National Anesthesia Clinical Outcomes Registry Research Articles

Factors associated with unintended perianesthesia hypothermia

Background Our hypothesis was that total intravenous anesthesia (TIVA) is associated with an increase in hypothermia. Methods Inclusion criteria were patients from the National Anesthesia Clinical Outcomes Registry undergoing a general anesthetic during 2019. Data collected included patient age, sex, American Society of Anesthesiologists physical status classification system score (ASAPS), duration of anesthetic, use of TIVA, type of procedure, and hypothermia. Continuous variables were compared using Student’s t test or Mann Whitney rank sum as appropriate. Mixed effects multiple logistic regression was performed to determine the association between independent variables and hypothermia. Results There was a low incidence of hypothermia (1.2%). Patients who became hypothermic were older, had a higher median ASAPS, and had a higher rate of TIVA. TIVA patients had a significantly increased odds for hypothermia when controlling for covariates. Patients undergoing obstetrical, thoracic, or radiological procedures had increased odds for hypothermia. In a matched cohort subset, TIVA was associated with a greater rate and increased odds for hypothermia. Conclusions The novel and noteworthy finding was the association between TIVA and perianesthesia hypothermia. Thoracic, radiologic, and obstetrical procedures were associated with greater rates of and odds for hypothermia. Other identified factors can help to stratify patients for risk for hypothermia.

Anesthetic Management for Ventricular Tachycardia Ablation: A National Anesthesia Clinical Outcomes Registry Analysis

Objectives: We analyzed anesthetic management trends during ventricular tachycardia (VT) ablation, hypothesizing that (1) monitored anesthesia care (MAC) is more commonly used than general anesthesia (GA), (2) MAC use significantly increased after release of the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias, and (3) anesthetic approach varies based on patient and hospital characteristics. Design: Retrospective study. Setting: National Anesthesia Clinical Outcomes Registry data. Participants: Patients ≥18 years who underwent elective VT ablation between 2013-2021. Interventions: None. Measurements and main results: Covariates were selected a priori within multivariate models, and interrupted time-series analysis was performed. Of the 15,505 patients who underwent VT ablation between 2013-2021, 9,790 (63.1%) received GA. After the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias supported avoidance of GA, no statistically significant increase in MAC was evident (immediate change in intercept post-consensus statement release AOR 1.41, p=0.1629; change in slope post-consensus statement release AOR 1.06 per quarter, p=0.1591). Multivariate analysis demonstrated that sex, ASA physical status, age, and geographic location were statistically significantly associated with anesthetic approach. Conclusions: GA has remained the primary anesthetic type for VT ablation despite the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias suggesting its avoidance in idiopathic VT. Achieving widespread clinical practice change is an ongoing challenge in medicine, emphasizing the importance of developing effective implementation strategies to facilitate awareness of guideline release and subsequent adherence to and adoption of recommendations.

Anesthetic Choice for Cardiovascular Implantable Electronic Device Placement and Lead Removal: A National Anesthesia Clinical Outcomes Registry Analysis

The authors evaluated the anesthetic approach for cardiovascular implantable electronic device (CIED) placement and transvenous lead removal, hypothesizing that monitored anesthesia care is used more frequently than general anesthesia. A retrospective study. National Anesthesia Clinical Outcomes Registry data. Adult patients who underwent CIED (permanent cardiac pacemaker or implantable cardioverter-defibrillator [ICD]) placement or transvenous lead removal between 2010 and 2021. None. Covariates were selected a priori within multivariate models to assess predictors of anesthetic type. A total of 87,530 patients underwent pacemaker placement, 76,140 had ICD placement, 2,568 had pacemaker transvenous lead removal, and 4,861 had ICD transvenous lead extraction; 51.2%, 45.64%, 16.82%, and 45.64% received monitored anesthesia care, respectively. A 2%, 1% (both p < 0.0001), and 2% (p=0.0003) increase in monitored anesthesia care occurred for each 1-year increase in age for pacemaker placement, ICD placement, and pacemaker transvenous lead removal, respectively. American Society of Anesthesiologists (ASA) physical status ≤III for pacemaker placement, ASA ≥IV for ICD placement, and ASA ≤III for pacemaker transvenous lead removal were 7% (p=0.0013), 5% (p=0.0144), and 27% (p = 0.0247) more likely to receive monitored anesthesia care, respectively. Patients treated in the Northeast were more likely to receive monitored anesthesia care than in the West for all groups analyzed (p < 0.0024). Male patients were 24% less likely to receive monitored anesthesia care for pacemaker transvenous lead removal (p=0.0378). For every additional 10 pacemaker or ICD lead removals performed in a year, a 2% decrease in monitored anesthesia care was evident (p=0.0271, p < 0.0001, respectively). General anesthesia still has a strong presence in the anesthetic management of both CIED placement and transvenous lead removal. Anesthetic choice, however, varies with patient demographics, hospital characteristics, and geographic region.

Trends in pediatric non-operating room anesthesia: Data from the National Anesthesia Clinical Outcomes Registry.

Modern pediatric anesthetic encounters occur in operating rooms and non-operating room settings. Most anesthesia providers have cared for children in radiology, endoscopy, and other interventional settings at some point in their training and career. There is an absence of published data on the frequency, timing, and demographics of these pediatric anesthesia encounters. The primary goal of our study is to present data spanning a variety of institutions and practice settings in the United States to define the percentage of non-operating room anesthetic encounters in children. We also set out to characterize the frequency of the most common procedures in the non-operating room setting within the United States. Using the National Anesthesia Clinical Outcomes Registry data from 2015-2019, we analyzed and reported data on current trends in non-operating room anesthesia including patient demographics, encounter setting, procedure type, and the time at which anesthetic encounters occurred. 2 236 788 pediatric anesthetic encounters (patient age <18 y.o.) were analyzed revealing that 22.7% of all pediatric anesthetics occur in non-operating room settings. Patients were more likely to have higher American Society of Anesthesiologists Physical Status classifications in the non-operating room anesthesia group. Gastroenterological suites are the most common setting reported for pediatric non-operating room anesthesia. Non-operating room anesthesia in the United States is a prominent segment of pediatric anesthetic practice. Pediatric patients encountered in the non-operating room setting have more comorbidities, though further studies are needed to characterize the implication of this finding.

Anesthetic management for transcatheter aortic valve replacement: A national anesthesia clinical outcomes registry analysis.

General anesthesia has traditionally been used in transcatheter aortic valve replacement; however, there has been increasing interest and momentum in alternative anesthetic techniques. To perform a descriptive study of anesthetic management options in transcatheter aortic valve replacements in the United States, comparing trends in use of monitored anesthesia care versus general anesthesia. Data evaluated from the American Society of Anesthesiologists' (ASA) Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry. Multivariable logistic regression was used to identify predictors associated with use of monitored anesthesia care compared to general anesthesia. The use of monitored anesthesia care has increased from 1.8% of cases in 2013 to 25.2% in 2017 (p = 0.0001). Patients were more likely ages 80+ (66% vs. 61%; p = 0.0001), male (54% vs. 52%; p = 0.0001), ASA physical status > III (86% vs. 80%; p = 0.0001), cared for in the Northeast (38% vs. 22%; p = 0.0001), and residents in zip codes with higher median income ($63,382 vs. $55,311; p = 0.0001). Multivariable analysis revealed each one-year increase in age, every 50 procedures performed annually at a practice, and being male were associated with 3% (p = 0.0001), 33% (p = 0.012), and 16% (p = 0.026) increased odds of monitored anesthesia care, respectively. Centers in the Northeast were more likely to use monitored anesthesia care (all p < 0.005). Patients who underwent approaches other than percutaneous femoral arterial were less likely to receive monitored anesthesia care (adjusted odds ratios all < 0.51; all p = 0.0001). Anesthetic type for transcatheter aortic valve replacements in the United States varies with age, sex, geography, volume of cases performed at a center, and procedural approach.

The problem with dichotomizing quality improvement measures

The Anesthesia Quality Institute (AQI) promotes improvements in clinical care outcomes by managing data entered in the National Anesthesia Clinical Outcomes Registry (NACOR). Each case included in NACOR is classified as “performance met” or “performance not met” and expressed as a percentage for a length of time. The clarity associated with this binary classification is associated with limitations on data analysis and presentations that may not be optimal guides to evaluate the quality of care. High compliance benchmarks present another obstacle for evaluating quality. Traditional approaches for interpreting statistical process control (SPC) charts depend on data points above and below a center line, which may not provide adequate characterizations of a QI process with a low failure rate, or few possible data points below the center line. This article demonstrates the limitations associated with the use of binary datasets to evaluate the quality of care at an individual organization with QI measures, describes a method for characterizing binary data with continuous variables and presents a solution to analyze rare QI events using g charts.

Anesthetic choice for arteriovenous access creation: A National Anesthesia Clinical Outcomes Registry analysis.

We sought to evaluate differences in primary anesthetic type used in arteriovenous access creation with the hypothesis that administration of regional anesthesia and monitored anesthesia care (MAC) with local anesthesia as the primary anesthetic has increased over time. National Anesthesia Clinical Outcomes Registry data were retrospectively evaluated. Covariates were selected a priori within multivariate models to determine predictors of anesthetic type in adults who underwent elective arteriovenous access creation between 2010 and 2018. A total of 144,392 patients met criteria; 90,741 (62.8%) received general anesthesia. The use of regional anesthesia and MAC decreased over time (8.0%-6.8%, 36.8%-27.8%, respectively; both p < 0.0001). Patients who underwent regional anesthesia were more likely to have ASA physical status >III and to reside in rural areas (52.3% and 12.9%, respectively; both p < 0.0001). Patients who underwent MAC were more likely to be older, male, receive care outside the South, and reside in urban areas (median age 65, 56.8%, 68.1%, and 70.8%, respectively; all p < 0.0001). Multivariate analysis revealed that being male, having an ASA physical status >III, and each 5-year increase in age resulted in increased odds of receiving alternatives to general anesthesia (regional anesthesia adjusted odds ratios (AORs) 1.06, 1.12, and 1.26, MAC AORs 1.09, 1.2, and 1.1, respectively; all p < 0.0001). Treatment in the Midwest, South, or West was associated with decreased odds of receiving alternatives to general anesthesia compared to the Northeast (regional anesthesia AORs 0.28, 0.38, and 0.03, all p < 0.0001; MAC 0.76, 0.13, and 0.43, respectively; all p < 0.05). Use of regional anesthesia and MAC with local anesthesia for arteriovenous access creation has decreased over time with general anesthesia remaining the primary anesthetic type. Anesthetic choice, however, varies with patient characteristics and geography.

Groups and Individuals to See Increased Data Auditing

Quality & Regulatory| July 2021 Groups and Individuals to See Increased Data Auditing Matthew T. Popovich, PhD; Matthew T. Popovich, PhD Search for other works by this author on: This Site PubMed Google Scholar DeLaine Schmitz, MSHL DeLaine Schmitz, MSHL Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor July 2021, Vol. 85, 37–38. https://doi.org/10.1097/01.ASM.0000758380.94963.28 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share MailTo Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Matthew T. Popovich, DeLaine Schmitz; Groups and Individuals to See Increased Data Auditing. ASA Monitor 2021; 85:37–38 doi: https://doi.org/10.1097/01.ASM.0000758380.94963.28 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: aqi nacor, mips, quality indicators, quality payment program, registries, surgical procedures, operative, outcome measures, pain management As anesthesiologists and their groups settle in for another year of the Merit-based Incentive Payment System (MIPS), a lesser-known requirement for validating measure and improvement activity reporting is emerging as an added burden – audits. Individuals and groups may have seen this as part of their 2020 participation in the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (AQI NACOR) Qualified Registry or Qualified Clinical Data Registry (QCDR), as part of a different MIPS registry, or from a direct notification from CMS. Regardless, individuals and groups should make sure that their quality measure data is complete, documented, and readily available should they encounter an audit. Unfortunately, the added emphasis on auditing may surprise some who have viewed MIPS reporting as another “check-the-box” sort of program. CMS requires that individuals and groups maintain documentation related to their MIPS data for a minimum of six years. At any time within that six-year... You do not currently have access to this content.

Leveraging the Existing Anesthesia Information Management System to Improve Anesthesia Quality Assurance Outcome Reporting.

Tracking measures of quality over time has been shown to improve care within institutions and across health systems. Perioperative quality assurance (QA) tracking by anesthesia departments in the Military Health System (MHS) has not used a uniform system integrated into the workflow of anesthesia providers. The purpose of this study was to demonstrate that the use of the embedded QA outcome reporting feature in the anesthesia information management system (AIMS) increased the rate of reporting compared to the current paper reporting system in a military anesthesia department. An electronic outcome reporting mechanism embedded in the AIMS was activated as an alternative to paper QA outcome reporting. The proportion of anesthesia cases per month in a 12-month period with a reported QA outcome was compared to the previous year in which only the paper reporting system was used. The total number of cases in each time period with an outcome reported was compared using chi square for proportions, and systems were evaluated using the Statistical Process Control methodology. This project was evaluated and determined to be exempt from review by our institutional review board. There was a 389.8% increase in the number of cases with a QA outcome reported after the implementation of the outcome reporting function integrated into the AIMS (χ2 = 207.72; P <.001, Table I). Systems before and after the intervention were stable, and special cause variation was noted only at the point of implementation of the electronic reporting system. Anesthesia providers were surveyed and felt that the addition of QA reporting to the AIMS made QA reporting more likely. The use of an electronic QA outcome reporting method integrated into the AIMS dramatically increased the likelihood that a QA outcome would be reported. The decreased administrative burden of the integrated outcome reporting system was likely the primary reason for this increase. This study was limited by the fact that it was done in a single institution; however, the size and timing of the increase clearly indicate that the intervention was the reason for improved reporting. Electronic health record upgrades should consider incorporating QA reporting into the AIMS across the MHS. These measures could allow for system-wide improvement, evaluation, and evidence-based education on their own, but also by facilitating participation in the American Society of Anesthesiologists' Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry. This report serves as a valuable example to institutions and perioperative leaders in the MHS of how to improve the robustness of perioperative QA reporting such that it could be used to validate and improve the value of care.

Trends in Peripheral Nerve Block Usage in Mastectomy and Lumpectomy: Analysis of a National Database From 2010 to 2018.

Compared to general anesthesia, regional anesthesia confers several benefits including improved pain control and decreased postoperative opioid consumption. While the benefits of peripheral nerve blocks (PNB) have been well studied, there are little epidemiological data on PNB usage in mastectomy and lumpectomy procedures. The primary objective of our study was to assess national trends of the annual proportion of PNB use in breast surgery from 2010 to 2018. We also identified factors associated with PNB use for breast surgery. We identified lumpectomy and mastectomy surgical cases with and without PNB between 2010 and 2018 using the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (AQI NACOR). We modeled the nonlinear association between year of procedure and PNB use with segmented mixed-effects logistic regression clustered on facility identifier. The association between PNB use and year of procedure, age, sex, American Society of Anesthesiologists physical status (ASA PS), facility type, facility region, weekday, and tissue expander use was also modeled using mixed-effects logistic regression. Of the 189,854 surgical cases from 2010 to 2018 that met criteria, 86.2% were lumpectomy cases and 13.8% were mastectomy cases. The proportion of lumpectomy cases with PNB was <0.1% in 2010 and increased each subsequent year to 1.9% in 2018 (trend P < .0001). The proportion of mastectomy cases with PNB was 0.5% in 2010 and 13% in 2018 (trend P < .0001). The year 2014 was the breakpoint selected for segmented regression. Before 2014, the odds of PNB among the mastectomy cases was not significantly different from year to year. After 2014, the odds of PNB increased by 2.24-fold each year (95% confidence interval [CI], 2.00-2.49; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. Similar trends were seen in the lumpectomy cases, where after 2014, the odds of PNB increased by 2.03-fold (95% CI, 1.81-2.27; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. In the mastectomy cohort, year of procedure ≥2014, female sex, facility region, and tissue expander use were associated with higher odds of PNB. For lumpectomy cases, year of procedure ≥2014 and facility region were associated with higher odds of PNB use. We found increased annual utilization of PNB for mastectomy and lumpectomy since 2010, although absolute prevalence is low. PNB use was associated with year of procedure for both lumpectomy and mastectomy, particularly post-2014.

Anesthetic Choice for Atrial Fibrillation Ablation: A National Anesthesia Clinical Outcomes Registry Analysis

The authors evaluated the type of anesthesia administered in atrial fibrillation ablation, hypothesizing that monitored anesthesia care is used less frequently than general anesthesia. A retrospective study. National Anesthesia Clinical Outcomes Registry data, which are multi-institutional from across the United States. Adult patients who underwent elective atrial fibrillation ablation between 2013 and 2018. None. National Anesthesia Clinical Outcomes Registry data were evaluated, and covariates were selected a priori within multivariate models to assess for predictors of anesthetic type. A total of 54,321 patients underwent atrial fibrillation ablation; 3,251 (6.0%) received monitored anesthesia care. Patients who received monitored anesthesia care were more likely to be >80 years old (12.4% v 4.9%; p < 0.0001), female (36.1% v 34.3%; p < 0.0001), have American Society of Anesthesiologists physical status >III (17.28% v 10.48%; p < 0.0001), and reside in urban areas (62.23% v 53.37%; p < 0.0001). They received care in the Northeast (17.6% v 10.1%; p < 0.0001) at low-volume centers (median 224 v 284 procedures; p < 0.0001). Multivariate analysis revealed that each five-year increase in age, being female, and having an American Society of Anesthesiologists physical status >III resulted in a 7% (p < 0.0001), 9% (p = 0.032), and 200% (p < 0.0001) increased odds of receiving monitored anesthesia care, respectively. Requiring additional ablation of atria or of a second arrhythmia and residing outside the Northeast resulted in a decreased odds of monitored anesthesia care (adjusted odds ratio 0.24 [p=0.002] and < 0.5 [p < 0.03], respectively). For each 50 cases performed annually at a center, the odds decreased by 5% (p = 0.005). General anesthesia is the most common type of anesthesia administered for atrial fibrillation ablation. The type of anesthesia administered, however, varies with patient, procedural, and hospital characteristics.

Complications Associated With Anesthesia Services in Endoscopic Procedures Among Patients With Cirrhosis.

Anesthesia services for endoscopic procedures have proliferated with the promise of increased comfort and safety. Cirrhosis patients are higher risk for sedation, yet limited data are available describing anesthesia complications in this population. This cross-sectional study utilized the National Anesthesia Clinical Outcomes Registry, a multicenter quality-improvement database from 2010 to 2015. Patients with cirrhosis undergoing an endoscopy were identified by International Classification of Diseases, Ninth Revision (ICD-9)/Current Procedures Terminology (CPT) codes. The outcome of interest was serious anesthesia-related complication defined as cardiovascular, respiratory, neurological, drug related, patient injury, death, or unexpected admission. A mixed-effects multivariate logistic regression model determined odds ratios (ORs) between variables and serious complications, adjusting for potential confounders. In total, 9,007 endoscopic procedures were performed among patients with cirrhosis; 92% were esophagogastroduodenoscopies. The majority (81%) were American Society of Anesthesiologists (ASA) class ≥3, and 72% had a history of hepatic encephalopathy, ascites, varices, hepatorenal syndrome, or spontaneous bacterial peritonitis identified by ICD-9/CPT codes. In total, 87 complications were reported, 33 of which were serious. Frequency of serious complications was 0.4% or 378.6 per 100,000 procedures (95% confidence interval [CI], 260.8, 531.3). The majority of serious complications were cardiovascular (21 of 33), including 15 cardiac arrests. Serious complications were significantly associated with ASA 4/5 (OR, 3.84; 95% CI, 1.09, 13.57) and general anesthesia (OR, 4.71; 95% CI, 1.20, 18.50), adjusting for age, sex, ASA class, anesthesia type, inpatient status, portal hypertension history, and variable complication reporting practices. Anesthesia complications among endoscopic procedures in cirrhosis are rare overall. Serious complications were predominantly cardiac and associated with sicker patients undergoing general anesthesia. The complexity of end-stage liver disease may warrant more intensive care during endoscopic procedures, including anesthesia monitoring.

Patient health status and case complexity of outpatient surgeries at various facility types in the United States: An analysis using the National Anesthesia Clinical Outcomes Registry

Study objectiveAmong the various types of outpatient surgery centers, there are differences in higher American Society of Anesthesiologists Physical Status (ASA PS) scores and surgical complexity among patients who are undergoing surgery. The primary objective of this study was to describe the differences performed at various types of outpatient surgery facilities. DesignWe performed a retrospective analysis of the National Anesthesia Clinical Outcomes Registry (NACOR) data. SettingNACOR from 2012 to 2017. PatientsFrom 2012 to 2017, there were a total of 13,053,115 outpatient surgeries in the database. After removing cases with unknown facility type, the final study sample was 9,217,336. InterventionsNone. MeasurementsTo calculate the probability of either American Society of Anesthesiologists Physical Status (ASA PS) score ≥ 3 or physiologically complex cases (defined as Common Procedural Terminology start-up units ≥8), we performed mixed effects logistic regression for each institution per facility type, controlling for year and using facility identification as the random effect. We present the mean rate of these two classifications as case per 10,000 cases and report the 99.9% confidence interval (CI), to control for multiple comparisons. Main resultsAmong all cases, 5,919,844 (64.2%) were classified as ASA PS 1 or 2 and 254,110 (2.8%) of surgical procedures were considered physiologically complex. The mean rate of cases with ASA PS ≥ 3in the university setting was 2982 per 10,000 cases [99.9% CI 2701–3278 per 10,000 cases]. Large community hospitals had a higher proportion of ASA PS ≥3 patients, medium-sized hospitals had no difference, and all other facility types had a decreased proportion. The mean rate of cases that were physiologically complex in the university setting was 133 per 10,000 cases [99.9% CI 117–151 per 10,000 cases]. Large community hospitals had a higher proportion of physiologically complex cases, medium-sized and small-sized hospitals had no difference, and all other facility types had a decreased proportion. ConclusionsFreestanding and attached surgery centers exhibited smaller rates of patients that were ASA PS ≥ 3, as well as a decrease in surgically complex cases, when compared to university settings. This suggests that the level of conservativeness for patient and surgery appropriateness for outpatient surgery differs across various facility types.

Complications of Anesthesia Services in Gastrointestinal Endoscopic Procedures

Despite the increased use of anesthesia services for endoscopic procedures in the United States, the risks of anesthesia-directed sedation (ADS) are unclear. We analyzed national data from multiple centers to determine patterns of use of anesthesia services and risk factors for serious complications. We performed a cross-sectional study using the National Anesthesia Clinical Outcomes Registry, a national quality improvement database. Univariable and bivariate analyses investigated frequencies and relationships between predefined variables and serious complications of anesthesia (cardiovascular, respiratory, neurologic, drug-related, patient injury, death, or unexpected admission). A multivariable mixed-effects model determined the odds ratios between these variables and serious complications, adjusting for confounders and varying reporting practices. In total, 428,947 endoscopic procedures of adults were performed using ADS from 2010 to 2015. The population was 54.9% female with a mean age of 59.1 years, and predominantly American Society of Anesthesiologists classes 2 and 3 (74.4%). More than half of the procedures were colonoscopies (51.4%); 37.4% were esophagogastroduodenoscopies and 6.5% were endoscopic retrograde cholangiopancreatographies. A total of 4441 complications (1.09%) were reported; 1349 were serious complications (0.34%). In multivariable analysis, older age, American Society of Anesthesiologists classes 4 and 5, esophagogastroduodenoscopy, general anesthesia, cases performed on an overnight shift, and longer cases were associated independently and significantly with serious complications. In an analysis of data from the National Anesthesia Clinical Outcomes Registry, we found ADS during endoscopy to be safe, with few serious complications (<1% of procedures). Risk of ADS complications increased with older age, more severe disease, procedure type, and case complexity.

Prolonged Anesthetic Exposure in Children and Factors Associated With Exposure Duration.

Anesthetic exposure duration has come under scrutiny because of a Food and Drug Administration warning against prolonged use of anesthesia in children, defined as exposures longer than 3 hours. Data for 2,613,344 pediatric anesthetic records from the American Society of Anesthesiologist's National Anesthesia Clinical Outcomes Registry from 2010 to 2015 were analyzed to describe anesthetic duration and the prevalence of prolonged exposures in children. Common pediatric inpatient procedures were independently assessed to determine factors associated with exposure duration. The overall mean pediatric anesthetic duration was 83.3±107.4 minutes (median, 57 min). Prolonged exposures comprised 7% of pediatric anesthetic records, and 15% of anesthetic records in infants. After restricting to common pediatric inpatient procedures (n=96,603) and adjusting for procedure type using a Poisson model, compared with children 10 years or older, exposures in infants were 20.5% longer (anesthetic duration ratio [ADR], 1.205; 95% confidence interval [CI], 1.202-1.208). Longer exposures were also seen with a variety of other patient and hospital factors including ASA 4 patients versus ASA 1 patients, (ADR, 1.381; 95% CI, 1.376-1.386), and university hospitals versus surgery centers (ADR, 1.241; 95% CI, 1.236-1.246). Most pediatric anesthetic exposures last <1 hour with a small percentage lasting over 3 hours. Anesthetic duration for inpatient pediatric procedures, however, is associated with specific patient and hospital characteristics. These results may help identify children potentially at risk for prolonged anesthetic exposure and inform procedure time prediction and operating room scheduling.

Variability in Case Durations for Common Surgical Procedures.

Under the Merit-based Incentive Payment System, physician payment will be adjusted using a composite performance score that has 4 components, one of which is resource use. The objective of this exploratory study is to quantify the facility-level variation in surgical case duration for common surgeries to examine the feasibility of using surgical case duration as a performance metric. We used data from the National Anesthesia Clinical Outcomes Registry on 404,987 adult patients undergoing one of 6 general surgical or orthopedic procedures: laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram, knee arthroscopy, laminectomy, and total hip replacement. We constructed separate mixed-effects multivariable time-to-event models (survival analysis) for each of the 6 procedures to model surgical case duration. We identified performance outliers, based on surgical case duration, using 2013 data and then quantified the gap between high- and low-performance outliers using 2014 data. After adjusting for patient risk, patients undergoing surgery at high-performance facilities were between 54% and 79% more likely to exit the operating room (OR) per unit time compared to average-performing facilities, depending on the procedure. For example, patients undergoing a laparoscopic appendectomy at high-performance facilities were 68% more likely to exit the OR per unit time (hazard ratio, 1.68; 95% CI, 1.40-2.02; P < .001) compared to average-performing facilities. Patients undergoing a laparoscopic appendectomy at low-performance facilities were 41% less likely to exit the OR per unit time (hazard ratio, 0.59; 95% CI, 0.47-0.74; P < .001) compared to average-performing facilities. The adjusted median surgical case duration for patients undergoing laparoscopic appendectomy was 69 minutes at high-performance centers and 92 minutes at low-performance centers. Similar results were obtained for the other procedures. There was wide variation in surgery case duration for patients undergoing common general surgical and orthopedic surgeries. This variability in care delivery may represent an important opportunity to promote more efficient use of health care resources.

Variation in Frequency of Intraoperative Arterial, Central Venous and Pulmonary Artery Catheter Placement During Kidney Transplantation: An Analysis of Invasive Monitoring Trends.

The rapidly increasing number of kidney transplantations warrants assessment of anesthesia care in this patient population. We explored the frequency of arterial catheter (AC), central venous catheter (CVC) and pulmonary artery catheter (PAC) placement during kidney transplantation in the USA using data from the National Anesthesia Clinical Outcomes Registry (NACOR) and assessed the between-facility variation in the frequency of catheter placement. We defined cases of kidney transplantation using Agency for Healthcare Research and Quality Clinical Classification Software. Placement of AC, CVC and PAC was defined by respective Current Procedural Terminology codes. The frequency of vascular catheter placement across facility types was compared using Pearson χ2 test. We identified 10,580 cases of kidney transplantation performed in 100 facilities from January 1, 2010 to December 31, 2014. Placement of an AC was reported in 1700 (16.1%), CVC in 2580 (24.4%) and PAC in 50 (0.5%) of cases. The frequency of placement of specific types of catheters was statistically different across facility types (p < 0.001). Within individual facilities that reported at least 50 cases of kidney transplantation, the percentages of cases performed with AC, CVC and PAC ranged from 0% to 86%, 0% to 90% and 0% to 3%, respectively. Considerable between-facility variation in the frequency of AC, CVC and PAC placement during kidney transplantation raises concerns about the need for better practice standardization. Excess invasive monitoring may represent a safety risk as well as unnecessary additional cost. If kidney transplantation can be safely performed without an AC, CVC or PAC in most patients, facilities with above-average catheter placement rates may have an opportunity for measurable reduction in catheter-related perioperative complications. Optimizing perioperative monitoring is an important component of ensuring high functioning, high-value medical systems.

Time of day is not associated with increased rates of mortality in emergency surgery: An analysis of 49,196 surgical procedures

Study objectiveThere is a lack of large, multi-institutional studies analyzing the association of timing of emergency surgery with death occurring either intraoperatively or in the recovery room setting. The primary objective of this study was to determine if time of day for emergency surgeries was associated with mortality. DesignRetrospective analysis. SettingU.S. healthcare facilities. PatientsAdult patients undergoing emergency surgery and general anesthesia. InterventionsNo intervention. MeasurementsUtilizing the National Anesthesia Clinical Outcomes Registry database, all emergency non-cardiac, non-obstetric surgeries undergoing general anesthesia occurring between 2010 and 2015 in the United States were identified. We performed mixed effects logistic regression to determine the effect of time of day with mortality occurring during the intraoperative and immediate postoperative period. Main resultsThere were 46,196 cases that were eligible for this analysis, in which 24,247 and 21,949 occurred during day and after-hours shifts, respectively. The overall morality rate was 0.28%. Mortality rates were 0.17% and 0.41% in the day and after-hour shifts, respectively. There was no statistically significant association of time of day with mortality (odds ratio 1.31, 95% CI 0.90–1.92, p = 0.16). American Society of Anesthesiologists physical status classification, age, and operative body part were all associated with mortality. ConclusionsAlthough, theoretically, health care providers working after-hour shifts may be impacted by sleep deprivation and/or limited resources, we found that time of day was not associated with increased risk of mortality during the intraoperative and immediate postoperative period in emergency surgery.

Antiemetic Prophylaxis as a Marker of Health Care Disparities in the National Anesthesia Clinical Outcomes Registry.

US health care disparities persist despite repeated countermeasures. Research identified race, ethnicity, gender, and socioeconomic status as factors, mediated through individual provider and/or systemic biases; little research exists in anesthesiology. We investigated antiemetic prophylaxis as a surrogate marker for anesthesia quality by individual providers because antiemetics are universally available, indicated contingent on patient characteristics (gender, age, etc), but independent of comorbidities and not yet impacted by regulatory or financial constraints. We hypothesized that socioeconomic indicators (measured as insurance status or median income in the patients' home zip code area) are associated with the utilization of antiemetic prophylaxis (as a marker of anesthesia quality). We tested our hypothesis in several subsets of electronic anesthesia records from the National Anesthesia Clinical Outcomes Registry (NACOR), fitting frequentist and novel Bayesian multilevel logistic regression models. NACOR contained 12 million cases in 2013. Six institutions reported on antiemetic prophylaxis for 441,645 anesthesia cases. Only 173,133 cases included details on insurance information. Even fewer (n = 92,683) contained complete data on procedure codes and provider identifiers. Bivariate analysis, multivariable logistic regression, and our Bayesian hierarchical model all showed a large and statistically significant association between socioeconomic markers and antiemetic prophylaxis (ondansetron and dexamethasone). For Medicaid versus commercially insured patients, the odds ratio of receiving the antiemetic ondansetron is 0.85 in our Bayesian hierarchical mixed regression model, with a 95% Bayesian credible interval of 0.81-0.89 with similar inferences in classical (frequentist) regression models. Our analyses of NACOR anesthesia records raise concerns that patients with lower socioeconomic status may receive inferior anesthesia care provided by individual anesthesiologists, as indicated by less antiemetics administered. Effects persisted after we controlled for important patient characteristics and for procedure and provider influences. Findings were robust to sensitivity analyses. Our results challenge the notion that anesthesia providers do not contribute to health care disparities.

A retrospective analysis of factors associated with anesthetic case duration for cesarean deliveries

IntroductionAccurately predicting cesarean delivery case duration is an integral component of designing appropriate workflow protocols and ensuring adequate provider availability. Our primary objective was to describe the variability of case duration, based on factors that we hypothesized would be influential, such as hospital facility type, United States region, time of day, case volume, and patient and provider characteristics. MethodsWe analyzed hospital-, patient-, and provider-level variables from the National Anesthesia Clinical Outcomes Registry, a voluntary registry created to share anesthesia-related data and outcomes. Multivariable linear regression was performed to assess the association of these variables to case duration. ResultsA total of 205332 cases were included in the final analysis. The majority of these cases came from medium-sized community hospitals (50.8%). Mean and median case duration were 115 and 79 minutes, respectively. Mean duration was longest for cases performed at university hospitals (143 min, standard deviation 136 min). Case duration varied in clinically meaningful ways based on hospital facility type, United States region, presence of a Certified Registered Nurse Anesthetist, and anesthesia type. Differences were not clinically significant with respect to other variables studied. ConclusionThis study analyzed national cesarean delivery data and determined factors associated with cesarean delivery duration. We showed that case durations varied in meaningful ways according to facility type, United States region, presence of a Certified Registered Nurse Anesthetist, and anesthesia type. Our work contributes to a small but growing body of research on optimal staffing models for anesthesia practices.