TY - JOUR
T1 - Provider variability in the intraoperative use of neuromuscular blocking agents
T2 - A retrospective multicentre cohort study
AU - Althoff, Friederike C.
AU - Xu, Xinling
AU - Wachtendorf, Luca J.
AU - Shay, Denys
AU - Patrocinio, Maria
AU - Schaefer, Maximilian S.
AU - Houle, Timothy T.
AU - Fassbender, Philipp
AU - Eikermann, Matthias
AU - Wongtangman, Karuna
N1 - Funding Information:
Competing interests TTH reports grants from NINDS (PI), grants from NIGMS, personal fees from Headache, personal fees from Anesthesiology, personal fees from Cephalalgia, outside the submitted work. ME received honorarium for giving advice to Merck, holds equity of Calabash Bioscience and is an Associate Editor of the British Journal of Anaesthesia.
Funding Information:
This work was supported by Jeffrey and Judith Buzen in an unrestricted grant to ME (222302). ME received funding for investigator-initiated trials from Merck (agreement number 57669 US).
Publisher Copyright:
© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
PY - 2021/4/14
Y1 - 2021/4/14
N2 - To assess variability in the intraoperative use of non-depolarising neuromuscular blocking agents (NMBAs) across individual anaesthesia providers, surgeons and hospitals. Retrospective observational cohort study. Two major tertiary referral centres, Boston, Massachusetts, USA. 265 537 adult participants undergoing non-cardiac surgery between October 2005 and September 2017. We analysed the variances in NMBA use across 958 anaesthesia and 623 surgical providers, across anaesthesia provider types (anaesthesia residents, certified registered nurse anaesthetists, attendings) and across hospitals using multivariable-adjusted mixed effects logistic regression. Intraclass correlations (ICC) were calculated to further quantify the variability in NMBA use that was unexplained by other covariates. Procedure-specific subgroup analyses were performed. NMBAs were used in 183 242 (69%) surgical cases. Variances in NMBA use were significantly higher among individual surgeons than among anaesthesia providers (variance 1.32 (95% CI 1.06 to 1.60) vs 0.24 (95% CI 0.19 to 0.28), p<0.001). Procedure-specific subgroup analysis of hernia repairs, spine surgeries and mastectomies confirmed our findings: the total variance in NMBA use that was unexplained by the covariate model was higher for surgeons versus anaesthesia providers (ICC 37.0% vs 13.0%, 69.7% vs 25.5%, 69.8% vs 19.5%, respectively; p<0.001). Variances in NMBA use were also partially explained by the anaesthesia provider’s hospital network (Massachusetts General Hospital: variance 0.35 (95% CI 0.27 to 0.43) vs Beth Israel Deaconess Medical Center: 0.15 (95% CI 0.12 to 0.19); p<0.001). Across provider types, surgeons showed the highest variance, and anaesthesia residents showed the lowest variance in NMBA use. There is wide variability across individual surgeons and anaesthesia providers and institutions in the use of NMBAs, which could not sufficiently be explained by a large number of patient-related and procedure-related characteristics, but may instead be driven by preference. Surgeons may have a stronger influence on a key aspect of anaesthesia management than anticipated.
AB - To assess variability in the intraoperative use of non-depolarising neuromuscular blocking agents (NMBAs) across individual anaesthesia providers, surgeons and hospitals. Retrospective observational cohort study. Two major tertiary referral centres, Boston, Massachusetts, USA. 265 537 adult participants undergoing non-cardiac surgery between October 2005 and September 2017. We analysed the variances in NMBA use across 958 anaesthesia and 623 surgical providers, across anaesthesia provider types (anaesthesia residents, certified registered nurse anaesthetists, attendings) and across hospitals using multivariable-adjusted mixed effects logistic regression. Intraclass correlations (ICC) were calculated to further quantify the variability in NMBA use that was unexplained by other covariates. Procedure-specific subgroup analyses were performed. NMBAs were used in 183 242 (69%) surgical cases. Variances in NMBA use were significantly higher among individual surgeons than among anaesthesia providers (variance 1.32 (95% CI 1.06 to 1.60) vs 0.24 (95% CI 0.19 to 0.28), p<0.001). Procedure-specific subgroup analysis of hernia repairs, spine surgeries and mastectomies confirmed our findings: the total variance in NMBA use that was unexplained by the covariate model was higher for surgeons versus anaesthesia providers (ICC 37.0% vs 13.0%, 69.7% vs 25.5%, 69.8% vs 19.5%, respectively; p<0.001). Variances in NMBA use were also partially explained by the anaesthesia provider’s hospital network (Massachusetts General Hospital: variance 0.35 (95% CI 0.27 to 0.43) vs Beth Israel Deaconess Medical Center: 0.15 (95% CI 0.12 to 0.19); p<0.001). Across provider types, surgeons showed the highest variance, and anaesthesia residents showed the lowest variance in NMBA use. There is wide variability across individual surgeons and anaesthesia providers and institutions in the use of NMBAs, which could not sufficiently be explained by a large number of patient-related and procedure-related characteristics, but may instead be driven by preference. Surgeons may have a stronger influence on a key aspect of anaesthesia management than anticipated.
KW - adult anaesthesia
KW - clinical pharmacology
KW - health & safety
KW - neuromuscular disease
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U2 - 10.1136/bmjopen-2020-048509
DO - 10.1136/bmjopen-2020-048509
M3 - Article
C2 - 33853808
AN - SCOPUS:85104244065
SN - 2044-6055
VL - 11
JO - BMJ Open
JF - BMJ Open
IS - 4
M1 - e048509
ER -