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Table 3 Summary of effect outcomes for ‘placebo’ A&F studies (RCTs, controlled and uncontrolled before after studies)

From: Audit and feedback to improve laboratory test and transfusion ordering in critical care: a systematic review

Study

Design

Change sought in primary outcome

Absolute Δ

Time 1- Time 2

Reported p value

Absolute Δ

Time 1- Time 3

Reported

p value

Solomon 1988

UBA

Transfusion ordering: Decrease in use of FFP /month for the SICU and MICU (units not reported)

-79

NR

  

Paes 1994

UBA

Lab test ordering: Decrease number of superficial cultures per patient

-1.72

NR

  

Hendryx 1998

RCT

Lab test ordering: Improveϕ process compliance for ‘lab work’ (%)

Treatment = +17%

Control = -7%

<0.0001

  

Merlani 2001 and Diby 2005

UBA

Lab test ordering:

    

Decrease median # ABGs (per patient day)

-1.7

<0.001

-3.4

<0.001

Improveϕ average adherence to guideline (%)

+15%

<0.0001

+27%

<0.0001

Beland 2003

UBA

Lab test ordering: Decrease & ImproveΣ:

    

Total # of ‘blood work’ tests per patient

+144

NR

+214

NR

Unordered ‘blood work’ tests per patient

+15

NR

+6

NR

Wisser 2003

UBA

Lab test ordering: Decrease number of tests (various) per patient

-8

NR

  

Petäjä 2004a

UBA

Transfusion ordering: Improve:

    

FFP (transfusions per patient)

-0.74

NR*

+0.03

NR*

Platelets (units per patient)

-0.05

NR*

-0.47

NR*

Distribution of pre-transfusion platelet counts

  

Δ Time 2 – Time3

Presented graphically

0.452

Distribution of pre-transfusion prothrombin time values

  

Presented graphically

<0.001

Audited + Prothrombin time value > 39%

  

-17%

<0.0001

Audited + Prothrombin time value > 49%

  

-9.7%

<0.0001

All transfusions + Prothrombin time value > 49%

  

-6.9%

<0.0001

Calderon-Margalit 2005

UBA

Lab test ordering:

    

Decrease clinical Biochemistry Test orders per 100 hospital days for ICUs (mean volume per 4-month period) (TARGET)

-613.1 (-5579)

0.009

  

Hematology Test orders per 100 hospital days for ICUs (mean volume per 4-month period) (not targeted)

+34.2 (+707)

NS (NR)

  

Schramm 2011b

UBA

Lab test and transfusion ordering:

ImproveΔ # of compliant episodes:

    

Lactate measured (%)

+15.8%

<0.001

+21.6%

<0.001

Blood cultures before antibiotics (%)

+5.3%

<0.001

+10.0%

<0.001

Appropriate RBC transfusion (%)

+3.8%

0.397

+3.1

0.397

Masud 2011c

CBA

Transfusion ordering:

    

Decrease proportion of CABG patients receiving transfusion (total blood product use)

Δ 2006-2007= -9.9%

Δ 2007-2008= -6%

NR

NR

Δ 2006-2008=

-15.9%

<0.005

Decrease Volume (units) for CVICU Patients

    

All products

Δ 2007-2008= -2288

NR

  

Red Cells

Δ 2007-2008= -870

NR

  

Platelets (concentration)

Δ 2007-2008= -566

NR

  

Plateletpheresis

Δ 2007-2008= -53

NR

  

Fresh Frozen Plasma

Δ 2007-2008= -660

NR

  

Cryoprecipitate

Δ 2007-2008= -139

NR

  

Arnold 2011

UBA

Transfusion ordering: Improveϑ:

    

Number of frozen plasma (FP) requests per patient

-0.36

NR*

-0.19

NR*

Inappropriate FP requests

T2 reported graphically

NR

-14%

0.09

FP requests consistent with guidelines

T2 reported graphically

NR

-1%

0.86

FP requests inconsistent with guidelines yet appropriate for the ICU

T2 reported graphically

NR

+15%

0.04

Beaty 2013d

UBA

Transfusion ordering:

    

Improveϕ Odds Ratio (risk of RBC transfusion above a Hgb threshold of 8gm/dL determined by univariate logistic regression)

T2 OR= 0.52

0.003

T3 OR= 0.37

< 0.001

Improve proportion of RBC units with a Hgb threshold of ≥ 8gm/dL

Reported graphically (decrease)

<0.001

Reported graphically (decrease)

<0.001

Gutsche 2013

UBA

Transfusion ordering: Improve appropriatenessϕ; assessed proportion of patients receiving unnecessary RBC transfusion (%)

-6.6%

0.016

  

Yeh 2015

UBA

Transfusion ordering: Improveϕ:

    

RBC Transfusions (U per event)

-0.4

NR*

Unclear; -0.53 to -0.73

NR*

Hgb trigger >8.0 g/dL

-23%

<0.001

-8%

0.44

Over-transfusion rate (post-transfusion Hgb >10 g/dL)

-8%

0.004

-5%

0.50

Mean pre-transfusion Hgb trigger (g/dL)

-0.5

<0.001

-0.3

0.068

Murphy 2016

UBA

Lab test and transfusion ordering:

    

Decrease mean ABG orders per encounter

-1.6

< 0.05

-1.6

<0.05

Decrease mean RBC unit orders per encounter

-0.1

<0.05

-0.1

<0.05

  1. ABGs arterial blood gases, CBC complete blood count, FFP fresh frozen plasma, LFT liver function tests, MICU medical intensive care unit, NR not reported, NS not significant, PT/PPT prothrombin time/partial thromboplastin time, RBCs red blood cells, SICU surgical intensive care unit, T1 time 1 (baseline), T2 time 2 (implementation), T3 time 3 (follow-up)
  2. aStudy reported appropriateness data for T2 and T3 combined (not shown), T2: after audit system activated, T3: audit system + post-feedback
  3. bP values for comparison of all three periods
  4. c2005-2006= standard care, 2007= standard care/ education and A&F (“Educational initiative began in late 2007”), 2008= education and A&F “fully implemented”
  5. dT2: weekly, group feedback; T3: weekly, individual feedback as a group
  6. Measures of Appropriateness: Δ = Bundle; ϕ= Guidelines/Algorithm/Protocol/Standards for Practice; Σ= aimed to reduce ‘unordered tests’ (tests with no written order); ϑ= Guidelines + Clinical Context; = combination of transfusion triggers and audit of patient factors (specifics unclear). *Not the aim of the study. Note: p values are those reported in studies