EVALUATING ANESTHESIA HEALTH-CARE-DELIVERY FOR CARDIAC-SURGERY - THE ROLE OF PROCESS AND STRUCTURE VARIABLES

Anesthesia care is an integral component of cardiac surgery Emphasis o n cost-effectiveness and decreased hospital stay has prompted reevalua tion of anesthesia practice. However, the role of anesthesia process a nd structure variables in relation to patient outcomes is largely unkn own. Processes, Structures and Outcomes of Care in Cardiac Surgery is the first epidemiologic study to collect data on anesthesia processes, such as the pharmacologic components of anesthesia and types of cardi ovascular monitors used. Structures of care, such as resident staffing supervision, completeness of documentation, and training and experien ce of care providers, are also being assessed. Pilot data collected fr om September 1992 to September 1993 demonstrate substantial variation between the six study sites in selected processes and structures. Desp ite the near-universal use of narcotic anesthesia as the primary anest hetic technique, variation in the type of opioid and adjuvant benzodia zepine used was observed. Regarding invasive hemodynamic monitoring, m ost centers used only one type of catheter. Intraoperative transesopha geal echocardiography was used commonly at several centers for valve s urgery, whereas other centers did not use it at all. Its use during co ronary artery bypass grafting was less common. Assessment of the preop erative anesthesia note revealed that coronary anatomy and ventricular function were noted in nearly all instances. However, a clear notatio n that risks and benefits of anesthesia were discussed was less freque nt. Structures related to anesthesia attending staffing, board certifi cation, and experience revealed variation. Some sites had smaller and/ or more experienced attending staffs, whereas others had larger and/or less experienced staffs. These pilot findings appear to validate the authors' hypotheses that variations in anesthesia practice are present within the Veterans Affairs system. They suggest that the variable se t is robust enough to relate processes and structures of anesthesia ca re to patient outcome.