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J Neurosurg Anesthesiol. Author manuscript; available in PMC 2022 May 20.
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Published in final edited form as:

J Neurosurg Anesthesiol. 2019 January ; 31(1): 134–139. doi:10.1097/ANA.0000000000000540.

Prolonged Anesthetic Exposure in Children and Factors

Associated with Exposure Duration
Caleb Ing, MD, MS,
Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New
York, NY

Xiaoyue Ma, MS,

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Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New

York, NY

Anna J. Klausner, MD,

Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New
York, NY

Richard P. Dutton, MD, MBA,

US Anesthesia Partners, Dallas, TX

Guohua Li, MD, DrPH

Departments of Anesthesiology and Epidemiology, Columbia University College of Physicians
and Surgeons and Mailman School of Public Health, New York, NY
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Abstract
Introduction: Anesthetic exposure duration has come under scrutiny due to a Food and Drug
Administration (FDA) warning against prolonged use of anesthesia in children, defined as
exposures longer than 3 hours.

Methods: Data for 2,613,344 pediatric anesthetic records from the American Society of
Anesthesiologist’s National Anesthesia Clinical Outcomes Registry (NACOR) from 2010 to
2015 were analyzed to describe anesthetic duration and the prevalence of prolonged exposures
in children. Common pediatric inpatient procedures were independently assessed to determine
factors associated with exposure duration.

Results: The overall mean pediatric anesthetic duration was 83.3 ± 107.4 minutes (median
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57 minutes). Prolonged exposures comprised 7% of pediatric anesthetic records, and 15%

of anesthetic records in infants. After restricting to common pediatric inpatient procedures
(n=96,603) and adjusting for procedure type using a Poisson model, compared to children ≥10
years old, exposures in infants were 20.5% longer (anesthetic duration ratio [ADR], 1.205; [95%
confidence interval (CI), 1.202–1.208]). Longer exposures were also seen with a variety of other
patient and hospital factors including ASA 4 patients vs. ASA 1 patients, ([ADR], 1.381; [95% CI,
1.376–1.386]), and university hospitals vs. surgery centers ([ADR], 1.241; [95% CI, 1.236–1.246])

Corresponding Author ci2119@cumc.columbia.edu, Address: 622 W. 168th St. BHN 4-440, New York, NY 10032, USA, Phone:
212-305-2413, Fax: 212-305-2395.
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Conclusions: Most pediatric anesthetic exposures last less than one hour with a small
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percentage lasting over 3 hours. Anesthetic duration for inpatient pediatric procedures however
is associated with specific patient and hospital characteristics. These results may help identify
children potentially at risk for prolonged anesthetic exposure, and inform procedure time
prediction and operating room scheduling.

Keywords
Anesthetic neurotoxicity; pediatric anesthesia; operating room efficiency

Introduction:
The evaluation of procedure duration has a variety of applications including the
improvement of operating room efficiency and resource allocation.1 Procedure duration
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and the associated duration of anesthetic exposure has also gained additional relevance in
children due to a recent recommendation by the Food and Drug Administration (FDA)
against prolonged anesthetic exposures (defined as exposures longer than 3 hours) in
young children given the possible risks to neurodevelopment.2 While there is some
controversy regarding this recommendation, and the long-term effects of anesthesia on
neurodevelopment are still unclear, associations between prolonged or multiple anesthetic
exposures and an increased risk of neurodevelopmental deficit have been described.3-9
However, little is known about the prevalence of prolonged anesthetic exposures in children,
or factors that are associated with exposure duration.

Procedure time is commonly reported in individual studies of surgery and anesthesia in

children, but these studies are typically performed at single centers with a limited number of
patients, and often evaluate just one specific procedure.10-12 Procedure duration information
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typically requires abstraction of data from medical records and is therefore difficult to
perform on a large-scale multicenter basis. Anesthetic duration for surgical procedures can
also vary widely, particularly in children as there is a wide range of patient size, weight,
and pathology.13 Predictors of duration have been explored in adults, with a multi-center
study finding increased anesthesia time to be associated with race, coagulation disorders,
and paraplegia.14 However to our knowledge, only one large scale single center study has
evaluated procedure time in children, but was unable to identify any factors associated with
anesthesia or procedure duration.13

In order to address these gaps in knowledge, the goals of the present study are to use a
large multicenter database to: 1) evaluate the incidence of prolonged anesthetic duration as
defined by the FDA in children of different ages, and 2) identify patient and hospital factors
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associated with anesthetic duration.

Methods:
Data Source:
The data were obtained from the American Society of Anesthesiologists (ASA) Anesthesia
Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR). The

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NACOR is a voluntary submission registry created with the goal of sharing anesthesia-
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related data and outcomes. The purpose of the database is to generate a representative view
of anesthetic practice in the United States, and to describe patient demographics and quality
of anesthetic care on a local and national level.15 The NACOR data is directly imported from
participating institutions through their billing, anesthesia information management, quality
assurance, and hospital electronic record systems.16

In the present study, data from the NACOR Participant User Files from 2010 to 2015 were
used. The primary variable of interest was case duration, defined as the reported billing
interval between anesthesia start and stop times, and measured in minutes. This duration
describes a period of time that includes all time for anesthesia care including patient transfer
to a post-operative recovery location. All records with missing values for patient age or case
duration were excluded from analysis. Analysis was also restricted to records for patients
aged <18 years old.
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To evaluate the incidence of prolonged anesthetic duration, patient characteristics and

durations for all cases were evaluated. Records were then evaluated after stratifying by
patient age in the following categories: age <1 year, ≥1 to <3 years, ≥3 to <5 years, ≥5 to
<10 years, and ≥10 to <18 years old. According to the FDA recommendation, the duration of
time specified as a prolonged exposure to be avoided in children is 3 hours, and the children
potentially at risk were identified as those below 3 years of age.2 Therefore, the percentage
of cases with durations greater than 3 hours was evaluated in children of each age category.
As anesthesia time may also include time for patient transfer after the completion of the
intraoperative anesthetic, to calculate a more conservative estimate of anesthetic exposures
of greater than 3 hours, the percentage of cases with durations greater than 4 hours was also
evaluated.
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To assess patient and hospital level factors associated with anesthetic duration while
adjusting for the type of procedure, the NACOR was queried for records of children
receiving anesthesia for the ten most common inpatient general surgical procedures
performed in the United States in 2009.17 These procedures were identified using Current
Procedural Terminology 4th edition (CPT-4) codes listed in the NACOR records. In order
to remove outlier duration records for this analysis, patients in the 0.5 percentile of the
shortest and longest durations for each procedure were excluded, leaving 99% of the records
for each procedure available for analysis. The variables evaluated for their association with
duration of anesthesia were patient sex, age, and ASA Status, as well as the type and US
geographical region of the medical facility. The US geographical regions were facilities
in the Northeast, Midwest, South, and West regions. The facility types were university
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hospitals, large community hospitals (consisting of > 500 beds), medium-sized community
hospitals (consisting of 100 – 500 beds), small community hospitals (less than 100 beds),
specialty hospitals, and surgery centers.

Statistical Analysis:
To evaluate prolonged duration in pediatric procedures, means and standard deviations, and
median values of procedure duration were calculated for all available cases. The incidence
of prolonged duration in children (>3 hours or >4 hours) of different age groups was

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then calculated. To assess predictors of duration in the ten most common pediatric general
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surgical procedures, means and standard deviations, median values, quartiles, and highest
and lowest deciles were first calculated. Given that procedure duration is not normally
distributed, Poisson regression was used to evaluate the association between the duration
of anesthesia and all patient and hospital level covariates. Surgical procedure type was
also included as a multilevel categorical variable. Records with missing data in any of the
covariates or records with “Other” listed as the facility type were excluded from regression
analysis. All statistical analyses were performed using SAS version 9.4 (SAS Institute Inc.,
Cary, NC).

Results:
The study protocol was approved by the Institutional Review Board at Columbia University
(New York, New York) as exempt from written or informed consent. A total of over 30
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million records were identified in the NACOR participant user files from 2010 to 2015
with 3,341,655 records in children with age less than 18 years old. After also excluding all
records with missing duration of anesthesia, 2,613,344 records remained, with a total of 332
anesthesia practices submitting data.

Prolonged Anesthetic Duration in Children

Of these records, 5.8% (n=152,567) were from children <1 year, 18.6% (n=486,550)
from children ≥1 to <3 years, 15.5% (n=406,179) from children ≥3 to <5 years, 26.2%
(n=685,294) from children ≥5 to <10 years, and 33.8% (n=882,754) from children ≥10 to
<18 years old. The majority of children were ASA 1 or 2. (Table 1) Compared to other age
categories, children receiving anesthesia at <1 year of age had higher ASA statuses than
children in other age categories. There were similar distributions of facility types based on
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age, with the exception of more children <1 year of age receiving anesthesia at university
and large community hospitals.

The mean duration for all anesthetic records was 83.3 ± 107.4 minutes with a median
duration of 57 minutes. The mean durations were similar between age categories with
children between 1 and 10 years old, but longer mean durations were seen in children at ages
<1 year old and ≥10 years old.

The majority of anesthetic cases were less than 3 hours in duration, although longer
procedures were more common in younger children. The percentage of anesthetic cases
that lasted for longer than 3 hours for all children was 7.2%, with 4.2% lasting longer than 4
hours. In children <1 year old however, 15.6% of cases lasted longer than 3 hours with 9.4%
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lasting longer than 4 hours. (Figure 1)

Factors Associated with Anesthetic Duration

Using the NACOR database, a total of 96,603 records from children receiving one of
the ten most common inpatient general surgical procedures were identified. These records
originated from 187 anesthesia practices. Compared to the records of children receiving
anesthesia for all procedures, these children tended to be younger in age, with a higher
percentage of children in the <1 year old category and a lower percentage of children in the

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≥10 year old category. (Table 2) These children also had overall higher ASA statuses and
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were less likely to be performed at surgery centers. The duration of these cases ranged from
22 to 712 minutes with a right skewed distribution. (Figure 2) The overall median duration
of these most common pediatric procedures was 75 minutes but ranged from 51 to 180
minutes based on procedure type. (Table 3) The longest duration was found with anti-reflux
procedures and bladder ureter reconstructions while gastrostomy tube placements had the
shortest median durations. The durations of anesthetic care within the same procedure type
also varied, with the highest duration decile ranging from 1.9 to 4.6 times longer than the
lowest decile.

All covariates as well as a surgical procedure type variable were included in a multivariable
Poisson regression model. After adjusting for procedure type, given the large sample size,
nearly all covariates were found to be statistically associated with anesthesia duration.
The patient level covariates with potential clinical significance however included ages <1
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year old as well as ≥1 to <3 years old, with anesthesia duration ratios (ADR) of 1.205
(95% confidence interval [CI], 1.202–1.208) and 1.125 (95% CI, 1.122–1.128) respectively
compared to children ≥10 years old. (Table 4) This can be interpreted as children <1 year
old having a 20.5% increased duration of anesthesia compared to children ≥10 years old
after accounting for procedure type and other covariates. Male sex was associated with
statistically longer duration, but an estimated 1.9% higher duration ([ADR]: 1.019 (95%
CI, 1.017–1.020) is unlikely to be clinically significant. Durations in children between 3
and 5, and 5 and 10 years old were 1.2% and 2.9% shorter respectively than children older
than 10 years of age, which is also unlikely to be clinically significant. Of all covariates,
ASA 4 status was associated with the largest increase in duration with ADR: 1.381 (95%
CI, 1.376–1.386), while ASA 3 status also conferred a rate of additional anesthetic duration
ADR, 1.161 (95% CI, 1.158–1.163). The hospital level covariates associated with longer
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anesthetic duration included geographical region, with hospitals located in the Northeast
having the longest durations. When evaluating facility type, the longest durations were seen
at university hospitals, with ADR, 1.241 (95% CI, 1.236–1.246) compared to the reference
of surgical centers, which had the shortest durations overall. This represents a 24.1% higher
anesthetic duration in university hospitals compared to surgery centers.

Discussion:
In this study, we found that the median anesthetic duration in children was 57 minutes
and that 7% of children had anesthetic durations greater than 3 hours. Longer exposures
however were more commonly seen in younger children, with 15% of anesthetic cases
lasting longer than 3 hours in children aged <1 year old. While the FDA has recommended
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avoiding anesthetic exposures of longer than 3 hours in children,2 there remains some debate
about this particular time threshold. One major reason for the lack of consensus is that the
determination of this threshold is based on animal models and not clinical studies.18 Also
while a number of clinical studies have evaluated anesthetic exposure duration, associations
with neurodevelopmental deficits have been seen in exposures as short as 35 minutes to as
long as 120 minutes3-6 Interpretation of these studies however is complicated by the fact
that a range of many different surgical procedures were included in the studies. As longer
anesthetic duration is also related to the complexity of the surgical procedure and underlying

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comorbid disease, the increased risks of neurodevelopmental deficit cannot be conclusively

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attributed to the prolonged anesthetic exposure. As a result, while this warning against
3-hour exposures remains, the exact threshold of vulnerability in children, and whether a
threshold even exists is still unclear.

When assessing the most commonly performed pediatric general surgery procedures, we
found a significant amount of variation in anesthetic duration between procedure types.
There was even significant variation within procedures, with the longest anesthetics for a
given procedure lasting several times longer than the shortest anesthetic. This may have
some important implications for population-based studies of anesthetic neurotoxicity, as
there may be significant variability in the dose of anesthesia even for children receiving the
same procedure.

In evaluating patient level factors associated with anesthetic duration, after adjusting for
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procedure type, procedures in children younger than 3 years old and those with ASA status
higher than 3 were associated with longer anesthetic durations. These results are in contrast
to a prior single center study which was unable to find associations between patient age
and ASA status and differences in procedure duration.13 As age and ASA status are easily
identifiable in patients preoperatively, these results may play a role in helping to predict
surgical and anesthetic duration and thereby improve operating room efficiency. With regard
to hospital level factors, that university hospitals were associated with the longest anesthetic
exposures is not surprising given the participation of surgery and anesthesia trainees in
intraoperative patient care. These results however are novel as we were able to compare and
quantify the differences between the different facility types.

There are a number of limitations inherent in this study. First, the NACOR data is composed
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of records from institutions that voluntarily submit data and therefore these records may
not be representative of the general population, or of all medical institutions within the
United States. The NACOR however is the largest repository of anesthesia billing data in
the US and offers data from a mixture of university and community hospitals. Second,
there may be inconsistencies and inaccuracies between the participating institutions in the
reporting of data. However, since the anesthetic duration is directly related to anesthesia
billing, this variable is likely to be accurate. Third, while these durations identify exposure
to anesthesia during individual procedures, since individual patients cannot be identified, the
total duration of exposure for individual children who may have received multiple exposures
cannot be calculated. As a result, if neurodevelopmental risk after anesthetic exposure is
cumulative, this analysis may underestimate the total number of children with cumulative
exposures of greater than 3 hours. Finally, while our results have found associations between
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specific patient and hospital level covariates and anesthesia duration, prediction of duration
is complicated and a more complex model will likely be needed for anesthesia case time
prediction.

Conclusions:
To our knowledge, this study is the first to evaluate anesthetic exposure duration in
children and identify specific factors associated with duration using a large, multi-centered

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database. The results from this study have a number of important implications for the fields
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of anesthetic neurotoxicity as well as operating room efficiency. If prolonged anesthetic

exposure is ultimately found to contribute to neurodevelopmental deficit in children,
knowledge of the proportion of children with prolonged exposures will be helpful for
determining the number of children potentially at risk for anesthetic induced neurotoxicity.
In addition, an understanding of the factors associated with anesthetic exposure duration
would not only help to further identify patients potentially at risk for prolonged exposures,
but would also allow for the development of systems that may help to more efficiently
allocate operating room resources.

Acknowledgments:
We acknowledge Meghan Cahill for her contributions in generating study figures and advising the data analysis for
parts of the study.
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References:
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based on operating room efficiency and patient waiting times. Anesthesiology 2004;101:1444–53.
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2. FDA Drug Safety Communication: FDA review results in new warnings about
using general anesthetics and sedation drugs in young children and pregnant
women [12-14-2016]. (Accessed January 3, 2017, at http://www.fda.gov/Drugs/DrugSafety/
ucm532356.htm?source=govdelivery&utm_medium=email&utm_source=govdelivery.)
3. Wilder RT, Flick RP, Sprung J, et al. Early exposure to anesthesia and learning disabilities in a
population-based birth cohort. Anesthesiology 2009;110:796–804. [PubMed: 19293700]
4. Block RI, Thomas JJ, Bayman EO, Choi JY, Kimble KK, Todd MM. Are anesthesia and surgery
during infancy associated with altered academic performance during childhood? Anesthesiology
2012;117:494–503. [PubMed: 22801049]
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5. Ing C, Hegarty MK, Perkins JW, et al. Duration of general anaesthetic exposure in early childhood
and long-term language and cognitive ability. Br J Anaesth 2017;119:532–40. [PubMed: 28969309]
6. Hu D, Flick RP, Zaccariello MJ, et al. Association between Exposure of Young Children to
Procedures Requiring General Anesthesia and Learning and Behavioral Outcomes in a Population-
based Birth Cohort. Anesthesiology 2017.
7. Flick RP, Katusic SK, Colligan RC, et al. Cognitive and behavioral outcomes after early exposure to
anesthesia and surgery. Pediatrics 2011;128:e1053–61. [PubMed: 21969289]
8. Glatz P, Sandin RH, Pedersen NL, Bonamy AK, Eriksson LI, Granath F. Association of
Anesthesia and Surgery During Childhood With Long-term Academic Performance. JAMA Pediatr
2016:e163470.
9. Warner DO, Zaccariello MJ, Katusic SK, et al. Neuropsychological and Behavioral Outcomes after
Exposure of Young Children to Procedures Requiring General Anesthesia: The Mayo Anesthesia
Safety in Kids (MASK) Study. Anesthesiology 2018.
10. Gunter JB, Dunn CM, Bennie JB, Pentecost DL, Bower RJ, Ternberg JL. Optimum concentration
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of bupivacaine for combined caudal--general anesthesia in children. Anesthesiology 1991;75:57–

61. [PubMed: 2064061]
11. Larsson S, Jonmarker C. Postoperative emesis after pediatric strabismus surgery: the effect
of dixyrazine compared to droperidol. Acta Anaesthesiol Scand 1990;34:227–30. [PubMed:
2343722]
12. Puram SV, Kozin ED, Sethi R, et al. Impact of resident surgeons on procedure length based on
common pediatric otolaryngology cases. Laryngoscope 2015;125:991–7. [PubMed: 25251257]
13. Bravo F, Levi R, Ferrari LR, McManus ML. The nature and sources of variability in pediatric
surgical case duration. Paediatr Anaesth 2015;25:999–1006. [PubMed: 26184574]

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14. Silber JH, Rosenbaum PR, Zhang X, Even-Shoshan O. Influence of patient and hospital
characteristics on anesthesia time in medicare patients undergoing general and orthopedic surgery.
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Anesthesiology 2007;106:356–64. [PubMed: 17264731]

15. Dutton RP. Making a difference: the Anesthesia Quality Institute. Anesth Analg 2015;120:507–9.
[PubMed: 25695566]
16. Abrecht CR, Gabriel RA, Dutton RP, Kaye AD, Michna E, Urman RD. National Perioperative
Outcomes for Intrathecal Pump, Spinal Cord Stimulator, and Peripheral Nerve Stimulator
Procedures. Pain Physician 2015;18:547–54. [PubMed: 26606006]
17. Somme S, Bronsert M, Morrato E, Ziegler M. Frequency and variety of inpatient pediatric surgical
procedures in the United States. Pediatrics 2013;132:e1466–72. [PubMed: 24276846]
18. FDA Drug Safety Communication: FDA approves label changes for use of general anesthetic
and sedation drugs in young children [4-27-2017]. (Accessed November 1, 2017, at https://
www.fda.gov/Drugs/DrugSafety/ucm554634.htm.)
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Figure 1: Percentage of Anesthesia Cases with Prolonged Duration

The percentages of anesthesia cases for the 2,613,344 pediatric anesthetic records reported
to the NACOR from 2010 to 2015 with durations >3 hours and >4 hours. Data are presented
for all ages and also stratified by patient age.
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Figure 2: Histogram of Anesthetic Durations for All Common Pediatric General Surgical
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Procedures
This histogram includes anesthetic records reported to the NACOR from 2010 to 2015. The
anesthetic durations of the 96,603 anesthetic records for the ten most common pediatric
general surgical inpatient procedures are represented.
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Table 1:

Patient Characteristics and Duration of Anesthesia by Age Category

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All ages <1 yo ≥1 to <3 yo ≥3 to <5 yo ≥5 to <10 yo ≥10 to <18 yo

(n=2,613,344) (n=152,567) (n=486,550) (n=406,179) (n=685,294) (n=882,754)
% % % % % %

Sex
Male 53.6 59.4 57.8 55.2 53.8 49.5
Female 41.9 33.8 37.4 40.4 41.8 46.6
Missing 4.5 6.8 4.8 4.4 4.4 3.9

ASA Status
1 47 33.7 48.6 49.7 47.4 46.9
2 25.1 20.2 23 23.8 26.1 26.8
3 9.2 19.5 8.9 8 8.3 8.7
≥4 1.6 11 1.6 0.9 0.8 1
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Missing 17.1 15.6 17.9 17.6 17.3 16.5

US Geographical Region
Northeast 11.2 10.5 9.2 11 11 12.7
Midwest 27.7 23.3 29.6 26.8 27.8 27.7
South 44.2 49.9 46.4 46.2 44.4 40.9
West 15.4 15.3 13.2 14.4 15.4 17
Missing 1.5 1.1 1.6 1.6 1.4 1.7

Facility Type
University 11.4 15.8 12.1 10.7 10.6 11.3
Large Community 13.9 18.1 13 13 13.5 14.3
Medium Community 23 19.6 21.3 22.1 22.9 25
Small Community 2 1.2 1.8 2.3 2.1 2.1
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Specialty 7.2 8.6 7.5 7.3 7.3 6.8

Surgery Center 19.3 8.9 21.8 22 21.4 16.8
Other 0.4 1.1 1.6 1.5 1.4 1.7
Missing 22.7 26.6 20.9 21 20.7 22.1

Duration (minutes)
Mean ± SD 83.3 ± 107.4 118.7 ± 141.3 72.6 ± 123.2 70.9 ± 85.4 71.4 ± 82.6 98.1 ± 114.1
Median (IQR) 57 (59) 81 (87) 44 (57) 53 (51) 53 (49) 67 (67)
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Table 2:

Characteristics of Patients Receiving the Ten Most Common Inpatient Procedures in Children
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All Procedures
(n=96,603)
%

Age
<1 years old 13.5
≥1 to <3 years old 12.1
≥3 to <5 years old 7.4
≥5 to <10 years old 21.4
≥10 to <18 years old 45.5

Sex
Male 60.3
Female 39.7
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ASA Status
1 49.7
2 30.4
3 16.1
≥4 3.9

US Geographical Region
Northeast 13.6
Midwest 23.1
South 41.2
West 22.2

Facility Type
University 11.7
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Large Community 28.6

Medium Community 39.6
Small Community 3.4
Specialty 11.9
Surgery Center 4.9
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Table 3:

Duration in Minutes of Common Pediatric General Surgical Procedures

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Duration in Minutes

10th 25th 75th 90th

Procedure Type n Mean ± SD Percentile Percentile Median Percentile Percentile
Bladder/ureter reconstruction 2,018 191.9 ± 90.2 98 136 180 227 290
Anti-reflux procedure 2,411 168.5 ± 71.2 104 124 152 195 250
Cholecystectomy 6,388 103.1 ± 46.1 63 76 93 119 151
Burn debridement 1,162 98.2 ± 68.9 38 56 81 117 175
PDA ligation 1,648 94.7 ± 69.8 45 57 75 110 155
Appendectomy 40,435 79.3 ± 32.9 53 62 73 89 109
Pyloromyotomy 3,187 80.9 ± 51.2 55 63 73 87 102
Central venous access 16,165 94.1 ± 84.7 39 51 71 100 157
Inguinal hernia 18,590 79.7 ± 50.8 44 55 70 91 118
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Gastrostomy tube 4,599 66 ± 53.2 30 37 51 76 117

All Procedures 96,603 87.9 ± 58.6 47 59 75 97 134

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Table 4:

Patient and Hospital Characteristics and Association with Anesthetic Duration

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Anesthesia Duration Ratio (ADR):

Estimate (95% CI)

Age
<1 year old
≥1 to <3 years old
≥3 to < 5 years old
≥ 5 to <10 years old
≥10 to < 18 years old
1.205 (1.202 – 1.208)
1.125 (1.122 – 1.128)
0.988 (0.985 – 0.991)
0.971 (0.969 – 0.973)
Reference

Sex
Male 1.019 (1.017 – 1.020)
Female Reference

ASA Status
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1 Reference
2 1.029 (1.028 – 1.031)
3 1.161 (1.158 – 1.163)
≥4 1.381 (1.376 – 1.386)

US Geographical Region
Northeast 1.134 (1.131 – 1.137)
Midwest 1.056 (1.054 – 1.058)
South 1.049 (1.047 – 1.051)
West Reference

Facility Type
University 1.241 (1.236 – 1.246)
Large Community 1.111 (1.107 – 1.115)
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Medium Community 1.068 (1.064 – 1.072)

Small Community 1.001 (0.996 – 1.006)
Specialty 1.112 (1.108 – 1.117)
Surgery Center Reference
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