Impact of the anesthesiologist and surgeon on cardiac surgical outcomes

摘要

Objective To determine the impact of anesthesiologists, surgeons, and their monthly caseload volume on mortality after cardiac surgery. Design Ten-year audit of prospectively collected cardiac surgical data. Setting Large adult cardiothoracic hospital. Participants A total of 18,569 cardiac surgical patients in the decade from April 2002 through March 2012, plus 21 consultant surgeons and 29 consultant anesthesiologists. Interventions Major risk-stratified cardiac surgical operations. Methods The primary outcome was in-hospital death. Random intercept models for the surgeon and anesthesiologist cluster, respectively, were fitted, achieving risk-adjustment through the logistic EuroSCORE. The intraclass correlation coefficient (ICC) subsequently was used to measure the amount of outcome variation due to clustering. Measurements and Main Results After exclusions (duplicates, very-short-term appointments, and cases performed by more than one consultant), there were 18,426 patients with 581 (3.15%) in-hospital deaths. The overwhelming factor associated with outcome variation was the patient risk profile, accounting for 97.14% of the variation. The impact of the surgeon was small (ICC = 2.78%), and the impact of the anesthesiologist was negligible (ICC = 0.08%). Low monthly surgeon volume of surgery, adjusted for average case mix, was associated with higher risk-adjusted mortality (odds ratio = 0.93, 95% CI 0.87-0.98). Conclusions Outcome was determined primarily by the patient. There were small but significant differences in outcome between surgeons. The attending anesthesiologist did not affect patient outcome in this institution. Low average monthly surgeon volume was a significant risk factor. In contrast, low average monthly anesthesiologist volume had no effect.