Improving quality and reducing costs

The aim of the Shine project, an annual programme initiated by the Health Foundation to look at new ways of improving healthcare quality, is to explore new ways to deliver services that can help the NHS to reduce costs while improving quality, in line with the requirement for the NHS to make savings of £20 billion in the coming years. This is at a time when demand for healthcare services continue to grow, due to a number of factors – such as an ageing population and growing levels of obesity in the UK. The Shine project supports healthcare teams to test out their own ideas for innovation and service redesign to help improve the quality of the service offered. Eighteen teams from health services cross the UK took up the challenge in 2010, with the Shine Project funding up to £75,000 to help put the projects into practice and gather evidence of impact and effectiveness over the course of a year. One of the projects, which was able to convincingly demonstrate quality improvements alongside actual cost savings, was undertaken at Airedale General Hospital, part of the Airedale NHS Foundation Trust. The project was led by Dr Alwyn Kotze, consultant anaesthetist and aimed to reduce the need for blood transfusions in joint replacement surgery by testing for and treating anaemia at an earlier point in the care pathway. Joint replacement surgery uses around 10% of national blood stocks. However, although it offers an effective method of boosting oxygen supply to tissues in the short term, transfusions can be problematic after surgery. Transfused patients are more prone to complications and take longer to recover from surgery, for example. Dr Kotze explained further: “No matter how closely the transfusion is matched to the patient’s own blood type, the body still recognises it as a foreign protein and mobilises the immune system to mop it up, so that person effectively becomes immune suppressed and vulnerable to infection.”

A Department of Health audit of blood use in elective primary hip replacements in 20071 showed variation in the use of blood transfusions among 180 hospital Trusts. These findings prompted Airedale NHS Foundation Trust to carry out its own audit of 250 hip replacement procedures. The audit results identified a link between transfusion rate and patient outcomes. A more extensive audit of the proportion of blood transfusions required for 361 hip and 356 knee replacements in 2008 and 20092 revealed that the Trust was slightly below the national average of 24%. Closer investigation, however, revealed that this figure masked considerable variation for both procedures. Dr Kotze explained why this is: “Many transfusion decisions are not made by the surgeon, but by junior doctors and nurses. Surgeons and anaesthetists do not realise how common transfusion is. It is therefore vital to look at the data and see exactly what the relationship is between transfusion and outcomes.” Examinining and understanding variation is a powerful tool for quality improvement. A key factor in the variation at the Trust was found to be preoperative haemoglobin (Hb). Normal levels are more than 12 grams per decilitre (g/dl) for women and more than 13 g/dl for men, anything below this is classed as anaemia. “We found that patients who had low blood counts before their operation had a greater chance of needing a blood transfusion, and they stayed in hospital longer, which was a surrogate marker for complications,” said Dr Kotze. The figures pointed to between 3.8 and 4.5 more days in hospital for transfused patients. The chances of readmission within 30 days of discharge were also significantly greater – 21% versus 5% for knee patients and 12% versus 6% for hip patients.

The published evidence3,4 backed up these local findings, showing that orthopaedic surgery patients with anaemia are more likely to need blood transfusions, stay in hospital longer and are less satisfied with their care. Anaemia is also associated with an increased risk of death, heart attack and stroke, falls and fractures, and poorer quality of life.5 The Airedale audit evidence also pointed towards the possibility of a reduction in the length of stay and complications for the patient if their anaemia can be corrected before surgery. This is supported by wider published evidence.6-9 “If you can bring haemoglobin up from 10 to 13 g/dl, that is equal to a 10-fold lower risk of needing a transfusion and about two fewer days in hospital,” explained Dr Kotze. The prevalence of anaemia in joint replacement patients is around 20%, a figure which is similar across much of Europe. Having gathered the evidence, the Shine project team at the Trust presented this to orthopaedic surgeons, anaesthetists and haematologists. “Once we showed them the evidence collected at our own Trust, it was not difficult to reach agreement,” said Dr Kotze. It was important for the project team to reassure their colleagues that a new approach would not interfere with the management of a case or lead to cancellations of scheduled surgery. However, providing evidence that the change would save money proved rather more challenging, as Dr Kotze explained: “Most hospitals have a silo structure financially: drugs do not come out of the same budget as length of stay, nurses’ salaries and blood products, so it can be difficult to quantify savings.” Dr Kotze approached the Trust’s medical director and chief executive convincing them to commit to taking a long-term holistic view. Once the Trust’s consultants and management colleagues became engaged with the project and the benefits of the change were fully understood, the next stage was to examine the published data to find the best treatments and to draw up evidence-based guidelines. This focused on assessing and treating the iron levels of patients for a period of between four and six weeks before scheduled surgery. Those with an Hb of under 12 g/dl are deemed to be at high risk (more than 50%) of needing a transfusion. Those with an Hb of 12-13 g/dl fall into the medium risk category (likelihood of transfusion of up to 40%), while those with an Hb above 13 g/dl are considered to be at a low (10%) risk of transfusion. At risk patients are treated with iron therapy or erythropoietin (a hormone that increases red blood cell production) before surgery. If necessary they are given tranexamic acid or have their blood pressure lowered to stem blood flow during surgery. These treatments minimise the need for transfusion. They also cost significantly less than the cost of the blood and related activity needed during a transfusion, making savings for the Trust.