title: Variability in surgeons' perioperative practices may influence the incidence of low-output failure after coronary artery bypass grafting surgery.
abstract: BACKGROUND
  Postoperative low-output failure (LOF) is an important contributor to morbidity and mortality after coronary artery bypass grafting surgery. We sought to understand which pre- and intra-operative factors contribute to postoperative LOF and to what degree the surgeon may influence rates of LOF.
  
  
  RESULTS
  We identified 11 838 patients undergoing nonemergent, isolated coronary artery bypass grafting surgery using cardiopulmonary bypass by 32 surgeons at 8 centers in northern New England from 2001 to 2009. Our cohort included patients with preoperative ejection fractions >40%. Patients with preoperative intraaortic balloon pumps were excluded. LOF was defined as the need for ≥2 inotropes at 48 hours, an intra- or post-operative intraaortic balloon pumps, or return to cardiopulmonary bypass (for hemodynamic reasons). Case volume varied across the 32 surgeons (limits, 80-766; median, 344). The overall rate of LOF was 4.3% (return to cardiopulmonary bypass, 2.6%; intraaortic balloon pumps, 1.0%; inotrope usage, 0.8%; combination, 1.0%). The predicted risk of LOF did not differ across surgeons, P=0.79, and the observed rates varied from 1.1% to 10.2%, P<0.001. Patients operated by low-rate surgeons had shorter clamp and bypass times, antegrade cardioplegia, longer maximum intervals between cardioplegia doses, lower cardioplegia volume per anastomosis or minute of ischemic time, and less hot-shot use. Patients operated on by higher LOF surgeons had higher rates of postoperative acute kidney injury.
  
  
  CONCLUSIONS
  Rates of LOF significantly varied across surgeons and could not be explained solely by patient case mix, suggesting that variability in perioperative practices influences risk of LOF.
authors: Departments of Medicine, Surgery, and Community and Family Medicine, and The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA. likosky@umich.edu
authors: Donald S
authors: DS
authors: Likosky
authors: Joshua B
authors: JB
authors: Goldberg
authors: Anthony W
authors: AW
authors: DiScipio
authors: Robert S
authors: RS
authors: Kramer
authors: Robert C
authors: RC
authors: Groom
authors: Bruce J
authors: BJ
authors: Leavitt
authors: Stephen D
authors: SD
authors: Surgenor
authors: Yvon R
authors: YR
authors: Baribeau
authors: David C
authors: DC
authors: Charlesworth
authors: Robert E
authors: RE
authors: Helm
authors: Carmine
authors: C
authors: Frumiento
authors: Gerald L
authors: GL
authors: Sardella
authors: Robert A
authors: RA
authors: Clough
authors: Todd A
authors: TA
authors: MacKenzie
authors: David J
authors: DJ
authors: Malenka
authors: Elaine M
authors: EM
authors: Olmstead
authors: Cathy S
authors: CS
authors: Ross
mesh_terms: D000368:Aged; D002303:Cardiac Output, Low / Q000453:epidemiology* / Q000628:therapy; D002315:Cardiopulmonary Bypass; D002316:Cardiotonic Agents / Q000627:therapeutic use; D016009:Chi-Square Distribution; D002983:Clinical Competence / Q000706:statistics & numerical data; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D005260:Female; D006333:Heart Failure / Q000453:epidemiology* / Q000628:therapy; D006801:Humans; D015994:Incidence; D007423:Intra-Aortic Balloon Pumping; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009511:New England / Q000453:epidemiology; D019990:Perioperative Care / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012042:Registries; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D002316:Cardiotonic Agents