Provider Variability in the Use of Neuromuscular Blocking Drugs and Reversal

More than 400 million people receive neuromuscular blocking agents (NMBA) annually, either in
the operating theatre to optimize surgical conditions, or in the intensive care unit to
facilitate mechanical ventilation in those with patient-ventilator asynchrony. NMBA have been
associated with increased morbidity secondary to postoperative residual neuromuscular
blockade. The incidence of residual blockade is about 20-60% of patients and depends on
compound and dose of NMBA reversal agent used. Despite disagreements over guidelines and
thresholds to define the optimal strategy to optimize surgical conditions, there is growing
evidence that very high doses of NMBA and neostigmine put the patients at risk of respiratory
complications and hospital readmission. The investigators have recently shown that dedicated
quality improvement initiatives substantially improve the utilization of non-depolarizing
muscle relaxants and their reversal agents.

This is a retrospective, observational, multi-centric cohort study based on on-file hospital
data from two institutions, Massachusetts General Hospital and Beth Israel Deaconess Medical
Center, Boston, Massachusetts. The investigators will compare the utilization of NMBA cross
different groups of anesthesia providers (anesthesiologists, anesthesia residents, CRNAs) who
provided anesthesia care in at least 100 cases in their institution. The investigators will
control our provider-specific findings for patient-, procedure-, and hospital-specific
differences in NMBA utilization.

Primary objective is to determine the variability between individual anesthesia providers in
the use of neuromuscular blocking drugs and reversal agents (neostigmine at Massachusetts
General Hospital/MGH and neostigmine or sugammadex at Beth Israel Deaconess Medical
Center/BIDMC) across provider-types (attending physician, resident, nurse anesthetists
(CRNA)), experience level (number of cases done in an institution), and hospitals (MGH,
BIDMC).

Potential mechanisms of the provider variability will then be examined, such as
providers´age, gender, race, profession, employment status and time of the procedure (surgery
conducted during daytime versus nighttime).

Additionally, the investigators will examine if the provider variance in the use of NMBA,
neostigmine, and sugammadex (based on mean dose across providers and individual mean dose
given for standardized surgical procedures) is associated with respiratory complications and
direct costs of care.

Inclusion Criteria:

- 18 years of age or older

- Non-cardiac surgical procedure

- Endotracheally intubated for surgery and extubated at the end of the case

Exclusion Criteria:

- American Society of Anesthesiologists (ASA) Classification Status of 5 or 6

- Other surgery within a month prior to the procedure considered

- Missing covariates