title: Association between anesthesiologist experience and mortality after orthotopic liver transplantation.
abstract: The anesthesiologist has been recognized as an integral member of the liver transplant team, and previous studies have demonstrated that inter-anesthesiologist variability can be a driver of outcomes for high-risk patients. We hypothesized that anesthesiologist experience, defined as the number of previous liver transplants performed at our institution, the Icahn School of Medicine at Mount Sinai, would be independently associated with outcomes for liver transplant patients. Eight hundred forty-nine liver transplants performed between January 2003 and January 2013 with a total of 22 anesthesiologists were analyzed. Each transplant was assigned an incremental case number that corresponded to the number of transplants that the attending anesthesiologist had already performed at our institution. Several perioperative covariates were controlled for in the context of a generalized linear mixed effects model to detail the influence of threshold levels of the incremental case number on the primary outcome, 30-day mortality, and a secondary outcome, 30-day graft failure. Sensitivity analyses were conducted to confirm the robustness of these findings. An incremental case number ≤ 5 was associated with a significantly greater risk of 30-day mortality (odds ratio = 2.24, 95% confidence interval = 1.11-4.54, P = 0.025), and there was evidence suggestive of a greater risk of 30-day graft failure (odds ratio = 1.93, 95% confidence interval = 0.95-3.93, P = 0.071). Sensitivity analyses ruled out threats to the validity of these findings, including dropout effects and time trends in the overall performance of the transplantation unit. In conclusion, this study shows that an anesthesiologist's level of experience has a significant effect on outcomes for liver transplant recipients, with increased mortality and possibly graft failure during a provider's first 5 cases. These findings may indicate the need for increased training and supervision for anesthesiologists joining the liver transplant team.
authors.affiliation: Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA.
authors.forename: Ira
authors.initials: I
authors.lastname: Hofer
authors.forename: John
authors.initials: J
authors.lastname: Spivack
authors.forename: Miguel
authors.initials: M
authors.lastname: Yaport
authors.forename: Jeron
authors.initials: J
authors.lastname: Zerillo
authors.forename: David L
authors.initials: DL
authors.lastname: Reich
authors.forename: David
authors.initials: D
authors.lastname: Wax
authors.forename: Samuel
authors.initials: S
authors.lastname: DeMaria
mesh_terms: D000328:Adult; D000368:Aged; D000758:Anesthesia / Q000401:mortality*; D002983:Clinical Competence; D005260:Female; D006801:Humans; D059032:Learning Curve; D016014:Linear Models; D016031:Liver Transplantation / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D009518:New York; D016017:Odds Ratio; D010348:Patient Care Team; D011183:Postoperative Complications / Q000401:mortality* / Q000503:physiopathology; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D016526:Workload