BMJ Open. 2017; 7(7): e014143.

Hospital variation in allogeneic transfusion and extended length of stay in primary elective hip and knee arthroplasty: a cross-sectional study

Veronique M A Voorn,1 Perla J Marang-van de Mheen,1 Anja van der Hout,1 Cynthia So-Osman,2,3 M Elske van den Akker–van Marle,1 Ankie W M M Koopman–van Gemert,4 Albert Dahan,5 Thea P M Vliet Vlieland,6 Rob G H H Nelissen,6 and Leti van Bodegom-Vos1, on behalf of the LISBOA study group

Hip Knee

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.

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