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Multicenter Study
. 2025 May 1;8(5):e258342.
doi: 10.1001/jamanetworkopen.2025.8342.

Hospital and Clinician Practice Variation in Cardiac Surgery and Postoperative Acute Kidney Injury

Michael R Mathis  1   2 , Graciela B Mentz  1 , Jie Cao  3 , Emily A Balczewski  2 , Allison M Janda  1 , Donald S Likosky  4 , Robert B Schonberger  5 , Robert B Hawkins  4 , Michael Heung  6 , Gorav Ailawadi  4 , Rahul Ladhania  7   8 , Michael W Sjoding  9 , Sachin Kheterpal  1 , Karandeep Singh  3   10 ; MPOG Collaborators
Collaborators, Affiliations
Multicenter Study

Hospital and Clinician Practice Variation in Cardiac Surgery and Postoperative Acute Kidney Injury

Michael R Mathis et al. JAMA Netw Open. .

Abstract

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 >60 minutes and vasopressor infusion >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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Mathis reported receiving grants from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) during the conduct of the study and Chiesi industry-sponsored research funding outside the submitted work. Dr Janda reported receiving grants from the National Institute of General Medical Sciences (NIGMS) and the NHLBI during the conduct of the study and grants paid to the University of Michigan from Haisco-USA Pharmaceuticals Inc and Bio IntelliSense Inc outside the submitted work. Prof Likosky reported receiving grants from the NIH during the conduct of the study and grants from the NIH and the Agency for Healthcare Research and Quality, personal fees from AmSECT, and salary support paid to institution from Blue Cross Blue Shield of Michigan (BCBSM) outside the submitted work. Dr Schonberger reported receiving personal fees from Johnson & Johnson and holding stock and grants from Merck Inc outside the submitted work. Dr Hawkins reported receiving personal fees from Medtronic outside the submitted work. Dr Ladhania reported receiving grants from the NIH during the conduct of the study. Dr Sjoding reported receiving grants from NIH outside the submitted work. Dr Kheterpal reported holding patent 11288445 (issued, The Regents of the University of Michigan, “Automated system and method for assigning billing codes to medical procedures”) outside the submitted work. Dr Singh reported receiving grants from the NIDDK during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Acute Kidney Injury (AKI) Rates by Hospital
Figure 2.
Figure 2.. Forest Plots of Clinician- and Hospital-Level Practices and Adjusted Odds Ratio (AOR) of Acute Kidney Injury
See this image and copyright information in PMC

References

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