Quality indicators (QIs) are measures that have been developed by Health Services to assess quality in healthcare. Many examples of quality indicators exist and various agencies in different countries make use of a selection to measure the status of their health system including the Agency for
Healthcare Research and Quality, The Joint Commission (and Joint Commission International), Canadian Institute for Health Information, (https://www.ahrq.gov, https://www.jointcommission.org,
https://www.chi.ca/en). Potential QIs should be assessed for feasibility depending on their practical application in health service studies and on the quality and availability of data; for reliability and reproducibility; for
acceptability both to assessors and institutions being scrutinised; for sensitivity to change; and for validity (Otsubo et al., 2016).
Blood product usage is ideally placed to be used as a quality indicator: Feasibility:
Blood product usage data can be very practically applied in healthcare services research. It is a measure that encapsulates appropriateness of practice in several clinical sectors simultaneously, health service funding, penetrance of policy and guidelines, the degree of unwarranted variation, and medical and nurse training. The data are readily available and are collected and published regularly conferring a huge advantage when compared to other indices. The quality of data is high and relatively easily retrieved from hospital and Blood Establishment databases.
Reliability:
Traceability of blood products has become a cornerstone of practice over the years. Legislation within the European Union for example has made
blood unit is accurately recorded allowing for extraction of very precise and reliable data.
Acceptability:
There appear to be no issues with acceptability. The values for national blood product usage are already published in Council of Europe reports and in various national reports and are freely available. Many hospitals voluntarily participate in international quality initiatives that include collection of data on blood usage e.g. the Performance Assessment Tool for Quality
Improvement in Hospitals (PATH) (www.pathqualityproject.eu). This is a system designed by the WHO to support hospitals defining strategies for improvement in quality (Groene et al., 2008).
Sensitivity to change:
Blood product usage is very sensitive to change. The financial crisis occurring in 2008 was followed by a significant downturn in the world economy. This had an extensive impact on most countries with health spending bearing its own share of cutbacks. Additionally the last few years have seen an emphasis on Patient Blood Management (PBM) programmes. PBM is a programme of initiatives some countries have adopted or are in the process of adopting to deal with optimising patient care in relation to blood transfusion. It aims for a multidisciplinary approach that encompasses measures to avoid
unnecessary transfusions and to ensure that patients receive optimal treatment. Both these initiatives and the financial crisis have had an impact on blood usage. It is immediately clear from the data in Tables 3.6 – 3.14 that in most countries red cell usage decreased on a national basis when
compared to the index value used throughout this thesis (Table 3.4). Validity:
Blood product usage, as an index measuring quality performance, has been validated by the analysis performed in this thesis. It was clearly shown that blood product usage does not relate to the overall performance of health care
systems. An index that moves with overall performance would not
necessarily be sensitive to change in the degree of unwarranted variation. Blood product usage however has been shown to move with markers that are directly related to supply sensitive care. Moreover, usage seems to be related also to cultural differences that may affect the extent of unwarranted
variation.
This thesis is therefore a powerful demonstration using very potent clinical totems – the widespread use of blood, the problems associated with it, the costs, the prevalence of guidelines, the existence of high grade studies in high grade journals – that irrational and evidence-denying variation in clinical practice exists and can be measured relatively easily, and that comparison of clinical use of blood in health care in discrete geographical regions may be used as a general measure of the effectiveness of different tools to improve practice over time and space, not just within the context of blood product use, but possibly in clinical practice in general.
Blood product usage is a valid measure of variation in practice within health care regions that do not have a reason for variation from other regions with similar economics and politics other than failure to implement good practice for whatever reason or reasons. It is therefore possible to envisage that variation in blood product usage can be used as a quality performance indicator to see whether direct interventions have an effect on this poor penetration of emerging evidence or to study the time to adoption of emerging evidence, and how that might be improved upon.
Variation in blood product usage would be an ideal candidate to measure changes brought about by the initiatives associated with transfusion which have been incorporated in the Choosing Wisely campaign. This started as an initiative of the American Board of Internal Medicine Foundation in the United States in 2012 aiming at helping physicians identify tests and
(Hurley, 2014). Since then this initiative has gone global: Canada, New
Zealand, Australia, Japan, and a number of European countries, Germany, the Netherlands, Italy, Switzerland and England and Wales, have launched similar campaigns (Vogel, 2015). Overuse of blood transfusion is listed as a
Choosing Wisely recommendation in the US. Similarly blood transfusion
recommendations have been made with regards to the UK Choosing Wisely campaign (Murphy, 2015). Blood product usage would be the ideal indicator to use to measure interventions within this campaign such as the one being suggested by Malhotra et al, where guideline committees are being
encouraged to produce tools to help doctors understand and share decisions with their patients based on best evidence (Malhotra et al., 2015).