Perioperative Medicine  |   December 2018
Hospital-, Anesthesiologist-, and Patient-level Variation in Primary Anesthesia Type for Hip Fracture Surgery: A Population-based Cross-sectional Analysis
Author Notes
  • From the Department of Anesthesiology and Pain Medicine (D.I.M., G.L.B., C.J.L.M.); the Division of Geriatric Medicine (A.H.); the Department of Medicine (C.v.W.); the School of Epidemiology and Public Health (D.I.M., G.L.B., C.J.L.M., C.v.W.), University of Ottawa and The Ottawa Hospital; the Ottawa Hospital Research Institute, The Ottawa Hospital (D.I.M., G.L.B., C.J.L.M., C.v.W.); the Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada (D.I.M., D.N.W., C.v.W.); the Departments of Anesthesiology, Toronto General Hospital and University of Toronto, Ontario, Canada (D.N.W.); and the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada (D.N.W.).
  • This article is featured in “This Month in Anesthesiology,” page 1A.
    This article is featured in “This Month in Anesthesiology,” page 1A.×
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    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication January 30, 2018. Accepted for publication August 22, 2018.
    Submitted for publication January 30, 2018. Accepted for publication August 22, 2018.×
  • Address correspondence to Dr. McIsaac: Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, 1053 Carling Avenue, Room B311, Ottawa, Ontario, Canada K1Y4E9. dmcisaac@toh.on.ca. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Clinical Science / Coagulation and Transfusion / Regional Anesthesia / Quality Improvement
Perioperative Medicine   |   December 2018
Hospital-, Anesthesiologist-, and Patient-level Variation in Primary Anesthesia Type for Hip Fracture Surgery: A Population-based Cross-sectional Analysis
Anesthesiology 12 2018, Vol.129, 1121-1131. doi:10.1097/ALN.0000000000002453
Anesthesiology 12 2018, Vol.129, 1121-1131. doi:10.1097/ALN.0000000000002453
Abstract

Editor’s Perspective:

What We Already Know about This Topic:

  • Neuraxial anesthesia use for hip fracture surgery has wide variation in use across hospitals, and hospitals using it for less than 25% of patients may have increased 30-day mortality

  • The proportion of the variation in use attributable to patient, provider, and hospital factors remains unknown

What This Manuscript Tells Us That Is New:

  • Canadian administrative data demonstrate that approximately 60% of the variation in neuraxial use is attributable to patient factors, 20% to provider factors, and 20% to hospital factors

  • The specific anesthesiologist or hospital a patient receives care from affects the likelihood of neuraxial use more than most clinical factors

Background: Substantial variation in primary anesthesia type for hip fracture surgery exists. Previous work has demonstrated that patients cared for at hospitals using less than 20 to 25% neuraxial anesthesia have decreased survival. Therefore, the authors aimed to identify sources of variation in anesthesia type, considering patient-, anesthesiologist-, and hospital-level variables.

Methods: Following protocol registration (NCT02787031), the authors conducted a cross-sectional analysis of a population-based cohort using linked administrative data in Ontario, Canada. The authors identified all people greater than 65 yr of age who had emergency hip fracture surgery from April 2002 to March 2014. Generalized linear mixed models were used to account for hierarchal data and measure the adjusted association of hospital-, anesthesiologist-, and patient-level factors with neuraxial anesthesia use. The proportion of variation attributable to each level was estimated using variance partition coefficients and the median odds ratio for receipt of neuraxial anesthesia.

Results: Of 107,317 patients, 57,080 (53.2%) had a neuraxial anesthetic. The median odds ratio for receiving neuraxial anesthesia was 2.36 between randomly selected hospitals and 2.36 between randomly selected anesthesiologists. The majority (60.1%) of variation in neuraxial anesthesia use was explained by patient factors; 19.9% was attributable to the anesthesiologist providing care and 20.0% to the hospital where surgery occurred. The strongest patient-level predictors were absence of preoperative anticoagulant or antiplatelet agents, absence of obesity, and presence of pulmonary disease.

Conclusions: While patient factors explain most of the variation in neuraxial anesthesia use for hip fracture surgery, 40% of variation is attributable to anesthesiologist and hospital-level practice. Efforts to change practice patterns will need to consider hospital-level processes and anesthesiologists’ intentions and behaviors.