Impact of Hospital Practice and Staffing Differences on Transesophageal Echocardiography Use in Cardiac Valve or Coronary Artery Bypass Graft Surgery.

OBJECTIVES: To identify and quantify the predictors of intraoperative transesophageal echocardiography (TEE) use among the patients undergoing cardiac valve or isolated coronary artery bypass graft (CABG) surgery. DESIGN: An observational cohort study. SETTING: This study used the Centers for Medicare and Medicaid Services administrative claims dataset of the beneficiaries undergoing valve or isolated CABG surgery between 2013 to 2015. PARTICIPANTS: Adults aged ≥65 years of age undergoing cardiac valve or isolated CABG surgery. INTERVENTIONS: Generalized linear mixed-model (GLMM) analyses were used to examine the relationship between the TEE and patient characteristics, hospital factors, and staffing differences, while accounting for clustering within hospitals. The proportion of variation in TEE use attributable to patient-level characteristics was quantified using odds ratios. Hospital-level factors and staffing differences were quantified using the median odds ratios (MOR) and interval odds ratios (IOR). MEASUREMENTS AND MAIN RESULTS: Among 261,860 patients (123,702 valve procedures and 138,158 isolated CABG), the GLMM analysis demonstrated that the strongest predictor for intraoperative TEE use was the hospital where the surgery occurred (MOR for TEE of 2.57 in valve and 4.16 in isolated CABG). The TEE staffing variable reduced the previously unexplained across-hospital variability by 9% in valve and 21% in isolated CABG, and hospitals with anesthesiologist TEE staffing (versus mixed) were more likely to use TEE in both valve and CABG (MOR for TEE of 1.21 in valve and 1.84 in isolated CABG). CONCLUSION: Hospital practice was the strongest predictor for TEE use overall. In isolated CABG surgery, hospitals with anesthesiologist TEE staffing were a primary predictor for TEE use.