Key result
Neuraxial anesthesia use for lower limb revascularization varied primarily at the hospital level (50.3%), resulting in a 5.7-fold difference in odds of receiving it between different hospitals.
Why the study?
Although neuraxial anesthesia may improve outcomes in lower limb revascularization surgery, its use is decreasing; determining the sources of practice variation could inform strategies to increase uptake.
Does the use of neuraxial versus general anesthesia for lower limb revascularization vary primarily at the hospital, anesthesiologist, surgeon, or patient level?
Cross-Sectional (n=11,849)
Yes
Does the use of neuraxial versus general anesthesia for lower limb revascularization vary primarily at the hospital, anesthesiologist, surgeon, or patient level?
Odds Ratio: 5.7
Efforts to promote the use of neuraxial anesthesia for lower limb revascularization should focus on hospital-level factors, as they account for the majority of practice variation.
Hospital-level factors drive most neuraxial anesthesia variation; supports targeted interventions but leaves open outcome effects.
BACKGROUND: Although neuraxial anesthesia may promote improved outcomes for patients undergoing lower limb revascularization surgery, its use is decreasing over time. Our objective was to estimate variation in neuraxial (versus general) anesthesia use for lower limb revascularization at the hospital, anesthesiologist, surgeon, and patient levels, which could inform strategies to increase uptake. METHODS: Following protocol registration, we conducted a historical cross-sectional analysis of population-based linked health administrative data in Ontario, Canada. All adults undergoing lower limb revascularization surgery between 2009 and 2018 were identified. Generalized linear models with binomial response distributions, logit links and random intercepts for hospitals, anesthesiologists, and surgeons were used to estimate the variation in neuraxial anesthesia use at the hospital, anesthesiologist, surgeon, and patient levels using variance partition coefficients and median odds ratios. Patient- and hospital-level predictors of neuraxial anesthesia use were identified. RESULTS: We identified 11,849 patients; 3489 (29.4%) received neuraxial anesthesia. The largest proportion of variation was attributable to the hospital level (50.3%), followed by the patient level (35.7%); anesthesiologists and surgeons had small attributable variation (11.3% and 2.8%, respectively). Mean odds ratio estimates suggested that 2 similar patients would experience a 5.7-fold difference in their odds of receiving a neuraxial anesthetic were they randomly sent to 2 different hospitals. Results were consistent in sensitivity analyses, including limiting analysis to patients with diagnosed peripheral artery disease and separately to those aged >66 years with complete prescription anticoagulant and antiplatelet usage data. CONCLUSIONS: Neuraxial anesthesia use primarily varies at the hospital level. Efforts to promote use of neuraxial anesthesia for lower limb revascularization should likely focus on the hospital context.
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Roberts et al. (2022) conducted a cross-sectional in lower limb revascularization surgery (n=11,849). Neuraxial anesthesia vs. general anesthesia was evaluated on variation in neuraxial anesthesia use (OR 5.7). Neuraxial anesthesia use for lower limb revascularization varied primarily at the hospital level (50.3%), resulting in a 5.7-fold difference in odds of receiving it between different hospitals.
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