Does surgeon workload per day affect outcomes after pulmonary lobectomies?

Video-Assisted vs Robotic-Assisted Lung Lobectomies for Operating Room Resource Utilization and Patient Outcomes

Importance

With increased use of robots, there is an inadequate understanding of minimally invasive modalities' time costs. This study evaluates the operative durations of robotic-assisted vs video-assisted lung lobectomies.

Objective

To compare resource utilization, specifically operative time, between video-assisted and robotic-assisted thoracoscopic lung lobectomies.

Design, Setting, and Participants

This retrospective cohort study evaluated patients aged 18 to 90 years who underwent minimally invasive (robotic-assisted or video-assisted) lung lobectomy from January 1, 2020, to December 31, 2022, with 90 days' follow-up after surgery. The study included multicenter electronic health record data from 21 hospitals within an integrated health care system in Northern California. Thoracic surgery was regionalized to 4 centers with 14 board-certified general thoracic surgeons.

Exposures

Robotic-assisted or video-assisted lung lobectomy.

Main Outcomes and Measures

The primary outcome was operative duration (cut to close) in minutes. Secondary outcomes were length of stay, 30-day readmission, and 90-day mortality. Comparisons between video-assisted and robotic-assisted lobectomies were generated using the Wilcoxon rank sum test for continuous variables and the χ2 test for categorical variables. The average treatment effects were estimated with augmented inverse probability treatment weighting (AIPTW). Patient and surgeon covariates were adjusted for and included patient demographics, comorbidities, and case complexity (age, sex, race and ethnicity, neighborhood deprivation index, body mass index, Charlson Comorbidity Index score, nonelective hospitalizations, emergency department visits, a validated laboratory derangement score, a validated institutional comorbidity score, a surgeon-designated complexity indicator, and a procedural code count), and a primary surgeon-specific indicator.

Results

The study included 1088 patients (median age, 70.1 years [IQR, 63.3-75.8 years]; 704 [64.7%] female), of whom 446 (41.0%) underwent robotic-assisted and 642 (59.0%) underwent video-assisted lobectomy. The median unadjusted operative duration was 172.0 minutes (IQR, 128.0-226.0 minutes). After AIPTW, there was less than a 10% difference in all covariates between groups, and operative duration was a median 20.6 minutes (95% CI, 12.9-28.2 minutes; P < .001) longer for robotic-assisted compared with video-assisted lobectomies. There was no difference in adjusted secondary patient outcomes, specifically for length of stay (0.3 days; 95% CI, -0.3 to 0.8 days; P = .11) or risk of 30-day readmission (adjusted odds ratio, 1.29; 95% CI, 0.84-1.98; P = .13). The unadjusted 90-day mortality rate (1.3% [n = 14]) was too low for the AIPTW modeling process.

Conclusions and Relevance

In this cohort study, there was no difference in patient outcomes between modalities, but operative duration was longer in robotic-assisted compared with video-assisted lung lobectomy. Given that this elevated operative duration is additive when applied systematically, increased consideration of appropriate patient selection for robotic-assisted lung lobectomy is needed to improve resource utilization.

Influence of Intraoperative Active and Passive Breaks in Simulated Minimally Invasive Procedures on Surgeons' Perceived Discomfort, Performance, and Workload

Laparoscopic surgeons are at high risk of experiencing musculoskeletal discomfort, which is considered the result of long-lasting static and awkward body postures. We primarily aimed to evaluate whether passive and active work breaks can reduce ratings of perceived discomfort among laparoscopic surgeons compared with no work breaks. We secondarily aimed to examine potential differences in performance and workload across work break conditions and requested the surgeons evaluate working with passive or active work breaks. Following a balanced, randomized cross-over design, laparoscopic surgeons performed three 90 min laparoscopic simulations without and with 2.5 min passive or active work breaks after 30 min work blocks on separate days. The simulation included the following tasks: a hot wire, peg transfer, pick-and-place, pick-and-tighten, pick-and-thread, and pull-and-stick tasks. Ratings of perceived discomfort (CR10 Borg Scale), performance per subtask, and perceived workload (NASA-TLX) were recorded, and the break interventions were evaluated (self-developed questionnaire). Statistical analyses were performed on the rating of perceived discomfort and a selection of the performance outcomes. Twenty-one participants (9F) were included, with a mean age of 36.6 years (SD 9.7) and an average experience in laparoscopies of 8.5 years (SD 5.6). Ratings of perceived musculoskeletal discomfort slightly increased over time from a mean level of 0.1 to 0.9 but did not statistically significantly differ between conditions (p = 0.439). Performance outcomes of the hot wire and peg transfer tasks did not statistically significantly differ between conditions. The overall evaluation by the participants was slightly in favor regarding the duration and content of active breaks and showed a 65% likelihood of implementing them on their own initiative in ≥90 min-lasting laparoscopic surgeries, compared with passive breaks. Both passive and active breaks did not statistically significantly influence ratings of perceived discomfort or perceived workload in a 90 min simulation of laparoscopic surgery, with an overall low mean level of perceived discomfort of 0.9 (SD 1.4). As work breaks do not lead to performance losses, rest breaks should be tested in real-life situations across a complete working shift, where perceived discomfort may differ from this laboratory situation. However, in this respect, it is crucial to investigate the acceptance and practicality of intraoperative work breaks in feasibility studies in advance of assessing their effectiveness in follow-up longitudinal trials.

Effect of Surgical Day of Week on Postoperative Outcomes After Robotic-Assisted Pulmonary Lobectomy

Introduction Patients who have surgery late in the week could potentially receive different postoperative care due to a reduced weekend staff compared to patients who have surgery early in the week, who will be cared for by a full staff during the work week. Our aim was to determine if patients who underwent robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy during the first half of the week had different outcomes than patients who also underwent RAVT pulmonary lobectomy during the second half of the week. Methods We analyzed 344 consecutive patients who underwent RAVT pulmonary lobectomy by one surgeon from 2010 to 2016. Depending on the day of the surgical procedure, these patients were either put into a Monday through Wednesday (M-W) group or a Thursday through Friday (Th-F) group. Patient demographics, tumor histopathology, intraoperative and postoperative complications, and perioperative outcomes were compared between groups using the Student's t-test, Kruskal-Wallis test, or chi-square (or Fisher's exact) test, with p≤0.05 as significant. Results There were more non-small cell lung cancers (NSCLCs) resected in the M-W group than in the Th-F group (p=0.005). Skin-to-skin and total operative times were greater for the Th-F group than for the M-W group (p=0.027 and p=0.017, respectively). There were no significant differences in any other variables assessed. Conclusions Our study showed that, despite reduced weekend staffing and potential differences in postoperative care, there were no significant differences seen in postoperative complications or perioperative outcomes based on surgical day of the week.

Association Between Physicians' Workload and Prescribing Quality in One Tertiary Hospital in China

BACKGROUND

Alarming increasing trends in physician workload have attracted much attention in recent years. Heavy workload may compromise the quality of medication use. Previous studies have identified a series of factors contributing to inappropriate prescribing; however, there is no demonstrated evidence supporting an association between workload and the appropriateness of physicians' prescriptions in China. This study aimed to investigate the relationship between physician workload and prescription quality in a tertiary hospital in Beijing, China.

METHODS

Our study was a single-center, retrospective study, with all outpatient electronic health records extracted from hospital information system of a tertiary hospital in Beijing from July 1 to November 30, 2015. We used outpatient volume in each 5-hour shift as the measure of physician workload. The evaluation of prescribing quality was based on the Rational Drug Use System. Generalized linear models with a γ distribution and a log link were used to explore factors associated with inappropriate prescribing, and we undertook a series of robustness tests with respect to different exclusion criteria.

RESULTS

A total of 457,784 prescriptions from 502 physicians were included in the study. Physicians had an average workload of 34.3 (±19.8) patients per shift, and the mean rate of inappropriate prescribing per shift was 14.1% (±14.6%). Higher rates of inappropriate prescribing were associated with heavier workloads (P < 0.001). Physicians who worked in the afternoon, chief physicians, those working in surgical department, males, and those with more than 20-year experience had higher rates of inappropriate prescribing with increasing workload.

CONCLUSIONS

Heavier workload was associated with higher risk of prescribing inappropriately. It requires great efforts to determine optimal physician workloads and mitigate the potential adverse effects on the prescription quality.

The Impact of Surgical Scheduling on Outcomes in Lumbar Laminectomy

Objective The purpose of this study was to determine whether surgical scheduling affected patient outcomes following lumbar laminectomy. Physician fatigue caused by prolonged work hours has been shown to worsen outcomes. Previous research has also established a relationship between surgical scheduling and outcomes. Methods This was a retrospective chart review of single-level lumbar laminectomy patients at the Penn State Milton S. Hershey Medical Center between 1992 and 2019. Patients who underwent a one-level laminectomy between 1992 and 2019 were included in the study. Patients with procedures defined as complex (>1 level, tumor or abscess removal, discectomy, implant removal) were excluded. The surgical complication rate [cerebrospinal fluid (CSF) leak, 30-day redo, 30-day ED visit, weakness, sensation loss, infection, urinary retention] was compared across surgical start times, day of the week, proximity to a holiday, and procedure length. Results Procedures that started between 9:01-11:00 were more likely to have a complication than those between 7:01-9:00 (p=0.04). For every 60-min increase in surgery length, odds of having a complication increased by 2.01 times (p=0.0041). Surgeries that started between 11:01-13:00 had a significantly longer median surgery length than those between 7:01-9:00. Conclusion The time of the day when the procedure was started was predictive of worse outcomes following laminectomy. This may be attributed to several factors, including fatigue and staff turnover. Additionally, increased surgical length was predictive of more complications. It remains unclear whether increased surgical time results from correction of noticed errors or a fatigue-related decline in speed and performance. These findings on one-level laminectomy warrant further investigations since they have implications for reducing systemic failures that impact patient outcomes.

Surgeon fatigue does not affect surgical outcomes: a systematic review and meta-analysis

PURPOSE

To systematically review the effects of surgeon fatigue on postoperative mortality and postoperative complications after elective and non-elective surgeries.

METHODS

A database search was conducted for original articles published in PubMed between 2000 and 2020 with the keywords: "surgeon," "sleep deprivation," "sleep deprived," "fatigued," "mortality," "morbidity," and "outcomes." We selected articles that disclosed actual numbers of patients who underwent surgery by fatigued or rested surgeons, rates of postoperative mortality, or total postoperative complications.

RESULTS

Of the 1427 articles identified, 16 met the selection criteria and were included. Eight of the 16 also included total postoperative complications. Analysis revealed no significant differences in the rates of postoperative mortality after elective and non-elective surgeries or total postoperative complications of elective surgeries or non-elective surgeries performed by fatigued vs. rested surgeons. The relative risks were 1.03 [95% confidence interval (CI), 0.86-1.24], 1.08 (95% CI, 0.85-1.38), 0.99 (95% CI, 0.95-1.04), and 0.93 (95% CI, 0.67-1.28), respectively.

CONCLUSION

Surgeon fatigue does not affect the rates of postoperative mortality or total postoperative complications after elective surgeries and may have little to no effect on the rates of postoperative mortality or total postoperative complications after non-elective surgeries.

Surgeon Workload in Colorectal Surgery: Perceived Drivers of Procedural Difficulty

BACKGROUND

To understand how surgeon expectation of case difficulty relates to workload for colon and rectal procedures and to identify possible surgeon-perceived drivers contributing to case difficulty.

MATERIALS AND METHODS

For 3 mo, surgeons were asked to complete a modified NASA-Task Load Index (NASA-TLX) questionnaire following each surgical case. Questions included items on distractions, fatigue, procedural difficulty, and expectation plus the validated NASA-TLX items. All but expectation were rated on a 20-point scale (0 = low, 20 = high). Expectation was rated on a 3-point scale (i.e., more difficult than expected, as expected, less difficult than expected). Surgeons also reported perceived drivers contributing to case ease or difficulty. Patient and procedural data were analyzed for procedures with completed surveys.

RESULTS

Seven surgeons (three female) rated 122 procedures over the research period using a modified NASA-TLX survey. Mean surgeon-perceived workload was highest for effort (mean [M] = 10.83, standard deviation [SD] = 5.66) followed by mental demand (M = 10.18, SD = 5.17), and physical demand (M = 9.19, SD = 5.60). Procedural difficulty varied significantly by procedure type (P < 0.001). Thirty-five percent of cases were considered more difficult than expected. Surgeon-perceived workload and most subscales differed significantly according to expectation level. There was no significant difference in patient factors by expectation level. Surgeons most frequently reported patient anatomy, body habitus, and operative team characteristics as drivers to difficulty and ease of cases.

CONCLUSIONS

Procedural difficulty significantly differed across procedure type. More than one-third of cases were more difficult than expected, during which surgeons attributed this to operative team characteristics as well as issues in patient anatomy and body habitus.

Comparison of nighttime and daytime operation on outcomes of kidney transplant with deceased donors: a retrospective analysis

Background:

Kidney transplant is always emergent operations and frequently need to be performed at nighttime to reduce cold ischemia time (CIT). Previous studies have revealed that fatigue and sleep deprivation can result in adverse consequences of medical procedures. This study aimed to evaluate whether nighttime operation has adverse impact on kidney transplant.

Methods:

A retrospective analysis of recipients accepted kidney transplant from deceased donors in one center from 2014 to 2016 was performed. Daytime transplant was defined as operation started after 8 am or ended before 8 pm and nighttime operation was defined as operation ended after 8 pm or started before 8 am. The incidences of complications such as delayed graft function, acute rejection, surgical complications and nosocomial infections were compared between 2 groups. Student's t-test was used to analyze continuous variables such as serum creatinine (Scr) at 1-year of post-transplant. The Chi-square test was used to analyze categorical variables. Differences in recipients and graft survival were analyzed using Kaplan–Meier methodology and log-rank tests.

Results:

Among the 443 recipients, 233 (52.6%) were classified into the daytime group and the others 210 (47.4%) were in the nighttime group. The 1-year survival rate of recipients was similar for the recipients in the daytime and nighttime groups (95.3% vs. 95.2%, P = 0.981). Although the 1-year graft survival rate in the nighttime group was slightly superior to that in the daytime group, the difference was not significant (92.4% vs. 88.4%, P = 0.164). Furthermore, Scr and incidence of complications were also not significantly different between the 2 groups.

Conclusions:

Our results suggested that operation time of kidney transplant with short CIT has no significant impact on the outcome of kidney transplant. Nighttime operation of kidney transplant with short CIT could be postponed to the following day to alleviate the burden on medical staffs and avoid the potential risk.

A review of current approaches for evaluating impaired performance in around-the-clock medical professionals

The need for data to study the relationship between fatigued healthcare professionals and performance outcomes is evident, however, it is unclear which methodology is most appropriate to provide these insights. To address this issue, we performed a systematic review of relevant articles by searching the MEDLINE, EMBASE, Cochrane, Web of Science, and CINAHL databases. The literature search identified 2960 unique references, of which 82 were identified eligible. The impact on performance was studied on clinical outcomes, medical simulation, neurocognitive performance, sleep quantification and subjective assessment. In general results on performance are conflicting; impairment, no effect, and improvement were found. This review outlines the various methods currently available for assessing fatigue-impaired performance. The contrasting outcomes can be attributed to three main factors: differences in the operationalisation of fatigue, incomplete control data, and the wide variety in the methods used. We recommend the implementation of a clinically applicable tool that can provide uniform data. Until these data become available, caution should be used when developing regulations that can have implications for physicians, education, manpower planning, and ‒ ultimately ‒ patient care.

Operation Start Times and Postoperative Morbidity from Liver Resection: A Propensity Score Matching Analysis

BACKGROUND

Surgeons are likely to get progressively fatigued and work less effectively during the course of a normal workday. We sought to examine the effects of surgery start times (morning vs. afternoon) and workload of the surgeons on morbidity of patients after partial liver resection (LR).

METHODS

A total of 155 pairs of the patients from 383 patients undergoing LR were generated by propensity score analysis (PSM) according to the start times of surgery: group M (morning surgery, 8 a.m.-1 p.m.) and group A (afternoon surgery, 1 p.m.-6 p.m.). Patients in group A were further divided depending on whether or not the surgeons had performed other surgeries earlier in the day and the exact duration of the other surgeries before the afternoon surgery (≤180 and >180 min). The incidence and severity of postoperative complications were compared between different groups.

RESULTS

By using PSM analysis, the patients in group M and group A were well matched in basic characteristics. The incidence and severity of the postoperative complications were similar between the two groups (all p > 0.05). Whether the surgeons had performed other surgeries prior to the afternoon surgery seemed not affecting the postoperative outcome (all p > 0.05). Moreover, the duration of other surgeries the surgeons had performed did not have significant influence on the outcome of patients undergoing afternoon surgery (all p > 0.05).

CONCLUSIONS

Surgery start times and workload of surgeons during working time did not measurably affect short-term outcomes of the patients. The negative findings might be a manifestation of professional judgment and self-regulation of the experienced physicians.

Associations between attending physician workload, teaching effectiveness, and patient safety

BACKGROUND

Prior studies suggest that high workload among attending physicians may be associated with reduced teaching effectiveness and poor patient outcomes, but these relationships have not been investigated using objective measures of workload and safety.

OBJECTIVE

To examine associations between attending workload, teaching effectiveness, and patient safety, hypothesizing that higher workload would be associated with lower teaching effectiveness and negative patient outcomes.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a retrospective study of 69,386 teaching evaluation items submitted by 543 internal medicine residents for 107 attending physicians who supervised inpatient teaching services from July 2, 2005 to July 1, 2011.

MEASUREMENTS

Attending workload measures included hospital service census, patient length of stay, daily admissions, daily discharges, and concurrent outpatient duties. Teaching effectiveness was measured using residents' evaluations of attendings. Patient outcomes considered were applicable patient safety indicators (PSIs), intensive care unit transfers, cardiopulmonary resuscitation/rapid response team calls, and patient deaths. Mixed linear models and generalized linear regression models were used for statistical analysis.

RESULTS

Workload measures of midnight census and daily discharges were associated with lower teaching evaluation scores (both β = -0.026, P < 0.0001). The number of daily admissions was associated with higher teaching scores (β = 0.021, P = 0.001) and increased PSIs (odds ratio = 1.81, P = 0.0001).

CONCLUSION

Several measures of attending physician workload were associated with slightly lower teaching effectiveness, and patient safety may be compromised when teams are managing new admissions. Ongoing efforts by residency programs to optimize the learning environment should include strategies to manage the workload of supervising attendings.

Division of surgeon workload in pancreaticoduodenectomy: striving to decrease post-operative pancreatic fistula

BACKGROUND

Many studies have reported factors affecting pancreatic leakage after pancreaticoduodenectomy (PD), but there have been few reports on surgeon workload and post-operative pancreatic fistula (POPF). This study was conducted to explore whether a surgeon's workload during PD impacts the occurrence of POPF.

METHODS

We retrospectively analysed 270 consecutive patients who underwent PD between January 2008 and June 2013 by a single experienced surgeon. These patients were divided into those who underwent PD entirely by a single operator (group 1) and those who received reconstructions by other operators (group 2). Duct-to-mucosa pancreaticojejunostomy was performed on all patients. The International Study Group on Pancreatic Fistula criteria were used to define POPF.

RESULTS

There were 157 patients (58.1%) in group 1 and 113 patients (41.9%) in group 2. The post-operative morbidity rate was comparable between the two groups (55.4% versus 52.2%; P = 0.603), but the clinical pancreatic fistula (grade B/C) rate was significantly different (10.8% versus 2.7%; P = 0.011). The overall post-operative mortality was one patient (0.4%). Significant associations were found between clinical pancreatic fistulas and soft pancreas texture (P = 0.021), preoperative serum albumin level ≤3.5 g/dL (P = 0.012), other pathology besides pancreatic cancer (P = 0.027) and a single-operator procedure (P = 0.019). A multivariate logistic regression analysis revealed that a single operator (odds ratio: 4.2, P = 0.029) was a significant predictive risk factor for clinically relevant POPF.

CONCLUSION

Dividing the surgeon's workload in PD is associated with lower rates of POPF.

The impact of hospital and surgeon volume on the 30-day mortality of lung cancer surgery: A nation-based reappraisal

OBJECTIVE

Our objective was to analyze the time trend variation of 30-day mortality after lung cancer surgery, and to quantify the impact of surgeon and hospital volumes over a 5-year period in France.

METHODS

We used Epithor, the French national thoracic database and benchmark tool, which catalogues more than 180,000 procedures of 89 private and public hospitals in France. From January 2005 to December 2010, 19,556 patients who underwent major lung resection (lobectomy, bilobectomy, pneumonectomy) were included in our study. Multilevel logistic models were designed to investigate the relationship between 30-day mortality and surgeon (model 1) or hospital (model 2) volumes. The 3 levels considered were the patient, the surgeon, and the hospital.

RESULTS

From 2005 to 2007, the 30-day mortality of patients who underwent major lung resection averaged 10%, and then decreased until it reached 3.8% in 2010 (P < .0001). A significant decrease in 30-day mortality was observed over time (P = .0046). During the study period, the mean annual number of procedures per surgeon was 46.1 (standard deviation [SD] = 23.6) and per hospital was 97.9 (SD = 50.8). Model 1 showed that surgeon volume had a significant impact on 30-day mortality (P = .03), whereas model 2 failed to show that hospital volume influenced 30-day mortality (P = .75).

CONCLUSIONS

Since 2007, when France's first National Cancer Plan became effective, 30-day mortality of primary lung cancer surgery has decreased and currently measures 3.8%. Low mortality was correlated with higher surgeon volume but was not influenced by hospital volume, which cannot be considered a proxy measure for determining the safety of lung cancer surgery.