Patient-, Clinician-, and Institution-level Variation in Inotrope Use for Cardiac Surgery: A Multicenter Observational Analysis

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Patient-, Clinician-, and Institution-level Variation in Inotrope Use for Cardiac Surgery: A Multicenter Observational Analysis


Mathis, M. R., Janda, A. M., Kheterpal, S., Schonberger, R. B., Pagani, F. D., Engoren, M. C., Mentz, G. B., Shook, D. C., Muehlschlegel, J. D., & the Multicenter Perioperative Outcomes Group. (2023). Patient-, Clinician-, and Institution-level Variation in Inotrope Use for Cardiac Surgery: A Multicenter Observational Analysis. Anesthesiology, 139(2), 122–142.

Context and Motivation

This research examines the variability in the use of inotropic infusions during cardiac surgery. Despite known physiological benefits, inotropes present risks such as myocardial ischemia and arrhythmias. The study explores how patient characteristics, clinician preferences, and institutional factors contribute to this variability, aiming to identify potential areas for standardizing practice to improve outcomes.

Key Concepts and Definitions

  • Inotropes: Medications used to increase heart contractility, often used during or after cardiac surgeries to support heart function.
  • Cardiopulmonary Bypass: A technique that temporarily takes over the function of the heart and lungs during surgery, maintaining the circulation of blood and oxygen content of the body.

Main Findings

The study found significant variability in inotrope use, influenced by patient conditions, the specific anesthesiologist, and the institution. Key patient-related factors include heart failure and preoperative use of loop diuretics. Institutional factors like affiliation with a medical school and clinician-related factors also significantly contributed to the variance in inotrope usage.

Data Sources

Data was collected from a multicenter cohort of academic and community hospitals from 2014 to 2019, involving 51,085 nonemergent adult cardiac surgeries. The Multicenter Perioperative Outcomes Group registry provided the data, ensuring a diverse and comprehensive dataset.

Methodological Approach

This observational study used statistical analyses to separate the variance in inotrope use into patient-, clinician-, and institution-level factors. Multilevel modeling techniques quantified the relative contributions of these factors, with findings supported by rigorous statistical testing and adherence to the RECORD guidelines.

Evaluation of the Study


  1. Comprehensive Data Set: The use of a large, multicenter registry encompassing 51,085 cases across multiple hospitals strengthens the generalizability of the findings. The diversity in settings, ranging from academic to community hospitals, provides a broad perspective on the practice variations.
  2. Robust Methodological Framework: The study’s application of multilevel modeling to parse out the relative contributions of patient, clinician, and institution-level factors to inotrope use is a methodological strength. This approach allows for a nuanced understanding of the sources of variation, which is crucial for targeting interventions.
  3. Focus on Multifactorial Influences: By considering a range of factors from demographic and preoperative conditions to systemic institutional characteristics, the research highlights the complexity of clinical decision-making in cardiac surgery. This multifaceted approach is vital for developing more tailored and effective clinical guidelines.


  1. Potential for Unmeasured Confounders: While the study is comprehensive, the potential for unmeasured variables that could influence inotrope use, such as detailed intraoperative hemodynamic parameters and more specific details on surgical complexity, might limit the accuracy of the conclusions.
  2. Lack of Outcome Data: The study does not link variability in inotrope use to clinical outcomes. Without this correlation, it is challenging to determine the implications of variability on patient health outcomes, such as survival or postoperative complications.
  3. Generalizability to Non-US Settings: Given that the study is confined to US hospitals, the findings may not be directly applicable to healthcare settings in other countries with different healthcare systems and practice standards.

Potential Biases

  • Selection Bias: The exclusion of emergency surgeries and certain high-risk patients could lead to selection bias, potentially underestimating the variability and complexity of inotrope use in all cardiac surgical populations.
  • Institutional Bias: The possibility that institutions with specific characteristics (e.g., teaching hospitals) might manage their patients differently, influencing the generalizability of the findings to non-academic settings.

Overall Impact

The study significantly contributes to the understanding of how different factors influence inotrope use in cardiac surgery. By identifying key drivers of variability, it lays the groundwork for further research to explore how these factors can be modified to enhance patient care and optimize outcomes. Moreover, it raises important questions about the standardization of care practices and the potential for developing more individualized, evidence-based approaches to inotrope administration in cardiac surgery settings.

This research could ultimately lead to improved clinical guidelines and policies that reduce unnecessary variability in treatment while accommodating necessary individualized approaches based on patient-specific and institutional factors.

Future Directions and Recommendations

1. Prospective Clinical Trials:

Given the identified variability in inotrope use and its potential impacts, prospective clinical trials are needed to directly compare different inotrope administration strategies. These studies should aim to link specific inotropic protocols with patient outcomes, providing evidence to either support current practices or suggest modifications. Trials should incorporate a range of patient demographics and conditions to ensure the findings are applicable across diverse patient populations.

2. Development of Tailored Guidelines:

The study highlights the significant influence of institutional policies and clinician preferences on inotrope use. This suggests a need for developing more detailed, evidence-based guidelines that can be tailored to different types of healthcare settings and patient groups. Such guidelines should balance standardized best practices with flexibility for clinician judgment and patient-specific needs.

3. Training and Education Programs:

To address the variations attributable to clinician preferences and potentially inconsistent training, comprehensive education and training programs should be developed. These programs would focus on the optimal use of inotropes during cardiac surgery, emphasizing evidence-based practices and the latest research findings. Additionally, they could include simulations and scenario-based training to help clinicians make informed decisions under varying clinical circumstances.

4. Quality Improvement Initiatives:

Hospitals and healthcare systems should consider implementing quality improvement initiatives that regularly review inotrope usage patterns, compare them with patient outcomes, and identify areas for improvement. These initiatives could help reduce unwarranted variability by ensuring that inotrope use is both clinically justified and aligned with the latest research.

5. Enhanced Data Collection and Analytics:

To further understand the underlying causes of variability, healthcare institutions should invest in better data collection systems that include more granular details about patient conditions, intraoperative events, and postoperative outcomes. Advanced analytics and machine learning could be employed to analyze these data, providing deeper insights into how inotrope use affects different patient groups and how it can be optimized.

6. Interdisciplinary Collaboration:

Encouraging closer collaboration between cardiac surgeons, anesthesiologists, cardiologists, and other healthcare professionals involved in cardiac care could facilitate more holistic care strategies. Such collaboration would help ensure that decisions about inotrope use are made with comprehensive consideration of all relevant patient factors and clinical guidelines.

7. Patient-Centered Approaches:

Finally, involving patients in discussions about their care, particularly in decisions about inotrope use, can ensure that treatment plans align with their preferences and values. This approach not only promotes patient autonomy but also enhances satisfaction with care and may improve adherence to prescribed treatment plans.

These recommendations aim to address the complexities and challenges identified in the study, guiding future research and clinical practices towards more standardized yet flexible and patient-centered approaches to inotrope use in cardiac surgery. By pursuing these directions, the medical community can enhance the quality of care and outcomes for patients undergoing these critical procedures.

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