Association between adherence to patient blood management recommendations and postoperative complications in hip and knee arthroplasty

Background: Patient blood management (PBM) is a set of evidence-based practices that reduces the need for blood transfusions. However, its impact on relevant clinical outcomes remains unclear. We evaluated the association between adherence to guideline-recommended PBM care and 30-day postoperative complications in patients undergoing primary total knee and hip arthroplasty. Secondary outcomes included the length of hospital stay and red blood cell utilization. Methods: This was a retrospective, multicenter cohort study including patients from 43 hospitals. The PBM clinical pathway comprised nine major guideline-recommended interventions, and adherence was assessed using a composite quality indicator. Multilevel multivariable regression models were used to evaluate the associations between PBM adherence and outcomes at the patient level while accounting for hospital characteristics and hospital variation. Results: A total of 30926 patients who underwent primary total knee or hip arthroplasty between 2016 and 2022 at 43 hospitals were included. Of these, 1335 (4.3%) had 30-day postoperative complications. The median adherence to the PBM clinical pathway was 60.%. Higher PBM adherence was associated with fewer 30-day postoperative complications (adjusted odds ratio, 0.43; 95% confidence interval (CI) 0.32 to 0.58; p < 0.001), including 65% lower odds of major adverse cardiac events and 45% lower odds of infection. Additionally, higher adherence was associated with shorter hospital stays (adjusted incidence rate ratio, 0.77; 95% CI 0.76 to 0.79; p < 0.001) and reduced transfusion rates (adjusted odds ratio, 0.11; 95% CI 0.09 to 0.14; p < 0.001). Sensitivity analyses confirmed these associations. Conclusions: Adherence to the PBM clinical pathway was associated with improved outcomes. While causality cannot be established, these findings support the potential effectiveness of PBM in reducing postoperative complications and its efficiency in shortening hospital stays, beyond minimizing blood transfusions, in patients undergoing knee and hip arthroplasty.