Quality Initiative Programs Can Decrease Total Joint Arthroplasty Transfusion RatesdA Multicenter Study Using the MARCQI Total Joint Registry Database David C. Markel, MD a , Mark W. Allen, DO b, * , Richard E. Hughes, PhD c, d, e , Bonita M. Singal, PhD, MD f , Brian R. Hallstrom, MD g a Department of Orthopaedics, The CORE Institute, Novi, Michigan b Department of Orthopaedics, The CORE Institute, Phoenix, Arizona c Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan d Department of Orthopedic Surgery, University of Michigan Health System, Ann Arbor, Michigan e Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan f Orthopedic Surgery, American Association for the Advancement of Sciences, Science and Technology Policy Fellow, Energy Policy and Systems Analysis, United States Department of Energy, Washington, DC g Department of Orthopaedic Surgery, University of Michigan Health System, A. Alfred Taubman Health Care Center, Ann Arbor, Michigan article info Article history: Received 4 March 2017 Received in revised form 29 May 2017 Accepted 5 June 2017 Available online xxx Keywords: transfusion TKA THA arthroplasty registry quality abstract Background: The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) noted wide variability between member hospitals in blood transfusion rates after primary total hip and knee arthroplasty (THA and TKA). Blood transfusion has substantial risks and accepted recommendations exist to guide transfusion practices. MARCQI began an initiative to decrease unnecessary transfusions by identifying/reporting outliers, discussing conservative transfusion practices, and recommending trans- fusion guidelines. There was a later recommendation to consider intraoperative use of tranexamic acid. Methods: All MARCQI-registered unilateral TKA and THA cases from the 28 member hospitals (pre- November 2013) were included. For 3 time periods (before November 13, 2013; November 13, 2013, to November 12, 2014; and after November 12, 2014), we calculated average risk and range of transfusion, transfusion with nadir hemoglobin >8 g/dL, mean length of stay, and 90-day risk of discharge to nursing home, readmission, deep infection, and emergency department visits. Results: For THA, risk and range of transfusion decreased over the 3 time periods: 12.6% (2.5%-36.2%), 7.6% (2.2%-23.8%), and 4.5% (0.7%-14.4%); for TKA, 6.3% (1.3%-15.6%), 3.1% (0%-12.5%), and 1.3% (0%-7.4%). Decreases were also noted for transfusion with a nadir hemoglobin >8 g/dL with a near elimination of “unnecessary” transfusions. There was no evidence of increase in length of stay, discharge to nursing home, readmission, deep infection, or emergency department visits. Conclusion: A simple intervention can decrease unnecessary blood transfusions during and after elective primary unilateral THA or TKA. A collaborative registry can be used effectively to improve the quality of patient care and set a new benchmark for transfusion. © 2017 Elsevier Inc. All rights reserved. In 2011, several Michigan hospitals along with Blue Cross Blue Shield of Michigan formed the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) to improve the quality of care for patients undergoing elective hip and knee arthroplasty in the state. As of this report, there were 59 hospital members who represent the institutions that perform at least 200 cases a year and capture 95% of all arthroplasty cases completed in the state. Approximately 142,000 total hip arthroplasty (THA) and total knee arthroplasty (TKA) cases have been abstracted to date. At each participating institution, clinical, administrative, and medical device data are collected on 100% of THA and TKA cases. A probability sample of the data is audited annually. Additional One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.06.009. * Reprint requests: Mark W. Allen, DO, The CORE Institute, Orthopedic Surgery, 18444 N. 25th Ave., Suite 210, Phoenix, AZ 85023. Contents lists available at ScienceDirect The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org http://dx.doi.org/10.1016/j.arth.2017.06.009 0883-5403/© 2017 Elsevier Inc. All rights reserved. The Journal of Arthroplasty xxx (2017) 1e6