Mathis Michael R, Mentz Graciela B, Cao Jie, Balczewski Emily A, Janda Allison M, Likosky Donald S, Schonberger Robert B, Hawkins Robert B, Heung Michael, Ailawadi Gorav, Ladhania Rahul, Sjoding Michael W, Kheterpal Sachin, Singh Karandeep
Department of Anesthesiology, University of Michigan Medical School, Ann Arbor.
Department of Computational Bioinformatics, University of Michigan Medical School, Ann Arbor.
JAMA Netw Open. 2025 May 1;8(5):e258342. doi: 10.1001/jamanetworkopen.2025.8342.
Approximately 30% of US patients develop acute kidney injury (AKI) after cardiac surgery, which is associated with increased morbidity, mortality, and health care costs. The variation in potentially modifiable hospital- and clinician-level operating room practices and their implications for AKI have not been rigorously evaluated.
To quantify variation in clinician- and hospital-level hemodynamic and resuscitative practices during cardiac surgery and identify their associations with AKI.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study analyzed integrated hospital, clinician, and patient data extracted from the Multicenter Perioperative Outcomes Group dataset and the Society of Thoracic Surgeons Adult Cardiac Surgical Database. Participants were adult patients (aged ≥18 years) who underwent cardiac surgical procedures between January 1, 2014, and February 1, 2022, at 8 geographically diverse US hospitals. Patients were followed up through March 2, 2022. Statistical analyses were performed from October 2024 to February 2025.
Hospital- and clinician-level variations in operating room hemodynamic practices (inotrope infusion >60 minutes and vasopressor infusion >60 minutes) and resuscitative practices (homologous red blood cell [RBC] transfusion and total fluid volume administration).
The primary outcome was consensus guideline-defined AKI (any stage) within 7 days after cardiac surgery. Hospital- and clinician-level variations were quantified using intraclass correlation coefficients (ICCs). Associations of hospital- and clinician-level practices with AKI were analyzed using multilevel mixed-effects models, adjusting for patient-level characteristics.
Among 23 389 patients (mean [SD] age, 63 [13] years; 16 122 males [68.9%]), 4779 (20.4%) developed AKI after cardiac surgery. AKI rates varied across hospitals (median [IQR], 21.7% [15.5%-27.2%]) and clinicians (18.1% [10.1%-23.7%]). Significant clinician- and hospital-level variation existed for inotrope infusion (ICC, 6.2% [95% CI, 4.2%-8.0%] vs 17.9% [95% CI, 3.3%-31.9%]), vasopressor infusion (ICC, 11.7% [95% CI, 8.3%-14.9%] vs 44.5% [95% CI, 11.7%-63.5%]), RBC transfusion (ICC, 1.7% [95% CI, 0.9%-2.6%] vs 4.5% [95% CI, 1.2%-9.4%]), and fluid volume administration (ICC, 2.1% [95% CI, 1.3%-2.7%] vs 23.8% [95% CI, 2.7%-39.9%]). In multilevel risk-adjusted models, the AKI rate was higher for patients at hospitals with higher inotrope infusion rates (adjusted odds ratio [AOR], 1.98; 95% CI, 1.18-3.33; P = .01) and lower among clinicians with higher RBC transfusion rates (AOR, 0.89; 95% CI, 0.79-0.99; P = .03). Other practice variations were not associated with AKI.
This cohort study of adult patients found that hospital- and clinician-level variation in operating room practices was associated with AKI after cardiac surgery, suggesting possible targets for intervention.
在美国，约30%的患者在心脏手术后发生急性肾损伤（AKI），这与发病率、死亡率和医疗费用增加相关。潜在可改变的医院和临床医生层面的手术室操作差异及其对AKI的影响尚未得到严格评估。
量化心脏手术期间临床医生和医院层面的血流动力学及复苏操作差异，并确定它们与AKI的关联。
设计、设置和参与者：这项队列研究分析了从多中心围手术期结果组数据集和胸外科医师协会成人心脏手术数据库中提取的综合医院、临床医生和患者数据。参与者为2014年1月1日至2022年2月1日期间在美国8家地理位置不同的医院接受心脏手术的成年患者（年龄≥18岁）。对患者随访至2022年3月2日。统计分析于2024年10月至2025年2月进行。
医院和临床医生层面手术室血流动力学操作（血管活性药物输注>60分钟和血管升压药输注>60分钟）和复苏操作（同源红细胞[RBC]输血和总液体量输注）的差异。
主要结局是心脏手术后7天内根据共识指南定义的AKI（任何阶段）。使用组内相关系数（ICC）对医院和临床医生层面的差异进行量化。使用多水平混合效应模型分析医院和临床医生层面的操作与AKI的关联，并对患者层面的特征进行调整。
在23389例患者（平均[标准差]年龄，63[13]岁；16122例男性[68.9%]）中，4779例（20.4%）在心脏手术后发生AKI。AKI发生率在不同医院（中位数[四分位间距]，21.7%[15.5%-27.2%]）和临床医生之间（18.1%[10.1%-23.7%]）存在差异。血管活性药物输注（ICC，6.2%[95%置信区间，4.2%-8.0%]对17.9%[95%置信区间，3.3%-31.9%]）、血管升压药输注（ICC，11.7%[95%置信区间，8.3%-14.9%]对44.5%[95%置信区间，11.7%-63.5%]）、RBC输血（ICC，1.7%[95%置信区间，0.9%-2.6%]对4.5%[95%置信区间，1.2%-9.4%]）和液体量输注（ICC，2.1%[95%置信区间，1.3%-2.7%]对23.8%[95%置信区间，2.7%-39.9%]）在临床医生和医院层面存在显著差异。在多水平风险调整模型中，血管活性药物输注率较高的医院的患者发生AKI的比率较高（调整后的优势比[AOR]，1.98；95%置信区间，1.18-3.33；P = 0.01），而RBC输血率较高的临床医生治疗的患者中AKI发生率较低（AOR，0.89；95%置信区间，0.79-0.99；P = 0.03）。其他操作差异与AKI无关。
这项针对成年患者的队列研究发现，医院和临床医生层面手术室操作的差异与心脏手术后的AKI相关，提示可能的干预靶点。
