title: Effect of hospital culture on blood transfusion in cardiac procedures.
abstract: BACKGROUND
  In our effort to reduce the use of blood products in cardiac operations in a health care system, we noted variations in transfusion practices among facilities. Interestingly, surgeons practicing at the same hospital had similar transfusion rates. We sought to quantitate the contribution of hospital influence on individual surgeons' transfusion practices.
  
  
  METHODS
  Blood transfusion data for coronary artery bypass graft operations at 12 Providence Health & Services facilities between January 2008 and June 2011 were reviewed. Frequency of perioperative blood transfusion, amount of transfusion, components transfused, and timing of transfusions were compared. Variation among surgeons at the same institution vs between institutions was computed based on multilevel mixed-effect logistic and linear regression models. Intraclass correlation coefficients were calculated.
  
  
  RESULTS
  A total of 5,744 nonemergency first-time coronary artery bypass graft procedures were performed by 42 not-low volume (n>30 in 2.5 years) surgeons at 12 Providence Health & Services hospitals during the 3.5-year study period. Frequency, amount, timing, and blood component usage were different among facilities but relatively similar for surgeons within a facility. The variance of red blood cell transfusion rate among hospitals (.82) is more than two times that among surgeons practicing within the same hospital (.35). Thus, surgeons contribute 30% to the variation, and 70% of the total variation can be explained by the hospital effect.
  
  
  CONCLUSIONS
  In our multihospital system, the hospital that a surgeon practices at plays a larger role in determining blood utilization than the individual surgeon's preference.
authors.affiliation: Medical Data Research Center, Providence Health & Services, Portland, Oregon 97225, USA. ruyun.jin@providence.org
authors.forename: Ruyun
authors.initials: R
authors.lastname: Jin
authors.forename: Edy S
authors.initials: ES
authors.lastname: Zelinka
authors.forename: Julie
authors.initials: J
authors.lastname: McDonald
authors.forename: Thomas
authors.initials: T
authors.lastname: Byrnes
authors.forename: Gary L
authors.initials: GL
authors.lastname: Grunkemeier
authors.forename: James
authors.initials: J
authors.lastname: Brevig
mesh_terms: D016063:Blood Loss, Surgical / Q000517:prevention & control / Q000706:statistics & numerical data*; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D002983:Clinical Competence / Q000592:standards*; D001026:Coronary Artery Bypass; D006761:Hospitals / Q000941:ethics*; D006801:Humans; D017202:Myocardial Ischemia / Q000601:surgery*; D012189:Retrospective Studies; D014481:United States