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Weaver MD, Landrigan CP, Sullivan JP, O'Brien CS, Qadri S, Viyaran N, Czeisler CA, Barger LK. National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies. BMJ Qual Saf 2023; 32:81-89. [PMID: 35537821 PMCID: PMC9887355 DOI: 10.1136/bmjqs-2021-014375] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 04/13/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) enacted a policy in 2011 that restricted first-year resident physicians in the USA to work no more than 16 consecutive hours. This was rescinded in 2017. METHODS We conducted a nationwide prospective cohort study of resident physicians for 5 academic years (2002-2007) before and for 3 academic years (2014-2017) after implementation of the 16 hours 2011 ACGME work-hour limit. Our analyses compare trends in resident physician-reported medical errors between the two cohorts to evaluate the impact of this policy change. RESULTS 14 796 residents provided data describing 78 101 months of direct patient care. After adjustment for potential confounders, the work-hour policy was associated with a 32% reduced risk of resident physician-reported significant medical errors (rate ratio (RR) 0.68; 95% CI 0.64 to 0.72), a 34% reduced risk of reported preventable adverse events (RR 0.66; 95% CI 0.59 to 0.74) and a 63% reduced risk of reported medical errors resulting in patient death (RR 0.37; 95% CI 0.28 to 0.49). CONCLUSIONS These findings have broad relevance for those who work in and receive care from academic hospitals in the USA. The decision to lift this work hour policy in 2017 may expose patients to preventable harm.
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Affiliation(s)
- Matthew D Weaver
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher P Landrigan
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Medicine, and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason P Sullivan
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
| | - Conor S O'Brien
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
| | - Salim Qadri
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
| | - Natalie Viyaran
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
| | - Charles A Czeisler
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura K Barger
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Golubkova A, Liebe H, Leiva T, Lees J, Reinschmidt KM, Hunter CJ. Ethics of Resident Involvement in Surgical Training. THE JOURNAL OF CLINICAL ETHICS 2023; 34:175-189. [PMID: 37229744 DOI: 10.1086/725083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
AbstractBackground: Attending surgeons must maintain balance between promoting education and assuring safe, transparent patient care. This investigation aimed to define ethics that guide surgical training. We hypothesized that resident autonomy in the operating room is influenced by attending approach to patients, specifically patients considered to be vulnerable. MATERIALS AND METHODS After IRB approval, surgeons from three institutions were invited to participate in a pilot, survey, exploring how principles of patient autonomy, physician beneficence, nonmaleficence, and justice apply to participant opinions. Responses were transcribed and coded for quantitative and qualitative analysis. RESULTS 51 attendings and 55 residents completed the survey. We identified that patient autonomy is upheld through transparent consent practices. Intraoperative supervision is a key practice that maintains the principles of physician beneficence and nonmaleficence and mitigates the risk of resident participation. Vulnerable patients were defined by respondents as those unable to participate in their own consent and those limited by social determinants of health and barriers to medical literacy. In contrast, resident participation is not limited in the care of vulnerable patients but is restricted in cases of higher complexity and those procedures deemed to have lower error margins. CONCLUSIONS Although residents measure the success of their training based on their level of intraoperative independence, autonomy afforded to the resident does not only depend on objective skill. There are ethical considerations that the attending must navigate as they decide on effective teaching and safe surgical management, which is especially relevant in the care of complex cases.
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de Geus SW, Papageorge MV, Woods AP, Wilson S, Ng SC, Merrill A, Cassidy M, McAneny D, Tseng JF, Sachs TE. A Rising Tide Lifts All Boats: Impact of Combined Volume of Complex Cancer Operations on Surgical Outcomes in a Low-Volume Setting. J Am Coll Surg 2022; 234:981-988. [PMID: 35703786 PMCID: PMC9204842 DOI: 10.1097/xcs.0000000000000228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Centralization for complex cancer surgery may not always be feasible owing to socioeconomic disparities, geographic constraints, or patient preference. The present study investigates how the combined volume of complex cancer operations impacts postoperative outcomes at hospitals that are low-volume for a specific high-risk cancer operation. STUDY DESIGN Patients who underwent pneumonectomy, esophagectomy, gastrectomy, hepatectomy, pancreatectomy, or proctectomy were identified from the National Cancer Database (2004-2017). For every operation, 3 separate cohorts were created: low-volume hospitals (LVH) for both the individual cancer operation and the total number of those complex operations, mixed-volume hospital (MVH) with low volume for the individual cancer operation but high volume for total number of complex operations, and high-volume hospitals (HVH) for each specific operation. RESULTS LVH was significantly (all p ≤ 0.01) predictive for 30-day mortality compared with HVH across all operations: pneumonectomy (9.5% vs 7.9%), esophagectomy (5.6% vs 3.2%), gastrectomy (6.8% vs 3.6%), hepatectomy (5.9% vs 3.2%), pancreatectomy (4.7% vs 2.3%), and proctectomy (2.4% vs 1.3%). Patients who underwent surgery at MVH and HVH demonstrated similar 30-day mortality: esophagectomy (3.2 vs 3.2%; p = 0.993), gastrectomy (3.2% vs 3.6%; p = 0.637), hepatectomy (3.8% vs 3.2%; p = 0.233), pancreatectomy (2.8% vs 2.3%; p = 0.293), and proctectomy (1.2% vs 1.3%; p = 0.843). Patients who underwent pneumonectomy at MVH demonstrated lower 30-day mortality compared with HVH (5.4% vs 7.9%; p = 0.045). CONCLUSION Patients who underwent complex operations at MVH had similar postoperative outcomes to those at HVH. MVH provide a model for the centralization of complex cancer surgery for patients who do not receive their care at HVH.
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Affiliation(s)
- Susanna Wl de Geus
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Marianna V Papageorge
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Alison P Woods
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Woods)
| | - Spencer Wilson
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Sing Chau Ng
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Andrea Merrill
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Michael Cassidy
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - David McAneny
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Jennifer F Tseng
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Teviah E Sachs
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
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Rigby BE, Malott K, Sample SJ, Hetzel SJ, Soukup JW. Impact of the Surgical Environment on the Incidence, Timing, and Severity of Complications Associated With Oromaxillofacial Oncologic Surgery in Dogs. Front Vet Sci 2022; 8:760642. [PMID: 34977206 PMCID: PMC8718541 DOI: 10.3389/fvets.2021.760642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/23/2021] [Indexed: 11/23/2022] Open
Abstract
Numerous reports describe complication rates associated with oromaxillofacial oncologic surgery in dogs, however, investigation regarding the impact of the surgical environment on the incidence of complications is under reported. The objective of this retrospective cohort study, including 226 dogs surgically treated for oromaxillofacial tumors between January 1, 1997 and December 31, 2018, is to evaluate the impact of the surgical environment on the incidence of complications in oromaxillofacial oncologic surgery in dogs. A secondary objective is to report the incidence of local complications in oromaxillofacial oncologic surgery and characterize the type, timing, and severity of complications encountered. Incidence of complications was identified to be 69.9%. No significant association was identified between the incidence, timing, or severity of complications and the training background of the clinician, physical location of the procedure, or the ostectomy instrument used. These results suggest that the surgical environment has little impact on the incidence, timing, and severity of complications in dogs undergoing oromaxillofacial oncologic surgery. The results also emphasize the importance of preparing the surgical team and the client for a high incidence of complications associated with oromaxillofacial oncologic surgery in dogs and indicate that both short-term and long-term follow up is important in these cases. Oromaxillofacial surgery performed by residents-in-training within a veterinary teaching environment with adequate supervision appears to be safe.
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Affiliation(s)
- Brittney E Rigby
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, WI, United States
| | - Kevin Malott
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, WI, United States
| | - Susannah J Sample
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, WI, United States
| | - Scott J Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, United States
| | - Jason W Soukup
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, WI, United States
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Effect of Resident and Fellow Involvement on Outcomes of Sarcoma Surgery: A NSQIP Database Cross-Sectional Study. Sarcoma 2021; 2021:2645737. [PMID: 34961809 PMCID: PMC8710164 DOI: 10.1155/2021/2645737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 10/20/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022] Open
Abstract
Background The complexity of sarcoma surgery often justifies surgical assistants of higher levels of academic training: senior residents, fellows, or co-surgeons. The association between the level of training of assistants and outcomes of these procedures has yet to be studied. Methods The Current Procedural Terminology (CPT) codes comprising the “core” procedures for musculoskeletal oncology fellowships were gathered. After CPTs primarily capturing nononcologic procedures were excluded, the National Surgical Quality Improvement Program (NSQIP) database was used to find procedures with these CPTs. The severity of complications was assessed using the Severity Weighting of Postoperative Adverse Events in Orthopedic Surgery (SWORD) score. Resident/fellow presence was analyzed both as a binary variable and stratified by level of training. Results In 159 cases meeting inclusion criteria, higher-level assistants were associated with increased rate of any complication (p=0.006) and greater need for transfusion (p=0.001) but also tended to be used in cases of longer duration (p=0.001) and with higher total work relative value units (wRVUs) (p=0.001). Multivariate analysis showed that while higher-wRVU procedures persisted as an independent predictor of increased complications (OR 1.028 per RVU unit, p=0.002), neither the presence nor level of training of assistants had an independent effect on complication rates. Other independent predictors of 30-day complications were treatment comorbidity (OR 3.433, p=0.010) and lower extremity location of the tumor (OR 4.393, p=0.006). Severity of complications did not differ between any of the groups on either univariate or multivariate analysis. Conclusions Trainees of higher levels of academic training tend to be present for longer, higher-complexity musculoskeletal oncology cases, but the overall severity of complications from these do not significantly differ from lower-risk cases without trainees. Orthopedic oncologists may reassure patients that the presence of trainees and co-surgeons is not only safe but it may also help reduce the severity of complications in more complex procedures.
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Evans RPT, Kamarajah SK, Bundred J, Nepogodiev D, Hodson J, van Hillegersberg R, Gossage J, Vohra R, Griffiths EA, Singh P, Evans RPT, Hodson J, Kamarajah SK, Griffiths EA, Singh P, Alderson D, Bundred J, Evans RPT, Gossage J, Griffiths EA, Jefferies B, Kamarajah SK, McKay S, Mohamed I, Nepogodiev D, Siaw- Acheampong K, Singh P, van Hillegersberg R, Vohra R, Wanigasooriya K, Whitehouse T, Gjata A, Moreno JI, Takeda FR, Kidane B, Guevara Castro R, Harustiak T, Bekele A, Kechagias A, Gockel I, Kennedy A, Da Roit A, Bagajevas A, Azagra JS, Mahendran HA, Mejía-Fernández L, Wijnhoven BPL, El Kafsi J, Sayyed RH, Sousa M, Sampaio AS, Negoi I, Blanco R, Wallner B, Schneider PM, Hsu PK, Isik A, Gananadha S, Wills V, Devadas M, Duong C, Talbot M, Hii MW, Jacobs R, Andreollo NA, Johnston B, Darling G, Isaza-Restrepo A, Rosero G, Arias-Amézquita F, Raptis D, Gaedcke J, Reim D, Izbicki J, Egberts JH, Dikinis S, Kjaer DW, Larsen MH, Achiam MP, Saarnio J, Theodorou D, Liakakos T, Korkolis DP, Robb WB, Collins C, Murphy T, Reynolds J, Tonini V, Migliore M, Bonavina L, Valmasoni M, Bardini R, Weindelmayer J, Terashima M, White RE, Alghunaim E, Elhadi M, Leon-Takahashi AM, Medina-Franco H, Lau PC, Okonta KE, Heisterkamp J, Rosman C, van Hillegersberg R, Beban G, Babor R, Gordon A, Rossaak JI, Pal KMI, Qureshi AU, Naqi SA, Syed AA, Barbosa J, Vicente CS, Leite J, Freire J, Casaca R, Costa RCT, Scurtu RR, Mogoanta SS, Bolca C, Constantinoiu S, Sekhniaidze D, Bjelović M, So JBY, Gačevski G, Loureiro C, Pera M, Bianchi A, Moreno Gijón M, Martín Fernández J, Trugeda Carrera MS, Vallve-Bernal M, Cítores Pascual MA, Elmahi S, Hedberg J, Mönig S, Gutknecht S, Tez M, Guner A, Tirnaksiz TB, Colak E, Sevinç B, Hindmarsh A, Khan I, Khoo D, Byrom R, Gokhale J, Wilkerson P, Jain P, Chan D, Robertson K, Iftikhar S, Skipworth R, Forshaw M, Higgs S, Gossage J, Nijjar R, Viswanath YKS, Turner P, Dexter S, Boddy A, Allum WH, Oglesby S, Cheong E, Beardsmore D, Vohra R, Maynard N, Berrisford R, Mercer S, Puig S, Melhado R, Kelty C, Underwood T, Dawas K, Lewis W, Al-Bahrani A, Bryce G, Thomas M, Arndt AT, Palazzo F, Meguid RA, Fergusson J, Beenen E, Mosse C, Salim J, Cheah S, Wright T, Cerdeira MP, McQuillan P, Richardson M, Liem H, Spillane J, Yacob M, Albadawi F, Thorpe T, Dingle A, Cabalag C, Loi K, Fisher OM, Ward S, Read M, Johnson M, Bassari R, Bui H, Cecconello I, Sallum RAA, da Rocha JRM, Lopes LR, Tercioti V, Coelho JDS, Ferrer JAP, Buduhan G, Tan L, Srinathan S, Shea P, Yeung J, Allison F, Carroll P, Vargas-Barato F, Gonzalez F, Ortega J, Nino-Torres L, Beltrán-García TC, Castilla L, Pineda M, Bastidas A, Gómez-Mayorga J, Cortés N, Cetares C, Caceres S, Duarte S, Pazdro A, Snajdauf M, Faltova H, Sevcikova M, Mortensen PB, Katballe N, Ingemann T, Morten B, Kruhlikava I, Ainswort AP, Stilling NM, Eckardt J, Holm J, Thorsteinsson M, Siemsen M, Brandt B, Nega B, Teferra E, Tizazu A, Kauppila JS, Koivukangas V, Meriläinen S, Gruetzmann R, Krautz C, Weber G, Golcher H, Emons G, Azizian A, Ebeling M, Niebisch S, Kreuser N, Albanese G, Hesse J, Volovnik L, Boecher U, Reeh M, Triantafyllou S, Schizas D, Michalinos A, Baili E, Mpoura M, Charalabopoulos A, Manatakis DK, Balalis D, Bolger J, Baban C, Mastrosimone A, McAnena O, Quinn A, Súilleabháin CBÓ, Hennessy MM, Ivanovski I, Khizer H, Ravi N, Donlon N, Cervellera M, Vaccari S, Bianchini S, Sartarelli L, Asti E, Bernardi D, Merigliano S, Provenzano L, Scarpa M, Saadeh L, Salmaso B, De Manzoni G, Giacopuzzi S, La Mendola R, De Pasqual CA, Tsubosa Y, Niihara M, Irino T, Makuuchi R, Ishii K, Mwachiro M, Fekadu A, Odera A, Mwachiro E, AlShehab D, Ahmed HA, Shebani AO, Elhadi A, Elnagar FA, Elnagar HF, Makkai-Popa ST, Wong LF, Yunrong T, Thanninalai S, Aik HC, Soon PW, Huei TJ, Basave HNL, Cortés-González R, Lagarde SM, van Lanschot JJB, Cords C, Jansen WA, Martijnse I, Matthijsen R, Bouwense S, Klarenbeek B, Verstegen M, van Workum F, Ruurda JP, van der Veen A, van den Berg JW, Evenett N, Johnston P, Patel R, MacCormick A, Young M, Smith B, Ekwunife C, Memon AH, Shaikh K, Wajid A, Khalil N, Haris M, Mirza ZU, Qudus SBA, Sarwar MZ, Shehzadi A, Raza A, Jhanzaib MH, Farmanali J, Zakir Z, Shakeel O, Nasir I, Khattak S, Baig M, Noor MA, Ahmed HH, Naeem A, Pinho AC, da Silva R, Matos H, Braga T, Monteiro C, Ramos P, Cabral F, Gomes MP, Martins PC, Correia AM, Videira JF, Ciuce C, Drasovean R, Apostu R, Ciuce C, Paitici S, Racu AE, Obleaga CV, Beuran M, Stoica B, Ciubotaru C, Negoita V, Cordos I, Birla RD, Predescu D, Hoara PA, Tomsa R, Shneider V, Agasiev M, Ganjara I, Gunjić D, Veselinović M, Babič T, Chin TS, Shabbir A, Kim G, Crnjac A, Samo H, Díez del Val I, Leturio S, Díez del Val I, Leturio S, Ramón JM, Dal Cero M, Rifá S, Rico M, Pagan Pomar A, Martinez Corcoles JA, Rodicio Miravalles JL, Pais SA, Turienzo SA, Alvarez LS, Campos PV, Rendo AG, García SS, Santos EPG, Martínez ET, Fernández Díaz MJ, Magadán Álvarez C, Concepción Martín V, Díaz López C, Rosat Rodrigo A, Pérez Sánchez LE, Bailón Cuadrado M, Tinoco Carrasco C, Choolani Bhojwani E, Sánchez DP, Ahmed ME, Dzhendov T, Lindberg F, Rutegård M, Sundbom M, Mickael C, Colucci N, Schnider A, Er S, Kurnaz E, Turkyilmaz S, Turkyilmaz A, Yildirim R, Baki BE, Akkapulu N, Karahan O, Damburaci N, Hardwick R, Safranek P, Sujendran V, Bennett J, Afzal Z, Shrotri M, Chan B, Exarchou K, Gilbert T, Amalesh T, Mukherjee D, Mukherjee S, Wiggins TH, Kennedy R, McCain S, Harris A, Dobson G, Davies N, Wilson I, Mayo D, Bennett D, Young R, Manby P, Blencowe N, Schiller M, Byrne B, Mitton D, Wong V, Elshaer A, Cowen M, Menon V, Tan LC, McLaughlin E, Koshy R, Sharp C, Brewer H, Das N, Cox M, Al Khyatt W, Worku D, Iqbal R, Walls L, McGregor R, Fullarton G, Macdonald A, MacKay C, Craig C, Dwerryhouse S, Hornby S, Jaunoo S, Wadley M, Baker C, Saad M, Kelly M, Davies A, Di Maggio F, McKay S, Mistry P, Singhal R, Tucker O, Kapoulas S, Powell-Brett S, Davis P, Bromley G, Watson L, Verma R, Ward J, Shetty V, Ball C, Pursnani K, Sarela A, Sue Ling H, Mehta S, Hayden J, To N, Palser T, Hunter D, Supramaniam K, Butt Z, Ahmed A, Kumar S, Chaudry A, Moussa O, Kordzadeh A, Lorenzi B, Wilson M, Patil P, Noaman I, Willem J, Bouras G, Evans R, Singh M, Warrilow H, Ahmad A, Tewari N, Yanni F, Couch J, Theophilidou E, Reilly JJ, Singh P, van Boxel G, Akbari K, Zanotti D, Sgromo B, Sanders G, Wheatley T, Ariyarathenam A, Reece-Smith A, Humphreys L, Choh C, Carter N, Knight B, Pucher P, Athanasiou A, Mohamed I, Tan B, Abdulrahman M, Vickers J, Akhtar K, Chaparala R, Brown R, Alasmar MMA, Ackroyd R, Patel K, Tamhankar A, Wyman A, Walker R, Grace B, Abbassi N, Slim N, Ioannidi L, Blackshaw G, Havard T, Escofet X, Powell A, Owera A, Rashid F, Jambulingam P, Padickakudi J, Ben-Younes H, McCormack K, Makey IA, Karush MK, Seder CW, Liptay MJ, Chmielewski G, Rosato EL, Berger AC, Zheng R, Okolo E, Singh A, Scott CD, Weyant MJ, Mitchell JD. Postoperative outcomes in oesophagectomy with trainee involvement. BJS Open 2021; 5:zrab132. [PMID: 35038327 PMCID: PMC8763367 DOI: 10.1093/bjsopen/zrab132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/15/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting. METHODS Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups. RESULTS Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005). CONCLUSION Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.
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Evaluating chief resident readiness for the teaching assistant role: The Teaching Evaluation assessment of the chief resident (TEACh-R) instrument. Am J Surg 2021; 222:1112-1119. [PMID: 34600735 DOI: 10.1016/j.amjsurg.2021.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The American Board of Surgery has mandated chief residents complete 25 cases in the teaching assistant (TA) role. We developed a structured instrument, the Teaching Evaluation and Assessment of the Chief Resident (TEACh-R), to determine readiness and provide feedback for residents in this role. METHODS Senior (PGY3-5) residents were scored on technical and teaching performance by faculty observers using the TEACh-R instrument in the simulation lab. Residents were provided with their TEACh-R scores and surveyed on their experience. RESULTS Scores in technical (p < 0.01) and teaching (p < 0.01) domains increased with PGY. Higher technical, but not teaching, scores correlated with attending-rated readiness for operative independence (p 0.02). Autonomy mismatch was inversely correlated with teaching competence (p < 0.01). Residents reported satisfaction with TEACh-R feedback and desire for use of this instrument in operating room settings. CONCLUSION Our TEACh-R instrument is an effective way to assess technical and teaching performance in the TA role.
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Luthra S, Leiva-Juarez MM, Duggan S, Malvindi P, Barlow CW, Tsang GM, Ohri SK. Is It Safe to Let Trainees Operate on High Risk Cardiac Surgery Cases? Semin Thorac Cardiovasc Surg 2021; 34:599-606. [PMID: 34089829 DOI: 10.1053/j.semtcvs.2021.04.052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 04/28/2021] [Indexed: 11/11/2022]
Abstract
Increasing complexity in cardiac operations has raised the discussion on trainee autonomy and the number of cases required to achieve competency. This study compares outcomes among cases done by trainees vs consultants for high risk patients. 696 (trainee=158 vs consultant=438) major high risk cardiac operations (Euroscore >10) were reviewed at a single center. Observations were propensity matched to consultant or trainee based on several baseline characteristics. Euroscore was: Trainee; 12.3 ± 1.6 versus Consultant; 12.8 ± 2.2, p=.036. Multivariable analysis did not identify trainee as a risk factor for worse in-hospital mortality (OR; 0.95, CI; 0.4-2.2, p=.914) or composite outcome of length of stay >30 days, deep sternal infection, new hemodialysis, new stroke or transient ischemic attack, in-hospital death or reoperation (OR; 0.64, CI; 0.39-1.03, p=.069). NYHA class, diabetes and emergency/salvage surgery were predictors of worse composite outcome. After propensity matching (130 pairs), there was no difference in reoperation rates (3.1% versus 4.6%, p=.727), inhospital death (5.4% versus 7.7%, p=.607) or composite outcome (20.8% versus 29.2%, p=.152). There was no statistical difference in cross clamp times (Trainee; 74.0 ± 32.7 min vs Consultant; 82.6 ± 51.1, p=.229) and bypass times (Trainee; 116.3 ± 52.8 min versus Consultant 135.3 ± 72.6 min, p=.055). The length of stay was similar (18.2 ± 13.2 days versus 19.9 ± 15.6 days, p=.302). It is possible for trainees to perform high risk cardiac surgery without compromising the quality of patient care.
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Affiliation(s)
- Suvitesh Luthra
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Trust, Southampton, UK.
| | - Miguel M Leiva-Juarez
- Department of Surgery, Brookdale University Hospital and Medical Center, Brooklyn, New York
| | - Simon Duggan
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Trust, Southampton, UK
| | - Pietro Malvindi
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Trust, Southampton, UK
| | - Clifford W Barlow
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Trust, Southampton, UK
| | - Geoffrey M Tsang
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Trust, Southampton, UK
| | - Sunil K Ohri
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Trust, Southampton, UK
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9
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Basques BA, Saltzman BM, Korber SS, Bolia IK, Mayer EN, Bach BR, Verma NN, Cole BJ, Weber AE. Resident Involvement in Arthroscopic Knee Surgery Is Not Associated With Increased Short-term Risk to Patients. Orthop J Sports Med 2020; 8:2325967120967460. [PMID: 33403211 PMCID: PMC7747120 DOI: 10.1177/2325967120967460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/24/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Whether resident involvement in surgical procedures affects intra- and/or postoperative outcomes is controversial. Purpose/Hypothesis: The purpose of this study was to compare operative time, adverse events, and readmission rate for arthroscopic knee surgery cases with and without resident involvement. We hypothesized that resident involvement would not negatively affect these variables. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of the prospectively maintained National Surgical Quality Improvement Program was performed. Patients who underwent arthroscopic knee surgery between 2005 and 2012 were identified. Multivariate Poisson regression with robust error variance was used to compare the rates of postoperative adverse events and readmission within 30 days between cases with and without resident involvement. Multivariate linear regression was used to compare operative time between cohorts. Because of multiple statistical comparisons, a Bonferroni correction was used, and statistical significance was set at P < .004. Results: A total of 29,539 patients who underwent arthroscopic knee surgery were included in the study, and 11.3% of these patients had a resident involved with the case. The overall rate of adverse events was 1.62%. On multivariate analysis, resident involvement was not associated with increased rates of adverse events or readmission. Resident cases had a mean 6-minute increase in operative time (P < .001). Conclusion: Overall, resident involvement in arthroscopic knee surgery was not associated with an increased risk of adverse events or readmission. Resident involvement was associated with only a mean increased operative time of 6 minutes, a difference that is not likely to be clinically significant. These results support the safety of resident involvement with arthroscopic knee surgery.
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Affiliation(s)
| | - Bryan M. Saltzman
- OrthoCarolina Sports Medicine Center, Charlotte, North Carolina, USA
| | - Shane S. Korber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Ioanna K. Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Erik N. Mayer
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | | | | | - Brian J. Cole
- Midwest Orthopaedics at Rush, Chicago, Illinois, USA
| | - Alexander E. Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
- Alexander E. Weber, MD, USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, 1520 San Pablo Street #2000, Los Angeles, CA 90033, USA ()
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10
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Baisiwala S, Shlobin NA, Cloney MB, Dahdaleh NS. Impact of Resident Participation During Surgery on Neurosurgical Outcomes: A Meta-Analysis. World Neurosurg 2020; 142:1-12. [DOI: 10.1016/j.wneu.2020.05.266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 11/28/2022]
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11
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Manning SW, Orr SL, Mastriani KS. General Surgery Residency and Emergency General Surgery Service Reduces Readmission Rates and Length of Stay in Nonoperative Small Bowel Obstruction. Am Surg 2020; 86:1178-1184. [PMID: 32935996 DOI: 10.1177/0003134820939900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nonoperative management of adhesive small bowel obstruction (ASBO) results in resolution for the majority of patients. Previous studies have demonstrated that outcomes for patients with ASBO are improved when patients are admitted to a surgical service, but the effect of general surgery resident coverage is unclear. This study measures quality outcomes for patients with ASBO after the establishment of a new general surgery residency program. METHODS An institutional review board-approved retrospective chart review of admissions for ASBO was conducted following the implementation of a protocol for ASBO nested within a newly developed resident-run emergency general surgery (EGS) service. Patients successfully treated without operative intervention were analyzed. RESULTS During the study period, 612 patients were admitted for ASBO. After initiation of the residency, 74% of ASBO were admitted to a surgical service compared with 35% prior to residency (P < .01). Length of stay was reduced by 0.77 days (P = .016), average direct total cost per patient was reduced by 24% (P = .002), and 30-day readmissions were reduced by 35.7% (P = .046). There was no significant difference in mortality (1.4% vs 1.0%). DISCUSSION Admission to a resident-run surgical service was associated with statistically significant improvement in outcomes for patients with ASBO. These data corroborate prior studies demonstrating the positive impact of residency programs on patient outcomes and provide additional evidence that general surgery residency programs improve outcomes for patients with surgical disease.
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Affiliation(s)
| | - Scotta L Orr
- Department of General Surgery, Mission Hospital, Asheville, NC, USA
| | - Katherine S Mastriani
- General Surgery Residency, Mountain Area Health Education Center, Asheville, NC, USA.,Department of Quality and Safety, Mission Hospital, Asheville, NC, USA
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12
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Pucher PH, Peckham-Cooper A, Fleming C, Mohamed W, Clements JM, Nally D, Humm G, Mohan HM. Consensus recommendations on balancing educational opportunities and service provision in surgical training: Association of Surgeons in Training Delphi qualitative study. Int J Surg 2020; 84:207-211. [PMID: 32276079 DOI: 10.1016/j.ijsu.2020.03.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/17/2020] [Accepted: 03/28/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ensuring the highest quality of surgical training remains a challenge as demands on health service provision rise. This study aimed to explore the differences and potential conflicts between service provision and dedicated training activity provided by surgical trainees, and recommend solutions. METHODS Participants were drawn from the Association of Surgeons in Training (ASiT) national council. Nominal Group Technique (NGT) was employed by members of the ASiT executive addressing 3 key domains (1) defining differences between training and service tasks, (2) impact of service-provision on training and (3) ways to improve training. A two-round Delphi process was conducted via electronic survey to ASiT council. Consensus was considered achieved for any statement where 80% or more of respondents indicated agreement. RESULTS 47 statements were generated through NGT which were put to the Delphi process. Consensus was reached on a total of 24/47 statements. Educational or training tasks were identified as being activities which progressed a trainee's skill set, could be tailored to a trainee's own ability, and involved acting as a trainer to more junior colleagues. The negative impact of excess service provision included training quality, trainee mental health, and surgical trainee recruitment. Potential measures to improve training included increasing hospital staffing and resources, protected training times, trainee-specific or competency-based learning and training or incentivising trainers. CONCLUSION This trainee-based study provides several consensus recommendations on the characteristics that define surgical training and how a balance between service provision and training can potentially be achieved. Policy makers and health systems may be guided by these to ensure high quality training and a satisfied workforce.
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Affiliation(s)
- Philip H Pucher
- The Association of Surgeons in Training, United Kingdom; Wessex Deanery HEE, United Kingdom.
| | - Adam Peckham-Cooper
- The Association of Surgeons in Training, United Kingdom; Yorkshire & Humber HEE, United Kingdom
| | - Christina Fleming
- The Association of Surgeons in Training, United Kingdom; Department of Colorectal Surgery, Cork University Hospital, Ireland
| | - Walid Mohamed
- The Association of Surgeons in Training, United Kingdom
| | | | - Deirdre Nally
- The Association of Surgeons in Training, United Kingdom
| | - Gemma Humm
- The Association of Surgeons in Training, United Kingdom
| | - Helen M Mohan
- The Association of Surgeons in Training, United Kingdom
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13
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Luther EM, McCarthy D, Berry KM, Rajulapati N, Shah AH, Eichberg DG, Komotar RJ, Ivan M. Hospital teaching status associated with reduced inpatient mortality and perioperative complications in surgical neuro-oncology. J Neurooncol 2020; 146:389-396. [PMID: 31939029 DOI: 10.1007/s11060-020-03395-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Studies have demonstrated that higher surgical volumes correlate with improved neurosurgical outcomes yet none exist evaluating the effects of hospital teaching status on the surgical neuro-oncology patient. We present the first analysis comparing brain tumor surgery perioperative outcomes at academic and non-teaching centers. METHODS Brain tumor surgeries in the Nationwide Inpatient Sample (NIS) from 1998 to 2014 were identified. A teaching hospital, defined by the NIS, must have ≥ 1 Accreditation Council of Graduate Medical Education (ACGME) approved residency programs, Council of Teaching Hospitals membership, or have a ratio ≥ 0.25 of full-time residents to hospital beds. Annual treatment trends were stratified by hospital teaching status, assessing yearly caseload with linear regression. Multivariable logistic regression determined predictors of inpatient mortality/complications. Hospitals were further divided into quartiles by case volume and teaching status was compared in each. RESULTS Teaching hospitals (THs) exhibited an average annual increase in brain tumor surgeries (+ 1057/year, p < 0.0001). In multivariable analysis, teaching status was associated with decreased risk of mortality (OR 0.82, p = 0.0003) and increased likelihood of discharge home (OR 1.21, p < 0.0001). In subgroup analysis, within the highest hospital quartile by caseload, higher mortality rates and lower routine discharges were again seen at non-teaching hospitals (NTHs) (p = 0.0002 and p = 0.0016, respectively). CONCLUSION THs are performing more brain tumor surgeries over time with lower rates of inpatient mortality and perioperative complications even after controlling for hospital case volume. These results suggest a shift in neuro-oncology practice patterns favoring THs to optimize patient outcomes especially at the highest volume centers.
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Affiliation(s)
- Evan M Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA.
| | - David McCarthy
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Katherine M Berry
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Nikhil Rajulapati
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA.,Sylvester Comprehensive Cancer Center, University of Miami Health System, 1475 NW 12th Avenue, Miami, FL, 33136, USA
| | - Michael Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA.,Sylvester Comprehensive Cancer Center, University of Miami Health System, 1475 NW 12th Avenue, Miami, FL, 33136, USA
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14
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Privé B, Kortleve M, van Basten JP. Evaluating the impact of resident involvement during the laparoscopic nephrectomy. Cent European J Urol 2019; 72:369-373. [PMID: 32015905 PMCID: PMC6979558 DOI: 10.5173/ceju.2019.0021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/17/2019] [Accepted: 10/16/2019] [Indexed: 11/22/2022] Open
Abstract
Introduction Laparoscopic nephrectomy (LN) is the most performed laparoscopic procedure by urologic residents (Res). A large amount of data exists on laparoscopic nephrectomies in terms of safety and surgical outcomes, but only a little is known about the influence of residents. The purpose of this study was to evaluate this influence on the clinical outcome of a laparoscopic nephrectomy. Material and methods Retrospectively, patients who had undergone a LN between 2010 and 2018 were assessed. Data included patient demographics, date of surgery, pre- and postoperative results and complications. The patients who had undergone a LN were divided into two groups: one where residents were involved and another group where only a staff surgeon (Sur) performed the operation. All training residents had a questionnaire sent to them to evaluate their role during the LN. Results A total of 229 patients met the study criteria, of which 78 patients were operated together with a resident and 151 by a staff surgeon alone. Both groups were homogeneous in terms of age, comorbidities, left/right sided LN and tumor-stage. Between these two groups, no significant differences were observed in median estimated blood loss (Res 87 ml vs. Sur 100 ml), intraoperative adverse events (Res 10.3% vs. Sur 6% p = 0.24), conversion to open surgery (Res 6.4% vs. Sur 6%) and high-grade postoperative complications (Res 3.9% vs. Sur 4.6%). However, when a resident participated, the LN lasted on average 20 minutes longer (Res mean 130 min vs. Sur 110 min p ≤0.001). Conclusions Our data shows that involvement of a resident in laparoscopic nephrectomy has no effect on the clinical outcome. Therefore, it is safe to perform a laparoscopic nephrectomy together with a resident, but it is important to take the additional surgical time into account.
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Affiliation(s)
- Bastiaan Privé
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Michael Kortleve
- Department of Urology, Hospital Gelderse Vallei, Ede, The Netherlands
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15
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Chaitoff A, Strong AT, Bauer SR, Garber A, Landreneau JP, French J, Rothberg MB, Lipman JM. Educational Targets to Reduce Medication Errors by General Surgery Residents. JOURNAL OF SURGICAL EDUCATION 2019; 76:1612-1621. [PMID: 31080123 DOI: 10.1016/j.jsurg.2019.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 04/02/2019] [Accepted: 04/16/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Hospitalized patients are exposed to more than 1 medication error per day, but there are limited data concerning the factors associated with medication order errors made by general surgery residents. The objective of this study was to identify patterns in medication order errors amongst general surgery residents, which may provide educational targets to reduce medication errors by this population of providers. DESIGN This study used a retrospective cohort design to review inpatient medication orders placed via a computerized physician order entry system by general surgery residents at a single academic medical center from July 2011 to February 2018. SETTING A single large academic medical center located in the Midwest, United States. PARTICIPANTS General surgery residents completing residency between July 2011 and February 2018 and their respective inpatient medication orders. RESULTS Of 571,811 included medication orders placed by 169 unique general surgery residents, 4.2% (n = 24,177) triggered pharmacist intervention, and 11 (0.001%) resulted in significant near-miss events. Of orders requiring pharmacist intervention, most were either duplicate therapies (n = 8703, 36.1%) or errors in renal dosing (n = 7576, 31.3%). Error rates were higher within pharmaceutical classes ordered less frequently, with the notable exception of antimicrobials and anticoagulants, which accounted for 20.1% (n = 5280) and 13.5% (n = 3270) of all order errors, respectively. In a multivariable model, errors were more likely to occur in the intensive care unit versus other units (OR = 1.21, 95%CI = 1.14-1.29) and in August versus other months (OR = 1.09, 95%CI = 1.01-1.17), but were independent of other resident and order characteristics. CONCLUSIONS This study identified that resident medication order errors are common and are associated with specific therapeutic classes, the beginning of academic years, and intensive care unit patients. These findings represent potential targets for educational interventions and highlight the role of interdisciplinary teams in providing quality surgical care.
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Affiliation(s)
- Alex Chaitoff
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Andrew T Strong
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Ari Garber
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joshua P Landreneau
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Judith French
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael B Rothberg
- Center for Value Based Care, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeremy M Lipman
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio.
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16
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Higgins MM, Bell JR. EDITORIAL COMMENT. Urology 2019; 132:53-54. [DOI: 10.1016/j.urology.2019.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 04/04/2019] [Indexed: 10/25/2022]
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17
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Dasani SS, Simmons KD, Wirtalla CJ, Hoffman RL, Kelz RR. Understanding the Clinical Implications of Resident Involvement in Uncommon Operations. JOURNAL OF SURGICAL EDUCATION 2019; 76:1319-1328. [PMID: 30979651 DOI: 10.1016/j.jsurg.2019.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 02/10/2019] [Accepted: 03/17/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The objective of this study was to examine uncommon operations in greater detail given that the outcomes of uncommon operations are largely understudied. This study examines the incidence of postoperative events and the role of the resident following uncommon operations. DESIGN We identified uncommon general surgical operations using the ACS National Surgical Quality Improvement Program Participant Use file (2008-2011). Death or serious morbidity (DSM) within 30 days of the operation was the primary outcome of interest. Failure to rescue (FTR) and prolonged operative time (PRopt) were evaluated as secondary outcome measures. PRopt was defined as ≥90 percentile of operative time for each procedure type. Independent multivariate logistic regression models were generated to examine the impact of these descriptors on the outcomes of interest. SETTING/PARTICIPANTS The dataset utilized was the United States National Surgical Quality Improvement Program Participant Use File which leverages data points from over 700 hospitals that range from primary to quaternary care centers. Resident participation was defined as resident involved (RI) or no resident involved (NRI), and stratified by postgraduate year (PGY): 1-3, 4-5, and 6+. RESULTS Resident participant data was available for 21,453 (84.5%) uncommon operations with NRI in 25.4% (5447). With regard to resident participation, PGY1-3 were found in 12.6% (2699), PGY4-5 in 50.4% (10,817), and PGY6+ in 11.6% (2490). The overall observed DSM rate was 28.6% and the observed FTR rate was 5.8%. Overall, there was no difference in DSM by RI status (NRI: 1528; 28.1% vs RI: 4602; 28.8%; p = 0.324); however, PGY level was associated with DSM (PGY1-3: 774, 28.7%, PGY4-5: 3210, 29.7%, PGY6+: 618, 24.8%; p < 0.001). Any RI was associated with a lower rate of FTR (5.1%) when compared to NRI (8.3%, p < 0.001) with decreasing FTR events by increasing PGY (PGY1-3: 6.4%, PGY4-5: 5.2%, PGY6+: 3.3%; p < 0.001). After adjustment for patient risk factors, any RI remained associated with a lower likelihood of FTR than NRI (odds ratio: 0.65, 95% confidence interval: 0.49-0.87) while only the PGY4-5 and PGY6+ groups were associated with lower likelihood of FTR in comparison to NRI. RI was associated with PRopt in univariate and multivariable analyses. CONCLUSIONS Uncommon operations were associated with substantial DSM. The involvement of PGY4-5 residents was associated with the greatest likelihood of DSM. With increasing PGY of the involved resident, cases with PGY > 5 demonstrated a lower likelihood of risk-adjusted FTR. The explanation for these findings is not clear; however, the involvement of more senior residents in the technical aspects of uncommon operations may lead to improved results.
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Affiliation(s)
- Serena S Dasani
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - K D Simmons
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - C J Wirtalla
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - R L Hoffman
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - R R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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18
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Nguyen AV, Coggins WS, Jain RR, Branch DW, Allison RZ, Maynard K, Lall RR. Effect of an additional neurosurgical resident on procedure length, operating room time, estimated blood loss, and post-operative length-of-stay. Br J Neurosurg 2019; 34:611-615. [PMID: 31328574 DOI: 10.1080/02688697.2019.1642446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Neurosurgical residency training is costly, with expenses largely borne by the academic institutions that train residents. One expense is increased operative duration, which leads to poorer patient outcomes. Although other studies have assessed the effect of one resident assisting, none have investigated two residents; thus, we sought to investigate if two residents versus one scrubbed-in impacted operative time, estimated blood loss (EBL), and length-of-stay (LOS).Methods: In this retrospective review of patients who underwent a neurosurgical procedure involving one or two residents between January 2013 and April 2016, we performed multivariable linear regression to determine if there was an association between resident participation and case length, operating room time, EBL, and LOS. We also included patient demographics, attending surgeon, day of the week, start time, pre-operative LOS, procedure performed, and other variables in our model. Only procedures performed at least 40 times during the study period were analyzed.Results: Of 860 procedures that met study criteria, 492 operations were one of six procedures performed at least 40 times, which were anterior cervical discectomy and fusion, cerebrospinal fluid (CSF) shunt insertion, CSF shunt revision, lumbar laminectomy, intracranial hematoma evacuation, and non-skull base, supratentorial parenchymal brain tumor resection. An additional resident was associated with a 35.1-min decrease (p = .01) in operative duration for lumbar laminectomies. However, for intracranial hematoma evacuations, an extra resident was associated with a 24.1 min increase (p = .03) in procedural length. There were no significant differences observed in the other four surgeries.Conclusion: An additional resident may lengthen duration of intracranial hematoma evacuations. However, two residents scrubbed-in were associated with decreased lumbar laminectomy duration. Overall, an extra resident does not increase procedural duration, total operating room utilization, EBL, or post-operative LOS. Allowing two residents to scrub in may be a safe and cost-effective method of educating neurosurgical residents.
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Affiliation(s)
- Anthony V Nguyen
- School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - William S Coggins
- School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Rishabh R Jain
- School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Daniel W Branch
- Division of Neurosurgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - Randall Z Allison
- Division of Neurosurgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - Ken Maynard
- Division of Neurosurgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - Rishi R Lall
- Division of Neurosurgery, The University of Texas Medical Branch, Galveston, TX, USA
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19
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Essien UR, He W, Ray A, Chang Y, Abraham JR, Singer DE, Atlas SJ. Disparities in Quality of Primary Care by Resident and Staff Physicians: Is There a Conflict Between Training and Equity? J Gen Intern Med 2019; 34:1184-1191. [PMID: 30963439 PMCID: PMC6614525 DOI: 10.1007/s11606-019-04960-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/30/2018] [Accepted: 02/26/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Outpatient primary care experience is vital to internal medicine resident training but may impact quality and equity of care delivered in practices that include resident physicians. Understanding whether quality differences exist among resident and staff primary care physicians (PCPs) may present an opportunity to address health disparities within academic medical centers. OBJECTIVE To determine whether there are differences in the quality of primary care provided by resident PCPs compared to staff PCPs. DESIGN A retrospective cohort study with a propensity-matched analysis. PARTICIPANTS 143,274 patients, including 10,870 patients managed by resident PCPs, seen in 16 primary care practices affiliated with an academic medical center. MAIN MEASURES Guideline-concordant chronic disease management of diabetes (HbA1c, LDL) and coronary artery disease (LDL), preventive breast, cervical, and colorectal cancer screening, and resource utilization measures including emergency department (ED) visits, hospitalizations, high-cost imaging, and patient-reported health experience. KEY RESULTS At baseline, there were significant differences in sociodemographic and clinical characteristics between resident and staff physician patients. Resident patients were less likely to achieve chronic disease and preventive cancer screening outcome measures including LDL at goal (adjusted OR [aOR] 0.77 [95% CI 0.65, 0.92]) for patients with coronary artery disease; HbA1c at goal (aOR 0.73 [95% CI 0.62, 0.85]) for patients with diabetes; breast (aOR 0.56 [95% CI 0.49, 0.63]), cervical (aOR 0.66 [95% CI 0.60, 0.74]), and colorectal (aOR 0.72 [95% CI 0.65, 0.79] cancer screening. Additionally, resident patients had higher rates of ED visits and hospitalizations but lower rates of high-cost imaging. Resident patients reported lower rates of satisfaction with certain access to care and communication measures. Similar outcomes were noted in propensity-matched sensitivity analyses. CONCLUSION After controlling for differences in sociodemographic and clinical factors, resident patients were less likely to achieve chronic disease and preventive cancer screening outcomes compared to staff patients. Further efforts to address ambulatory trainee education and primary care quality along with novel approaches to the management of the disproportionately disadvantaged resident patient panels are needed.
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Affiliation(s)
- Utibe R Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, 3609 Forbes Avenue, Suite 2, Pittsburgh, PA, USA. .,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Wei He
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Alaka Ray
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jonathan R Abraham
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel E Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Yousef Y, St-Louis E, Baird R, Smith ER, Guadagno E, St-Vil D, Poenaru D. A systematic review of capacity assessment tools in pediatric surgery: Global Assessment in Pediatric Surgery (GAPS) Phase I. J Pediatr Surg 2019; 54:831-837. [PMID: 30638893 DOI: 10.1016/j.jpedsurg.2018.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 10/24/2018] [Accepted: 11/18/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND The Lancet Commission on Global Surgery highlighted global surgical need but offered little insight into the specific surgical challenges of children in low-resource settings. Efforts to strengthen the quality of global pediatric surgical care have resulted in a proliferation of partnerships between low-and middle-income countries (LMICs) and high-income countries (HICs). Standardized tools able to reliably measure gaps in delivery and quality of care are important aids for these partnerships. We undertook a systematic review (SR) of capacity assessment tools (CATs) focused on needs assessment in pediatric surgery. METHODS A comprehensive search strategy of multiple electronic databases was conducted per PRISMA guidelines without linguistic or temporal restrictions. CATs were selected according to pre-defined inclusion criteria. Articles were assessed by two independent reviewers. Methodological quality of studies was appraised using the COSMIN checklist with 4-point scale. RESULTS The search strategy generated 16,641 original publications, of which three CATs were deemed eligible. Eligible tools were either excessively detailed or oversimplified. None used weighted scores to identify finer granularity between institutions. No CATs comprehensively included measures of resources, outcomes, accessibility/impact and training. DISCUSSION The results of this study identify the need for a CAT capable of objectively measuring key aspects of surgical capacity and performance in a weighted tool designed for pediatric surgical centers in LMICs. TYPE OF STUDY Systematic Review. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Yasmine Yousef
- McGill University Health Center, Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital; Centre Hospitalier de l'Université de Montréal, Hôpital Sainte-Justine, Département de chirurgie générale pédiatrique.
| | - Etienne St-Louis
- McGill University Health Center, Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital
| | - Robert Baird
- McGill University Health Center, Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital
| | | | - Elena Guadagno
- McGill University Health Center, Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital
| | - Dickens St-Vil
- Centre Hospitalier de l'Université de Montréal, Hôpital Sainte-Justine, Département de chirurgie générale pédiatrique
| | - Dan Poenaru
- McGill University Health Center, Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital
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Cobb AN, Eguia E, Janjua H, Kuo PC. Put Me in the Game Coach! Resident Participation in High-risk Surgery in the Era of Big Data. J Surg Res 2018; 232:308-317. [PMID: 30463734 PMCID: PMC6251497 DOI: 10.1016/j.jss.2018.06.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/11/2018] [Accepted: 06/14/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND With the emphasis on quality metrics guiding reimbursement, concerns have emerged regarding resident participation in patient care. This study aimed to evaluate whether resident participation in high-risk elective general surgery procedures is safe. MATERIALS AND METHODS The American College of Surgeons National Surgical Quality Improvement Program database (2005-2012) was used to identify patients undergoing one of five high-risk general surgery procedures. Resident and nonresident groups were created using a 2:1 propensity score match. Postoperative outcomes were calculated using univariate statistics and multivariable logistic regression for the two groups. Predictors of mortality and morbidity were identified using machine learning in the form of decision trees. RESULTS Twenty-five thousand three hundred sixty three patients met our inclusion criteria. Following matching, each group contained 500 patients and was comparable for matched characteristics. Thirty-day mortality was similar between the groups (2.4% versus 2.6%; P = 0.839). Deep surgical site infection (0% versus 1.6%; P = 0.005), urinary tract infection (5% versus 2.5%; P = 0.029), and operative time (275.6 min versus 250 min; P = 0.0064) were significantly higher with resident participation. Resident participation was not predictive of mortality or complications, while age, American society of anesthesiologists class, and functional status were leading predictors of both. CONCLUSIONS Despite growing time constraints and pressure to perform, surgical resident participation remains safe. Residents should be given active roles in the operating room, even in the most challenging cases.
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Affiliation(s)
- Adrienne N Cobb
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois; Department of Surgery, One:MAP Section of Surgical Analytics, Loyola University Chicago, Maywood, Illinois.
| | - Emanuel Eguia
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois; Department of Surgery, One:MAP Section of Surgical Analytics, Loyola University Chicago, Maywood, Illinois
| | - Haroon Janjua
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois; Department of Surgery, One:MAP Section of Surgical Analytics, Loyola University Chicago, Maywood, Illinois
| | - Paul C Kuo
- Department of Surgery, One:MAP Section of Surgical Analytics, Loyola University Chicago, Maywood, Illinois; Department of Surgery, University of South Florida, Tampa, Florida
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22
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Groves DK, Altieri MS, Sullivan B, Yang J, Talamini MA, Pryor AD. The Presence of an Advanced Gastrointestinal (GI)/Minimally Invasive Surgery (MIS) Fellowship Program Does Not Impact Short-Term Patient Outcomes Following Fundoplication or Esophagomyotomy. J Gastrointest Surg 2018; 22:1870-1880. [PMID: 29980972 DOI: 10.1007/s11605-018-3704-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/25/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The current surgical landscape reflects a continual trend towards sub-specialization, evidenced by an increasing number of US surgeons who pursue fellowship training after residency. Despite this growing trend, however, the effect of advanced gastrointestinal (GI)/minimally invasive surgery (MIS) fellowship programs on patient outcomes following foregut/esophageal operations remains unclear. This study looks at two representative foregut surgeries (laparoscopic fundoplication and esophagomyotomy) performed in New York State (NYS), comparing hospitals which do and do not possess a GI/MIS fellowship program, to examine the effect of such a program on perioperative outcomes. We also aimed to identify any patient or hospital factors which might influence perioperative outcomes. METHODS The SPARCS database was examined for all patients who underwent a foregut procedure (specifically, either an esophagomyotomy or a laparoscopic fundoplication) between 2012 and 2014. We compared the following outcomes between institutions with and without a GI/MIS fellowship program: 30-day readmission, hospital length of stay (LOS), and development of any major complication. RESULTS There were 3175 foregut procedures recorded from 2012 to 2014. Just below one third (n = 1041; 32.8%) were performed in hospitals possessing a GI/MIS fellowship program. Among our entire included study population, 154 patients (4.85%) had a single 30-day readmission, with no observed difference in readmission between hospitals with and without a GI/MIS fellowship program, even after controlling for potential confounding factors (p = 0.6406 and p = 0.2511, respectively). Additionally, when controlling for potential confounders, the presence/absence of a GI/MIS fellowship program was found to have no association with risk of having a major complication (p = 0.1163) or LOS (p = 0.7562). Our study revealed that postoperative outcomes were significantly influenced by patient race and payment method. Asians and Medicare patients had the highest risk of suffering a severe complication (10.00 and 7.44%; p = 0.0311 and p = 0.0036, respectively)-with race retaining significance even after adjusting for potential confounders (p = 0.0276). Asians and uninsured patients demonstrated the highest readmission rates (15.00 and 12.50%; p = 0.0129 and p = 0.0012, respectively)-with both race and payment method retaining significance after adjustment (p = 0.0362 and p = 0.0257, respectively). Lastly, payment method was significantly associated with postoperative LOS (p < 0.0001), with Medicaid patients experiencing the longest LOS (mean 3.99 days) and those with commercial insurance experiencing the shortest (mean 1.66 days), a relationship which retained significance even after adjusting for potential confounders (p < 0.0001). CONCLUSION The presence of a GI/MIS fellowship program does not impact short-term patient outcomes following laparoscopic fundoplication or esophagomyotomy (two representative foregut procedures). Presence of such a fellowship should not play a role in choosing a surgeon. Additionally, in these foregut procedures, patient race (particularly Asian race) and payment method were found to be independently associated with postoperative outcomes, including postoperative LOS.
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Affiliation(s)
- Donald K Groves
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA.
| | - Maria S Altieri
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Brianne Sullivan
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Jie Yang
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Mark A Talamini
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Aurora D Pryor
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
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Impact of resident participation on outcomes following lumbar fusion: An analysis of 5655 patients from the ACS-NSQIP database. J Clin Neurosci 2018; 56:131-136. [DOI: 10.1016/j.jocn.2018.06.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 05/01/2018] [Accepted: 06/19/2018] [Indexed: 01/21/2023]
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24
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Aisen CM, James M, Chung DE. The Impact of Teaching on Fundamental General Urologic Procedures: Do Residents Help or Hurt? Urology 2018; 121:44-50. [PMID: 30092301 DOI: 10.1016/j.urology.2018.05.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/06/2018] [Accepted: 05/29/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To examine the effects of trainee involvement on fundamental urology procedures. METHODS Current Procedural Terminology codes were used to identify patients within the National Surgical Quality Improvement Program database who underwent a selection of fundamental general urology procedures (2005-2013). Operative time and perioperative complications (30-day) were compared between cases with and without trainee involvement. RESULTS 29,488 patients had general urology procedures with information regarding trainee involvement, 13,251 (44.9%) with trainee involvement, and 16,237 (55.1%) without. Overall patients who underwent procedures with trainee involvement were younger and had fewer comorbidities (Table 1). Trainee involvement showed significant increase in operative time in all procedures included in the study (Table 2). On multivariate analysis trainee involvement increased the risk of complications (Odds Ratio (OR) 1.61, 95% CI 1.45-1.78, P < .001). Other factors that increased the risk of complications were: American Society of Anesthesiologists (ASA) class 3-4 (OR 2.01, 95% CI 1.46-2.77, P < .001), partially or totally dependent functional status (OR 2.22, 95% CI 1.68-2.94, P < .001), diabetes mellitus (OR 1.21, 95% CI 1.05-1.39, P = .008), heart disease (OR 1.19, 95% CI 1.02-1.38, P = .027), and respiratory disease (OR 1.33, 95% CI 1.09-1.63, P = .027). CONCLUSION While trainees are valuable members of the urology team at teaching hospitals and training is necessary, their involvement in urologic surgery appears to increase operative time for all procedures and complications in certain procedures. Further research needs to be done on how to mitigate these effects while preserving surgical education quality.
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Affiliation(s)
- Carrie M Aisen
- Department of Urology, Columbia University, New York, NY.
| | - Maxwell James
- Department of Urology, Columbia University, New York, NY
| | - Doreen E Chung
- Department of Urology, Columbia University, New York, NY
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25
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Bashjawish B, Patel S, Kılıç S, Hsueh WD, Liu JK, Baredes S, Eloy JA. Examining the "July effect" on patients undergoing pituitary surgery. Int Forum Allergy Rhinol 2018; 8:1157-1161. [PMID: 29905016 DOI: 10.1002/alr.22164] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/17/2018] [Accepted: 05/22/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Our aim in this study was to assess the impact of the turnover of residents in July on patients undergoing pituitary surgery. METHODS This work was a retrospective cohort study of cases from the National Inpatient Sample (NIS). Patients who underwent pituitary surgery from 2005 to 2012 were selected in the NIS. Patients undergoing surgery in July and in non-July months were compared to determine differences in demographics, comorbidities, and complications. RESULTS Of the 12,939 patients, 1098 (8.5%) underwent pituitary surgery in July. Patients receiving surgery in July had similar demographics and Agency for Healthcare Research and Quality comorbidity values compared with patients receiving surgery in other months. There were no significant differences in mortality, cerebral edema, cerebrospinal fluid leakage, iatrogenic pituitary complications, iatrogenic cerebrovascular accidents, urinary tract infections, pulmonary edema, pulmonary complications, or acute cardiac complications. There were no differences in the rate of postoperative fistulas, hematomas, perforations, or infections. The use of meningeal suturing, pedicled or free-flap reconstruction, and skin reconstruction was more frequent in July. Finally, hospitalization costs in July were similar to costs in other months. CONCLUSION The turnover of new residents in July showed no change in complication rates for patients undergoing pituitary surgery. Patient care in July is similar to care during other months, demonstrating that hospitals are adequately supervising surgical residents during this transition.
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Affiliation(s)
- Bassel Bashjawish
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Shreya Patel
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Suat Kılıç
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Wayne D Hsueh
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - James K Liu
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ.,Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ
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26
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Increased Postoperative Morbidity Associated With Prolonged Laparoscopic Colorectal Resections Is Not Increased by Resident Involvement. Dis Colon Rectum 2018. [PMID: 29528909 DOI: 10.1097/dcr.0000000000000934] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although longer operative times are associated with increased postoperative morbidity, the influence of surgical residents on this association is unclear. OBJECTIVE The purpose of this study was to evaluate whether morbidity associated with operative times in laparoscopic colorectal surgery is increased by resident training. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted using a national database. PATIENTS Laparoscopic ileocolectomies, partial colectomies, and low anterior resections were identified in the National Surgical Quality Improvement Project (2005-2012). This cohort was stratified by the presence of resident involvement (postgraduate clinical year ≤5) and then divided into tertiles of operative time (low, medium, and high), allowing comparisons of cases by duration with resident involvement with cases of similar length without resident involvement. MAIN OUTCOME MEASURES Postoperative morbidity (infectious and noninfectious), length of hospital stay, and unplanned reoperations were the primary study outcomes. RESULTS A total of 20,785 procedures were identified. In aggregate, prolonged operative time was associated with both infectious (OR = 1.49, p < 0.001 with residents; OR = 1.38, p < 0.001 without residents) and noninfectious complications (OR = 1.51, p < 0.001 with residents; OR = 1.48, p < 0.001 without residents) when compared with short cases without residents. Longer hospital stay was observed both within the highest (additional 1.2 days (p < 0.001) with residents; 1.1 days (p < 0.001) without residents) and middle (additional 0.4 days (p < 0.001) with residents; 0.4 days (p = 0.001) without residents) tertiles of operative time. Within the highest tertile of operative length, there was no statistically significant difference in complication rates between cases with and without resident participation. LIMITATIONS The study was limited by its retrospective design and inability to define the complexity of case and extent of resident involvement. CONCLUSIONS Although longer operative times confer increased postoperative morbidity, there was no significant difference in complication rates within the highest tertile between cases with and without resident participation. Resident involvement does not appear to add to the risk of morbidity associated with longer and more complicated surgeries. See Video Abstract at http://links.lww.com/DCR/A440.
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Moskalev AV, Gladkikh VS, Al'shevskaya AA, Kovalevskiy AP, Sakhanenko AI, Orlov KY, Konovalov NA, Krut'ko AV. [Evidence-based medicine: opportunities of the Propensity Score Matching (PSM) method in eliminating selection bias in retrospective neurosurgical studies]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018. [PMID: 29543216 DOI: 10.17116/neiro201882152-58] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To date, a large amount of retrospectively collected data about treatment of neurosurgical pathology have been accumulated. Modern methods of medical statistics are necessary for correct interpretation of the data. The article purpose is to demonstrate application of one of the modern methods, Propensity Score Matching (PSM), in neurosurgery. The use of PSM avoids misinterpretation of retrospectively collected data and obviates errors in planning further prospective studies. For the past 10 years, the number of published international PSM-based studies has increased more than 10-fold, with the number of articles by Russian authors accounting for less than 0.2%. In line with the tendencies of international studies, application of PSM in analysis of retrospectively collected data will enable testing of a number of hypotheses and correct planning of prospective randomized studies.
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Affiliation(s)
- A V Moskalev
- Research Center for Biostatistics and Clinical Research, Acad. Lavrentieva Ave., 6/1, Novosibirsk, Russia, 630090; Institute of Computational Mathematics and Mathematical Geophysics, Siberian Branch of the Russian Academy of Sciences, Acad. Lavrentieva Ave., 6, Novosibirsk, Russia, 630090
| | - V S Gladkikh
- Research Center for Biostatistics and Clinical Research, Acad. Lavrentieva Ave., 6/1, Novosibirsk, Russia, 630090; Institute of Computational Mathematics and Mathematical Geophysics, Siberian Branch of the Russian Academy of Sciences, Acad. Lavrentieva Ave., 6, Novosibirsk, Russia, 630090
| | - A A Al'shevskaya
- Research Center for Biostatistics and Clinical Research, Acad. Lavrentieva Ave., 6/1, Novosibirsk, Russia, 630090; Research Institute of Fundamental and Clinical Immunology, Yadrintsevskaya Str., 14, Novosibirsk, Russia, 630099
| | - A P Kovalevskiy
- Novosibirsk State University, Pirogova Str., 1, Novosibirsk, Russia, 630090
| | - A I Sakhanenko
- Novosibirsk State University, Pirogova Str., 1, Novosibirsk, Russia, 630090; Institute of Mathematics, Siberian Branch of the Russian Academy of Sciences, Universitetskiy Ave., 4, Novosibirsk, Russia, 630090
| | - K Yu Orlov
- Meshalkin Siberian Federal Biomedical Research Center, Novosibirsk, Russia, 630055
| | - N A Konovalov
- Burdenko Neurosurgical Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - A V Krut'ko
- Tsiv'yan Novosibirsk Research Institute of Traumatology and Orthopedics, Frunze Str., 17, Novosibirsk, Russia, 630091
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Slopnick EA, Hijaz AK, Henderson JW, Mahajan ST, Nguyen CT, Kim SP. Outcomes of minimally invasive abdominal sacrocolpopexy with resident operative involvement. Int Urogynecol J 2018; 29:1537-1542. [DOI: 10.1007/s00192-018-3578-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/26/2018] [Indexed: 12/11/2022]
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Liou DZ, Serna-Gallegos D, Mirocha J, Bairamian V, Alban RF, Soukiasian HJ. Predictors of Failure to Rescue After Esophagectomy. Ann Thorac Surg 2018; 105:871-878. [PMID: 29397102 DOI: 10.1016/j.athoracsur.2017.10.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 07/17/2017] [Accepted: 10/10/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Failure to rescue (FTR), defined as death after a major complication, is a metric increasingly being used to assess quality of care. Risk factors associated with FTR after esophagectomy have not been previously studied. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent esophagectomy with gastric conduit between 2010 and 2014. Patients with at least one major postoperative complication were grouped according to inhospital mortality (FTR group) and survival to discharge (SUR group). A stepwise logistic regression model was used to identify predictors of FTR. RESULTS A total of 1,730 patients comprised the study group, with 102 (5.9%) in the FTR group and 1,628 (94.1%) in the SUR group. The FTR patients were older (69.0 versus 64.0 years, p < 0.0001) compared with the SUR patients. There were no differences in sex, body mass index, preoperative weight loss, smoking status, operation type, or surgeon specialty between the two groups. Age greater than 75 years (adjusted odds ratio 2.68, p < 0.0001), black race (adjusted odds ratio 2.75, p = 0.001), American Society of Anesthesiologists class 4 or 5 (adjusted odds ratio 1.82, p = 0.02), and the occurrence of pneumonia, respiratory failure, acute renal failure, sepsis, or acute myocardial infarction were predictive of FTR based on multivariable logistic regression. CONCLUSIONS Nearly 6% of patients who have a major complication after esophagectomy do not survive to discharge. Age greater than 75 years, black race, American Society of Anesthesiologists class 4 or 5, and complications related to major infection or organ failure predict FTR. Further research is necessary to investigate how these factors affect survival after complications in order to improve rescue efforts.
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Affiliation(s)
- Douglas Z Liou
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Derek Serna-Gallegos
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - James Mirocha
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Vahak Bairamian
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F Alban
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Harmik J Soukiasian
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
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Brown DA, Himes BT, Major BT, Mundell BF, Kumar R, Kall B, Meyer FB, Link MJ, Pollock BE, Atkinson JD, Van Gompel JJ, Marsh WR, Lanzino G, Bydon M, Parney IF. Cranial Tumor Surgical Outcomes at a High-Volume Academic Referral Center. Mayo Clin Proc 2018; 93:16-24. [PMID: 29304919 DOI: 10.1016/j.mayocp.2017.08.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 08/15/2017] [Accepted: 08/30/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine adverse event rates for adult cranial neuro-oncologic surgeries performed at a high-volume quaternary academic center and assess the impact of resident participation on perioperative complication rates. PATIENTS AND METHODS All adult patients undergoing neurosurgical intervention for an intracranial neoplastic lesion between January 1, 2009, and December 31, 2013, were included. Cases were categorized as biopsy, extra-axial/skull base, intra-axial, or transsphenoidal. Complications were categorized as neurologic, medical, wound, mortality, or none and compared for patients managed by a chief resident vs a consultant neurosurgeon. RESULTS A total of 6277 neurosurgical procedures for intracranial neoplasms were performed. After excluding radiosurgical procedures and pediatric patients, 4151 adult patients who underwent 4423 procedures were available for analysis. Complications were infrequent, with overall rates of 9.8% (435 of 4423 procedures), 1.7% (73 of 4423), and 1.4% (63 of 4423) for neurologic, medical, and wound complications, respectively. The rate of perioperative mortality was 0.3% (14 of 4423 procedures). Case performance and management by a chief resident did not negatively impact outcome. CONCLUSION In our large-volume brain tumor practice, rates of complications were low, and management of cases by chief residents in a semiautonomous manner did not negatively impact surgical outcomes.
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Affiliation(s)
- Desmond A Brown
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | | | - Brittny T Major
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Ravi Kumar
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Bruce Kall
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Bruce E Pollock
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - John D Atkinson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | | | - W Richard Marsh
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | | | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Ian F Parney
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN.
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Youngerman BE, Bruce JN. Capturing Quality: The Challenge for High-Volume Academic Medical Centers. Mayo Clin Proc 2018; 93:4-6. [PMID: 29304920 DOI: 10.1016/j.mayocp.2017.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 11/21/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Brett E Youngerman
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY.
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Brady JS, Crippen MM, Filimonov A, Nadpara NV, Eloy JA, Baredes S, Park RCW. The effect of training level on complications after free flap surgery of the head and neck. Am J Otolaryngol 2017; 38:560-564. [PMID: 28716300 DOI: 10.1016/j.amjoto.2017.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/02/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Analyze postoperative complications after free flap surgery based on PGY training level. METHODS Data on free flap surgeries of the head and neck performed from 2005 to 2013 was collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Cases identifying the status of resident participation in the surgery and the PGY level were included. RESULTS There were 582 cases with primary surgeon data available. 63 cases were performed with a junior resident, 211 were performed with the assistance of a senior resident, 279 cases were performed with a fellow, and 29 cases were performed by an attending alone without resident involvement. The overall complication rate was 55.2%. There was no statistically significant difference in the rate of complications between groups (47.6%, 59.7%, 53.0%, 58.6%, p=0.277). After controlling for all confounding variables using multivariate analysis there was no significant difference in morbidity, mortality, readmissions, and reoperation amongst the groups. Furthermore, when comparing resident versus fellow involvement using multivariate analysis there were no significant differences in morbidity (OR=0.768[0.522-1.129]), mortality (OR=1.489[0.341-6.499]), readmissions (OR=1.018[0.458-2.262]), and reoperation (OR=0.863[0.446-1.670]). CONCLUSION Resident and fellow participation in microvascular reconstructive cases does not appear to increase 30-day rates of medical, surgical, or overall complications.
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Affiliation(s)
- Jacob S Brady
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Meghan M Crippen
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Andrey Filimonov
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Neil V Nadpara
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Jean Anderson Eloy
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ, USA; Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA; Department of Ophthalmology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Soly Baredes
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Richard Chan Woo Park
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
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Carr RA, Chung CW, Schmidt CM, Jester A, Kilbane ME, House MG, Zyromski NJ, Nakeeb A, Schmidt CM, Ceppa EP. Impact of Fellow Versus Resident Assistance on Outcomes Following Pancreatoduodenectomy. J Gastrointest Surg 2017; 21:1025-1030. [PMID: 28194616 DOI: 10.1007/s11605-017-3383-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 01/31/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Participation by surgical trainees in complex procedures is key to their development as future practicing surgeons. The impact of surgical fellows versus general surgery resident assistance on outcomes in pancreatoduodenectomy (PD) has not been well studied. The purpose of this study was to determine differences in patient outcomes based on level of surgical trainee. METHODS Consecutive cases of PD (n = 254) were reviewed at a single high-volume institution over a 2-year period (July 2013-June 2015). Thirty-day outcomes were monitored through the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) and Quality In-Training Initiative. Patient outcomes were compared between PD assisted by general surgery residents versus hepatopancreatobiliary fellows. RESULTS The hepatopancreatobiliary surgery fellows and general surgery residents participated in 109 and 145 PDs, respectively. The incidence of each individual postoperative complication (renal, infectious, pancreatectomy-specific, and cardiopulmonary), total morbidity, mortality, and failure to rescue were the same between groups. CONCLUSIONS Patient operative outcomes were the same between fellow- and resident-assisted PD. These results suggest that hepatopancreatobiliary surgery fellows and general surgery residents should be offered the same opportunities to participate in complex general surgery procedures.
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Affiliation(s)
- Rosalie A Carr
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Catherine W Chung
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Christian M Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Andrea Jester
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Molly E Kilbane
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA.
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Ferraris VA. Evidence and resident physician duty hours: Should scientific experiments be more suspect than universal implementation of an untested practice? J Thorac Cardiovasc Surg 2016; 153:632-635. [PMID: 27964977 DOI: 10.1016/j.jtcvs.2016.09.091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 09/20/2016] [Accepted: 09/22/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Victor A Ferraris
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, Lexington, Ky.
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Ertel AE, McHenry ZD, Venkatesan VK, Hanseman DJ, Wima K, Hoehn RS, Shah SA, Abbott DE. Surgeon, not technique, defines outcomes after central venous port insertion. J Surg Res 2016; 209:220-226. [PMID: 28032563 DOI: 10.1016/j.jss.2016.10.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/21/2016] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although central venous access for port placement is common and relatively safe, complications and poor resource utilization occur. We hypothesized that despite the simplicity of port placement, surgeon and/or resident performance-rather than technique-is associated with clinical outcomes and operating room efficiency. MATERIALS AND METHODS Medical records of 1200 patients who underwent port placement between 2012 and 2015 at our institution were retrospectively reviewed. Insertion route (subclavian, internal jugular, cephalic cutdown), individual surgeon (A-G), surgeon volume, body mass index, patient age, and resident presence were evaluated to determine their association with operating room time, complications, and need for alternate insertion route. RESULTS On univariate analysis, operating room times were significantly different among individual surgeons, with surgeons E and F having the longest operating room times (50 and 63 versus 31-40 min; P < 0.01) and switching to an alternate method more frequently (13.5% and 21.3%, versus 0%-10.3%, P < 0.01). On multivariate analyses, operating time was increased with elevated body mass index, resident presence, and switching to an alternate method. Individual surgeons had varied effects on operating time with two surgeons found to be the predominant drivers (OR 19 and 27; P < 0.01). With residents excluded, these two surgeons continued to increase operating times (OR 15 and 29; P < 0.01) and procedural complications (OR 3.2 and 5.9; P < 0.05). CONCLUSIONS Although port placement is ostensibly simple, individual surgeon performance is the primary driver of patient outcome and operative efficiency. In an era requiring optimized resource utilization and outcomes, these data demonstrate potential for enhanced programmatic organization and case distribution.
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Affiliation(s)
- Audrey E Ertel
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Zachary D McHenry
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Vijay K Venkatesan
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio; Department of Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Dennis J Hanseman
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Koffi Wima
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Richard S Hoehn
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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