Hospital and Clinician Practice Variation in Cardiac Surgery and Postoperative Acute Kidney Injury
Authors: Michael R. Mathis, Graciela B. Mentz, Jie Cao, Emily A. Balczewski, Allison M. Janda, Donald S. Likosky, Robert B. Schonberger, Robert B. Hawkins, Michael Heung, Gorav Ailawadi, Rahul Ladhania, Michael W. Sjoding, Sachin Kheterpal, Karandeep Singh, Thoralf M. Sundt, Michael G. Fitzsimons, Kenneth G. Shann, Vikram Kumar, Leora T. Yarboro, Bhiken I. Naik, Frederick A. Tibayan, Michael F. Aziz, Michael S. Mulligan, Srdjan Jelacic, Tsuyoshi Kaneko, Thomas J. Graetz, Roland Assi, Hari R. Mallidi, Gabriela Querejeta-Roca, Douglas C. Shook, Chu-An Tsai, Elizabeth S. Jewell, Jonathan P. Wanderer, Robert E. Freundlich, Peter Rock, Nicholas J. Douville, Clark A. Fisher, Nathan L. Pace, Karen B. Domino, Gebhard Wagener, Christopher R. King, Vikas O'Reilly-Shah, Amit Bardia, David J. Clark
Journal: JAMA Network Open (2025)

Importance Approximately 30% of US patients develop acute kidney injury (AKI) after cardiac surgery, which is associated with increased morbidity, mortality, and health care costs. The variation in potentially modifiable hospital- and clinician-level operating room practices and their implications for AKI have not been rigorously evaluated. Objective To quantify variation in clinician- and hospital-level hemodynamic and resuscitative practices during cardiac surgery and identify their associations with AKI. Design, Setting, and Participants This cohort study analyzed integrated hospital, clinician, and patient data extracted from the Multicenter Perioperative Outcomes Group dataset and the Society of Thoracic Surgeons Adult Cardiac Surgical Database. Participants were adult patients (aged ≥18 years) who underwent cardiac surgical procedures between January 1, 2014, and February 1, 2022, at 8 geographically diverse US hospitals. Patients were followed up through March 2, 2022. Statistical analyses were performed from October 2024 to February 2025. Exposures Hospital- and clinician-level variations in operating room hemodynamic practices (inotrope infusion &amp;amp;gt;60 minutes and vasopressor infusion &amp;amp;gt;60 minutes) and resuscitative practices (homologous red blood cell [RBC] transfusion and total fluid volume administration). Main Outcomes and Measures The primary outcome was consensus guideline–defined AKI (any stage) within 7 days after cardiac surgery. Hospital- and clinician-level variations were quantified using intraclass correlation coefficients (ICCs). Associations of hospital- and clinician-level practices with AKI were analyzed using multilevel mixed-effects models, adjusting for patient-level characteristics. Results Among 23 389 patients (mean [SD] age, 63 [13] years; 16 122 males [68.9%]), 4779 (20.4%) developed AKI after cardiac surgery. AKI rates varied across hospitals (median [IQR], 21.7% [15.5%-27.2%]) and clinicians (18.1% [10.1%-23.7%]). Significant clinician- and hospital-level variation existed for inotrope infusion (ICC, 6.2% [95% CI, 4.2%-8.0%] vs 17.9% [95% CI, 3.3%-31.9%]), vasopressor infusion (ICC, 11.7% [95% CI, 8.3%-14.9%] vs 44.5% [95% CI, 11.7%-63.5%]), RBC transfusion (ICC, 1.7% [95% CI, 0.9%-2.6%] vs 4.5% [95% CI, 1.2%-9.4%]), and fluid volume administration (ICC, 2.1% [95% CI, 1.3%-2.7%] vs 23.8% [95% CI, 2.7%-39.9%]). In multilevel risk-adjusted models, the AKI rate was higher for patients at hospitals with higher inotrope infusion rates (adjusted odds ratio [AOR], 1.98; 95% CI, 1.18-3.33; P = .01) and lower among clinicians with higher RBC transfusion rates (AOR, 0.89; 95% CI, 0.79-0.99; P = .03). Other practice variations were not associated with AKI. Conclusions and Relevance This cohort study of adult patients found that hospital- and clinician-level variation in operating room practices was associated with AKI after cardiac surgery, suggesting possible targets for intervention.