absence of anemia signs and/or symptoms pre- transfusion, and liberal transfusion triggers. There is still the need to educate physicians on appropriate indications for RBC transfusion in non-bleeding patients. 

/pdf/appropriateness-of-allogeneic-red-blood-cell-transfusions-in-3ehh7572.pdf

Appropriateness of Allogeneic Red Blood Cell Transfusions in Non-Bleeding Patients in a Large Teaching Hospital: A Retrospective Study

Whether clinical practice guidelines have a significant impact on practice is unclear. The effect of guideline recommendations on clinical practice often a lags behind the date of publication. We evaluated by means of a data-driven approach if and when the guidelines on red blood cell transfusions (RBCTs) issued by Swiss Smarter Medicine in 2016 had an impact on RBCTs practice within a hospital network, where awareness of guidelines was promoted mainly among internal medicine specialties. Data on RBCTs performed in a Swiss hospital network from January 2014 to April 2021 were analyzed by hospital site and specialty to assess whether guidelines led to a decrease in inappropriate RBCTs. RBCTs were defined as "inappropriate" if patients had a hemoglobin level ≥ 70 g/L without or ≥ 80 g/L with significant cardiovascular comorbidities. Changes in the rate of inappropriate transfusions were analyzed with an advanced statistical approach that included generalized additive models. Overall prior to March 2017 there were more inappropriate than appropriate RBCTs, but after October 2017 the opposite could be observed. A change-point in the time trend was estimated from transfusion data to occur in the time interval between March and October 2017. This change was mainly driven by practice changes in the medical wards, while no significant change was observed in the critical care, surgical and oncology wards. Change in practice varied by hospital site. In conclusion, our results show that a significant change in the RBCTs practice at the hospital level occurred approximately 18 months after national guidelines were issued. 

/pdf/differential-impact-of-transfusion-guidelines-on-blood-1sdavmlh.pdf

Differential impact of transfusion guidelines on blood transfusion practices within a health network.

A prospective multi‐faceted interventional study of blood bank technologist screening of red blood cell transfusion orders: The START study

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A prospective multi‐faceted interventional study of blood bank technologist screening of red blood cell transfusion orders: The START study