Variation in Anesthesiology Provider-Volume for Complex Gastrointestinal Cancer Surgery: A Population-Based Study.

OBJECTIVE: Examine between-hospital and between-anesthesiologist variation in anesthesiology provider-volume (PV) and delivery of high-volume anesthesiology care. BACKGROUND: Better outcomes for anesthesiologists with higher PV of complex gastrointestinal cancer surgery have been reported. The factors linking anesthesiology practice and organization to volume are unknown. METHODS: We identified patients undergoing elective esophagectomy, hepatectomy, and pancreatectomy using linked administrative health data sets (2007-2018). Anesthesiology PV was the annual number of procedures done by the primary anesthesiologist in the 2 years before the index surgery. High-volume anesthesiology was PV>6 procedures/year. Funnel plots to described variation in anesthesiology PV and delivery of high-volume care. Hierarchical regression models examined between-anesthesiologist and between-hospital variation in delivery of high-volume care use with variance partition coefficients (VPCs) and median odds ratios (MORs). RESULTS: Among 7893 patients cared for at 17 hospitals, funnel plots showed variation in anesthesiology PV (median ranging from 1.5, interquartile range: 1-2 to 11.5, interquartile range: 8-16) and delivery of HV care (ranging from 0% to 87%) across hospitals. After adjustment, 32% (VPC 0.32) and 16% (VPC: 0.16) of the variation were attributable to between-anesthesiologist and between-hospital differences, respectively. This translated to an anesthesiologist MOR of 4.81 (95% CI, 3.27-10.3) and hospital MOR of 3.04 (95% CI, 2.14-7.77). CONCLUSIONS: Substantial variation in anesthesiology PV and delivery of high-volume anesthesiology care existed across hospitals. The anesthesiologist and the hospital were key determinants of the variation in high-volume anesthesiology care delivery. This suggests that targeting anesthesiology structures of care could reduce variation and improve delivery of high-volume anesthesiology care.

The Association Between Hospital High-volume Anesthesiology Care and Patient Outcomes for Complex Gastrointestinal Cancer Surgery: A Population-based Study.

OBJECTIVE: To examine the association of between hospital rates of high-volume anesthesiology care and of postoperative major morbidity. BACKGROUND: Individual anesthesiology volume has been associated with individual patient outcomes for complex gastrointestinal cancer surgery. However, whether hospital-level anesthesiology care, where changes can be made, influences the outcomes of patients cared at this hospital is unknown. METHODS: We conducted a population-based retrospective cohort study of adults undergoing esophagectomy, pancreatectomy, or hepatectomy for cancer from 2007 to 2018. The exposure was hospital-level adjusted rate of high-volume anesthesiology care. The outcome was hospital-level adjusted rate of 90-day major morbidity (Clavien-Dindo grade 3-5). Scatterplots visualized the relationship between each hospital's adjusted rates of high-volume anesthesiology and major morbidity. Analyses at the hospital-year level examined the association with multivariable Poisson regression. RESULTS: For 7893 patients at 17 hospitals, the rates of high-volume anesthesiology varied from 0% to 87.6%, and of major morbidity from 38.2% to 45.4%. The scatter plot revealed a weak inverse relationship between hospital rates of high-volume anesthesiology and of major morbidity (Pearson: -0.23). The adjusted hospital rate of high-volume anesthesiology was independently associated with the adjusted hospital rate of major morbidity (rate ratio: 0.96; 95% CI, 0.95-0.98; P <0.001 for each 10% increase in the high-volume rate). CONCLUSIONS: Hospitals that provided high-volume anesthesiology care to a higher proportion of patients were associated with lower rates of 90-day major morbidity. For each additional 10% patients receiving care by a high-volume anesthesiologist at a given hospital, there was an associated reduction of 4% in that hospital's rate of major morbidity.

Association Between Familiarity of the Surgeon-Anesthesiologist Dyad and Postoperative Patient Outcomes for Complex Gastrointestinal Cancer Surgery.

Importance: The surgeon-anesthesiologist teamwork and relationship is crucial to good patient outcomes. Familiarity among work team members is associated with enhanced success in multiple fields but rarely studied in the operating room. Objective: To examine the association between surgeon-anesthesiologist dyad familiarity-as the number of times working together-with short-term postoperative outcomes for complex gastrointestinal cancer surgery. Design, Setting, and Participants: This population-based retrospective cohort study based in Ontario, Canada, included adults undergoing esophagectomy, pancreatectomy, and hepatectomy for cancer from 2007 through 2018. The data were analyzed January 1, 2007, through December 21, 2018. Exposures: Dyad familiarity captured as the annual volume of procedures of interest done by the surgeon-anesthesiologist dyad in the 4 years before the index surgery. Main Outcomes and Measures: Ninety-day major morbidity (any Clavien-Dindo grade 3 to 5). The association between exposure and outcome was examined using multivariable logistic regression. Results: Seven thousand eight hundred ninety-three patients with a median age of 65 years (66.3% men) were included. They were cared for by 737 anesthesiologists and 163 surgeons who were also included. The median surgeon-anesthesiologist dyad volume was 1 (range, 0-12.2) procedures per year. Ninety-day major morbidity occurred in 43.0% of patients. There was a linear association between dyad volume and 90-day major morbidity. After adjustment, the annual dyad volume was independently associated with lower odds of 90-day major morbidity, with an odds ratio of 0.95 (95% CI, 0.92-0.98; P = .01) for each incremental procedure per year, per dyad. The results did not change when examining 30-day major morbidity. Conclusions and Relevance: Among adults undergoing complex gastrointestinal cancer surgery, increasing familiarity of the surgeon-anesthesiologist dyad was associated with improved short-term patient outcomes. For each additional time that a unique surgeon-anesthesiologist dyad worked together, the odds of 90-day major morbidity decreased by 5%. These findings support organizing perioperative care to increase the familiarity of surgeon-anesthesiologist dyads.

Impact of fluid resuscitation on major adverse events following pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy remains a major undertaking with substantial perioperative morbidity and mortality. Previous studies in the colorectal population have noted a correlation between excessive postoperative fluid resuscitation and anastomotic complications. This study sought to assess the relationship between perioperative fluid management and clinical outcomes in patients undergoing pancreaticoduodenectomy. METHODS: Data from a single institution, prospective database over a 10-year period (2002 to 2012) were reviewed. Patients were compared for perioperative fluid balance and postoperative outcomes. Multivariable analysis was performed to assess the relationship between perioperative fluid administration and incidence of major adverse events. RESULTS: Higher positive fluid balance on postoperative day 0, postoperative day 1, and postoperative day 2 was associated with increased incidence of major adverse events, increased postoperative intensive care unit admission, and longer hospital stay. Higher positive fluid balance on postoperative day 0 was most strongly associated with postoperative morbidity (odds ratio 1.39, confidence interval 1.16 to 1.66, P = .0003). Fluid balance on postoperative day 3 was not associated with adverse events. CONCLUSIONS: Increased early perioperative fluid resuscitation is associated with major adverse events in patients undergoing pancreaticoduodenectomy. More restrictive fluid administration may improve postoperative outcomes; further prospective clinical trials focused on fluid resuscitation and goal-directed therapy are needed.

Clinical variables associated with mortality in out-of-hospital patients with hemodynamically significant bradycardia.

OBJECTIVES: To estimate mortality rates and identify clinical variables associated with mortality among patients with hemodynamically unstable bradycardia in an urban emergency medical services (EMS) system. METHODS: This was a retrospective study conducted in a large, urban EMS system. Adult non-cardiac arrest patients transported by advanced life support paramedics from March 1996 to February 1997 with a heart rate < or =60 beats/min and systolic blood pressure < or =90 mm Hg were included. Transcutaneous pacing was not available. Patients under age 18 years, pregnant, or presenting with vital signs absent were excluded from the study population. Multivariate analysis of the association of patient characteristics with 30-day mortality was conducted by using a Cox proportional hazards model. RESULTS: Of the 247 patients studied, 133 (53.9%) received a fluid bolus, 37 (15.0%) were treated with atropine, and 17 (6.9%) received dopamine. Fifty-one (20.7%) died in the 19-month follow-up period (15.6 per 100 person-years); 10.5% died on the same day, 15.8% within 30 days, and 17.8% within one year. Variables associated with 30-day mortality included wide QRS complex (adjusted risk ratio [RR] 2.6 [95% confidence interval (95% CI) = 1.3 to 5.2]), use of heart rate-lowering calcium channel blockers (adjusted RR 2.1 [95% CI = 1.0 to 4.7]), and paramedic assessment of lack of patient improvement over the course of the call (adjusted RR 0.2 [95% CI = 0.1 to 0.6]). CONCLUSIONS: Out-of-hospital patients with hemodynamically unstable bradycardia have a high mortality rate. A wide QRS complex and use of heart rate-lowering calcium channel blockers were associated with 30-day mortality.

The incidence of hematoma formation in patients with continuous femoral catheters following total knee arthroplasty while receiving rivaroxaban as thromboprophylaxis: an observational study.

BACKGROUND AND OBJECTIVES: Multimodal analgesia, including continuous femoral block, is often used to manage postoperative pain following total knee arthroplasty. To reduce the risk of deep vein thrombosis and pulmonary embolus formation, anticoagulation is also a part of the care for patients who undergo total knee arthroplasty. However, the concurrent use of continuous peripheral nerve block and anticoagulation can lead to hematoma formation. This prospective, single-center, observational study investigated the incidence of hematoma formation, causing neurovascular compromise, for patients with femoral catheters while taking the oral anticoagulant rivaroxaban. METHODS: Five hundred four eligible patients consented to participate in this study. A femoral nerve block catheter was inserted before surgery, and a continuous infusion of local anesthetic was continued for 36 to 48 hours postoperatively. Rivaroxaban 10 mg was administered daily, and the femoral catheter was removed 20 hours after a dose of rivaroxaban. Participants were assessed daily to postoperative day 3 for the presence of a hematoma causing neurovascular compromise or ecchymosis formation at the femoral catheter site; sensory and motor functions of the femoral nerve were also assessed. RESULTS: No participant presented with a hematoma causing neurovascular compromise at the femoral catheter site or groin area (upper confidence limit, 3.7). The most common complication was an ecchymosis in the groin or upper thigh, with the highest incidence of ecchymosis formation occurring on postoperative day 3. CONCLUSIONS: In this prospective observational study, the concurrent administration of continuous femoral nerve block, the once-daily administration of the anticoagulant rivaroxaban, and the timed removal of the femoral catheter were not associated with hematoma formation resulting in neurovascular compromise at the femoral catheter insertion site or groin area.