Anesthesiologist direction and patient outcomes

Background: Anesthesia services for surgical procedures may or may not be p ersonally performed or medically directed by anesthesiologists. This study compares the outcomes of surgical patients whose anesthesia care mas person ally performed or medically directed by an anesthesiologist with the outcom es of patients whose anesthesia tare was not personally performed or medica lly directed by an anesthesiologist. Methods: Cases were defined as being either "directed" or "undirected," dep ending on the type of involvement of the anesthesiologist, as determined by Health Care Financing Administration billing records. Outcome rates were a djusted to account for severity of disease and other provider characteristi cs using logistic regression models that included 64 patient and 42 procedu re covariates, plus an additional 11 hospital characteristics often associa ted with quality of care. Medicare claims records were analyzed for all eld erly patients in Pennsylvania who underwent general surgical or orthopedic procedures between 1991-1994. The study involved 194,430 directed and 23,01 0 undirected patients among 245 hospitals. Outcomes studied included death rate within 30 days of admission, in-hospital complication rate, and the fa ilure-to-rescue rate (defined as the rate of death after complications). Results: adjusted odds ratios for death and failure-to-rescue were greater when care was not directed by anesthesiologists (odds ratio for death = 1.0 8, P < 0.04; odds ratio for failure-to-rescue = 1.10, P < 0.01), whereas co mplications were not Increased (odds ratio for complication = 1.00, P < 0.7 9). This corresponds to 2.5 excess deaths/1,000 patients and 6.9 excess fai lures-to-rescue (deaths) per 1,000 patients with complications. Conclusions: Both 30-day mortality rate and mortality rate after complicati ons (failure-to-rescue) were lower when anesthesiologists directed anesthes ia care. These results suggest that surgical outcomes in Medicare patients are associated with anesthesiologist direction, and may provide insight reg arding potential approaches for improving surgical outcomes.