Making patient blood management the new norm(al) as experienced by implementors in diverse countries

Background Patient blood management (PBM) describes a set of evidence-based practices to optimize medical and surgical patient outcomes by clinically managing and preserving a patient’s own blood. This concepts aims to detect and treat anemia, minimize the risk for blood loss and the need for blood replacement for each patient through a coordinated multidisciplinary care process. In combination with blood loss, anemia is the main driver for transfusion and all three are independent risk factors for adverse outcomes including morbidity and mortality. Evidence demonstrates that PBM significantly improves outcomes and safety while reducing cost by macroeconomic magnitudes. Despite its huge potential to improve healthcare systems, PBM is not yet adopted broadly. The aim of this study is to analyze the collective experiences of a diverse group of PBM implementors across countries reflecting different healthcare contexts and to use these experiences to develop a guidance for initiating and orchestrating PBM implementation for stakeholders from diverse professional backgrounds. Methods Semi-structured interviews were conducted with 1–4 PBM implementors from 12 countries in Asia, Latin America, Australia, Central and Eastern Europe, the Middle East, and Africa. Responses reflecting the drivers, barriers, measures, and stakeholders regarding the implementation of PBM were summarized per country and underwent qualitative content analysis. Clustering the resulting implementation measures by levels of intervention for PBM implementation informed a PBM implementation framework. Results A set of PBM implementation measures were extracted from the interviews with the implementors. Most of these measures relate to one of six levels of implementation including government, healthcare providers, funding, research, training/education, and patients/public. Essential cross-level measures are multi-stakeholder communication and collaboration. Conclusion The implementation matrix resulting from this research helps to decompose the complexity of PBM implementation into concrete measures on each implementation level. It provides guidance for diverse stakeholders to design, initiate and develop strategies and plans to make PBM a national standard of care, thus closing current practice gaps and matching this unmet public health need. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06484-3.

The interviewer was introduced via E-Mail by name to the participants when the contact between the interviewer and the participants was established. They received an explanation of the interview objectives and process with the first E-Mail from the interviewer. The interviewers introduced themselves at the beginning of the interview. Where the interviews were conducted in Chinese language, both interviewers were introduced to the Chinese implementors and the implementors had the choice of who they preferred to talk to. N/A in manuscript 8. Interviewer characteristics What characteristics were reported about the interviewer/facilitator? e.g. Bias, assumptions, reasons, and interests in the research topic The interviewer introduced their academic background and interests in the subject at the beginning of the interview. Introduction in Additional File 1 Domain 2: study design. Theoretical framework 9. Methodological orientation and Theory What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis Content analysis (qualitative and quantitative). The interviewees were informed that the content of their responses would be evaluated for revealing potential commonalities and differences.
(They were also informed that it was planned to publish the findings in an international peer-reviewed journal and that their name and contribution through the interviews would be acknowledged in the publication and their consent was confirmed during the interview.

Participant selection
10. Sampling How were participants selected? e.g. purposive, convenience, consecutive, snowball The participants were selected for their leadership in implementing Patient Blood Management in their respective environments and their willingness to participate (purposive convenient sample). In a few cases (Mexico, Turkey), the first interviewee was asked for naming and making the link to additional implementors from that country (snowball). 11. Method of approach How were participants approached? e.g. face-to-face, telephone, mail, email The original contact was established via E-Mail. The interviews were scheduled electronically (Doodle). The interview was conducted by web-conference (GoToMeeting) or, if that was not possible for technical reasons, by telephone or WeChat (China): 29 interviews by webconference, 5 by telephone, 2 by WeChat. 12. Sample size How many participants were in the study? 13. Non-participation How many people refused to participate or dropped out? Reasons?
In addition to those implementors who were interviewed, 4 implementors from 4 countries never scheduled an interview date despite 2 reminders, and therefore, were not further contacted.
The reasons for not further responding are not known, but we assume that they were just too busy with their normal professional tasks or not interested due to other unknown reasons.
We only considered the implementors who scheduled an interview as 'participants'. Of these, one interview could not be realized (drop-out) due to time-constraints of the implementor. N/A in manuscript as not considered relevant to the research and results

Setting of data collection
Where was the data collected? e.g. home, clinic, workplace It was left to the interviewee when and where the interview happened. Some did it from their private office during their off-work time, some from the workplace during their worktime. N/A in manuscript as not considered relevant to the research and results 15. Presence of non-participants Was anyone else present besides the participants and researchers?
Participation of other people was not excluded or encouraged before the interview. In 2 interviews (both in Mexico), another person (invited by the interviewee and sitting in the same room with the interviewee) was present to help the interviewees in case of language problems. A few of the pilot interviews were conducted with a group of people (maximum 3) from pharmaceutical companies; usually with one main speaker. N/A in manuscript as not considered relevant to the research and results 16. Description of sample What are the important characteristics of the sample? e.g. demographic data, date We were looking for active implementors in each of the target countries. All participants were known for their active engagement for Patient Blood Management in their respective environment. They could be clinical specialists, hospital managers, blood bank managers, or healthcare policy stakeholders.
Data collection 17. Interview guide Were questions, prompts, guides provided by the authors? Was it pilot tested?
The interview was first designed by AP Holtorf and critically reviewed by A Hofmann. It was then pilot tested in 11 interviews with pharmaceutical industry experts (as listed in Table 1) and through an extensive interview with Prof DR Spahn, who had not been exposed to the interview before.
Only minor revision was deemed necessary after the piloting (e.g., there was 1 duplication in the barriers which was removed). The pilot interviews served multiple purposes: 1.) to pilot the questionnaire, 2.) to train and standardize the interviewer for the interview flow, 3.) to lay the baseline knowledge for the country context for the interviewer.
(not included in the manuscript) 18. Repeat interviews Were repeat interviews carried out? If yes, how many?
Each interview was individual and not repeated. However, the respondents received the interview notes and had the opportunity to add or change the contents as they deemed necessary. A few interviewees suggested minor corrections (language, clarification, or additional references). 19. Audio/visual recording Did the research use audio or visual recording to collect the data?
Where the interviews could be conducted by web-conference (in 29 cases), the screen of the interviewer was shared, and the interviewees could see the notes that were taken. The discussions were recorded and the recordings were used to validate and correct the notes. 20. Field notes Were field notes made during and/or after the interview or focus group?
The notes were taken during the interview. Directly after the interview (within a maximum of 76 hours), the notes were 'revised' (correcting typing mistakes, formulating full sentences, deleting duplications, etc.) with the help of the recordings. 21. Duration What was the duration of the interviews or focus group?
Except 2 interviews, all other lasted between 45 and 60 minutes. One interview expanded to 120 minutes and the shortest interview took 35 minutes. 22. Data saturation Was data saturation discussed? N.A. as not considered relevant to the research and results 23. Transcripts returned Were transcripts returned to participants for comment and/or correction?
Yes (see above) Domain 3: analysis and findings Data analysis 24. Number of data coders How many data coders coded the data? One (AP Holtorf evaluated and categorized all responses) 25. Description of the coding tree Did authors provide a description of the coding tree?
The approach to evaluation is explained in the methods section as steps 1 to 4 (manuscript, Lines 146-151) For the categories (coding), see results section (figures 1-3)

Derivation of themes
Were themes identified in advance or derived from the data? Derived from data (manuscript, lines 146-152) 27. Software What software, if applicable, was used to manage the data?
Numerical evaluation was done with an electronic spreadsheet.
(Manuscript, lines 150) 28. Participant checking Did participants provide feedback on the findings?
Interviewees provided feedback on the notes relating to their own contribution. The overall findings were not yet shared with the interviewees due to protect the ability to publish. They will be shared immediately after publication. N/A in manuscript as not considered relevant to research and results

Quotations presented
Were participant quotations presented to illustrate the themes/findings? Was each quotation identified? e.g. participant number There is only one direct quote in the manuscript, which is clearly marked as anonymous quote. 30. Data and findings consistent Was there consistency between the data presented and the findings?
Yes, the data presented in Tables 1-4 and Figures 1-3 represent the data collected during the interviews. The categorization was derived from the responses. Figure 4 presents and interprets the findings as a part of the discussion, which is also consistent with the results. 31. Clarity of major themes Were major themes clearly presented in the findings?
Yes (see also frequency analysis in Figures 1-3) 32. Clarity of minor themes Is there a description of diverse cases or discussion of minor themes?
Yes (see also frequency analysis in Figures 1-3) -however, a large congruency was found among all interviewees and there was no important diversion. Differences depended on country context, position of the implementor, and experience of the implementor. Not all implementors had experience in all levels of implementation.