Characterization of resident surgeon participation during carotid endarterectomy and impact on perioperative outcomes

Multivariable Cost Frontiers-Qualitative Financial Analyses Using Operational Metrics From the Implementation of a Surgery Fellowship

OBJECTIVE

We expand the application of cost frontiers and introduce a novel approach using qualitative multivariable financial analyses.

SUMMARY BACKGROUND DATA

With the creation of a 5 + 2-year fellowship program in July 2016, the Division of Vascular Surgery at the University of Vermont Medical Center altered the underlying operational structure of its inpatient services.

METHOD

Using WiseOR (Palo Alto, CA), a web-based OR management data system, we extracted the operating room metrics before and after August 1, 2016 service for each 4-week period spanning from September 2015 to July 2017. The cost per minute modeled after Childers et al's inpatient OR cost guidelines was multiplied by the after-hours utilization to determine variable cost. Zones with corresponding cutoffs were used to graphically represent cost efficiency trends.

RESULTS

Caseload/FTE for attending surgeons increased from 11.54 cases per month to 13.02 cases per month ( P = 0.0771). Monthly variable costs/FTE increased from $540.2 to $1873 ( P = 0.0138). Monthly revenue/FTE increased from $61,505 to $70,277 ( P = 0.2639). Adjusted monthly reve-nue/FTE increased from $60,965 to $68,403 ( P = 0.3374). Average monthly percent of adjusted revenue/FTE lost to variable costs increased from 0.85% to 2.77% ( P = 0.0078). Adjusted monthly revenue/case/FTE remained the same from $5309 to $5319 ( P = 0.9889).

CONCLUSION

In summary, we demonstrate that multivariable cost (or performance) frontiers can track a net increase in profitability associated with fellowship implementation despite diminishing returns at higher caseloads.

Does Surgical Trainee Participation Affect Infection Outcomes in Primary Total Knee Arthroplasty?

OBJECTIVE

To evaluate whether the involvement of surgeons-in-training was associated with increased infection rates, including both prosthetic joint infection (PJI) and surgical site infection (SSI), following primary total knee arthroplasty (TKA).

DESIGN

This was a retrospective review of outcomes following primary total knee arthroplasty. Surgeries were divided into two groups: (a) attending-only and (b) trainee-involved. Association with PJI and SSI were evaluated with univariate analysis and multivariate analysis to adjust for sex, age, body mass index (BMI), Charlson Comorbidity Index (CCI), year of surgery, operative time, and hospital/surgeon volume.

SETTING

A single, large North-American integrated healthcare system between January 1, 2014 and December 31, 2017.

PARTICIPANTS

A total of 12,664 primary TKAs with a minimum of one-year (mean of 2-years, range 1-4.5) follow-up were evaluated.

RESULTS

Residents and fellows were more likely to participate in cases with longer operative times (p<0.001) than the attending-only group. A significant difference existed on univariate analysis between the trainee-involved group and attending-only group for PJI incidence (p=0.015) but not for SSI (p=0.840). After adjusting for patient- and procedure-related features, however, neither PJI nor SSI were independently associated with trainee involvement (PJI: p=0.089; SSI: p=0.998).

CONCLUSIONS

Trainee participation did not directly correlate with increased infection risk, despite their association with longer-operative times and increased medical complexity. Further approaches to mitigating the risk of SSI and PJI for patients with increased comorbidities and in complex TKA cases, which demand longer operative times, are still required.

The presence of residents during orthopedic operation exerts no negative influence on outcome

BACKGROUND

Operative procedural training is a key component of orthopedic surgery residency. It is unclear how and whether residents participation in orthopedic surgical procedures impacts on post-operative outcomes.

SOURCES OF DATA

A systematic search was performed to identify articles in which the presence of a resident in the operating room was certified, and was compared with interventions without the presence of residents.

AREAS OF AGREEMENT

There is a likely beneficial role of residents in the operating room, and there is only a weak association between the presence of a resident and a worse outcome for orthopedic surgical patients.

AREAS OF CONTROVERSY

Most of the studies were undertaken in USA, and this represents a limit from the point of view of comparison with other academic and clinical realities.

GROWING POINT

The data provide support for continued and perhaps increased involvement of resident in orthopedic surgery.

AREAS OF RESEARCH

To clarify the role of residents on clinically relevant outcomes in orthopedic patients, appropriately powered randomized control trials should be planned.

Patient outcomes following carotid endarterectomy are not adversely affected by surgical trainees' operative involvement: A retrospective cohort study

Background

Surgical training is an increasingly controversial topic. Concerns have been raised about both training opportunities becoming scarcer and poorer outcomes in operations led by surgical trainees; despite the evidence base for this being mixed. This retrospective cohort study aims to compare outcomes following carotid endarterectomy in patients who were operated on by a surgical trainee to those operated on by consultants.

Materials and methods

Consecutive patients, who underwent carotid endarterectomy between 01/06/2012 and 1/12/2016, were entered into a prospectively maintained database. Patients were grouped according to whether a consultant or trainee vascular surgeon was the lead operating surgeon. Outcomes were 30-day mortality, 30-day stroke rate, operation time and complication rate.

Results

One-hundred-and-twenty-one patients, with a mean age of 70.3 years, underwent carotid endarterectomy over a 4.5-year period. They were classified by the grade of the lead operating surgeon: consultant (n = 74) or registrar (n = 47). The median operative time was 117 min for consultants and 115 min for registrars with no significant difference between the two groups (p = 0.78). Three patients died in the post-op period, 2 secondary to post-operative stroke and a further 5 had nonfatal strokes. Grade of surgeon was also found to have no impact on 30- day mortality (p = 0.99) or stroke rate (p = 0.99). Sixty-six patients experienced post-operative complications, of varying severity, but no significant difference (p = 0.66) was found in incidence between trainee (57%) and consultant (53%) groups.

Conclusion

Trainee involvement in carotid endarterectomy, with consultant supervision, leads to equivalent outcomes and represents a safe and useful training opportunity.

•

There is a paucity of contemporary research assessing the safety of trainee involvement in carotid endarterectomy.

•

Complication rates were higher for trainees but major complications were more common with consultant led operations.

•

30-day mortality is slightly higher in patients operated on by a consultant but not significantly so.

•

Carotid endarterectomy can represent a safe and useful training opportunity for an appropriately supervised trainee.

Complications Following Overlapping Orthopaedic Procedures at an Ambulatory Surgery Center

BACKGROUND

Overlapping surgery occurs when a single surgeon is the primary surgeon for >1 patient in separate operating rooms simultaneously. The surgeon is present for the critical portions of each patient's operation although not present for the entirety of the case. While overlapping surgery has been widely utilized across surgical subspecialties, few large studies have compared the safety of overlapping and nonoverlapping surgery.

METHODS

In this retrospective cohort study, we reviewed the charts of patients who had undergone orthopaedic surgery at our ambulatory surgery center during the period of April 2009 and October 2015. A database of operations, including patient and surgical characteristics, was compiled. Complications had been identified and logged into the database by surgeons monthly over the study period. These monthly reports and case logs were reviewed retrospectively to identify complications. Propensity-score weighting and logistic regression models were used to determine the association between outcomes and overlapping surgery.

RESULTS

A total of 22,220 operations were included. Of these, 5,198 (23%) were overlapping, and 17,022 (77%) were nonoverlapping. The median duration of surgery overlap was 8 minutes (quartile 1 to quartile 3, 3 to 16 minutes); no operations were concurrent. After weighting, the only continuous variables that differed significantly between the groups were operative time (median, 57 compared with 56 minutes for the overlapping and the nonoverlapping group, respectively; p = 0.022), anesthesia time (median, 97 compared with 93 minutes; p < 0.001), and total tourniquet time (median, 26 compared with 22 minutes; p = 0.0093). Multivariable logistic regression models did not demonstrate an association between overlapping surgery and surgical site infection, noninfection surgical complications, hospitalization, or morbidity.

CONCLUSIONS

These data suggest that there is no association between briefly overlapping surgery and surgical site infection, noninfection surgical complications, hospitalization, and morbidity. When practiced in the manner described herein, overlapping orthopaedic surgery can be a safe practice in the ambulatory setting.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Practice of Overlapping Surgery Is Safe in Total Knee and Hip Arthroplasty

BACKGROUND

Overlapping surgery occurs when a surgeon performs 2 procedures in an overlapping time frame. This practice is commonplace in the setting of total joint arthroplasty and is intended to increase patient access to experienced surgeons, improve efficiency, and advance the surgical competence of surgeons and trainees. The practice of overlapping surgery has been questioned because of safety and ethical concerns. As the literature is scarce on this issue, we evaluated the unplanned hospital readmission and reoperation rates associated with overlapping and non-overlapping total joint arthroplasty procedures.

METHODS

We reviewed 3,290 consecutive primary total knee and hip arthroplasty procedures that had been performed between November 2010 and July 2016 by 2 fellowship-trained senior surgeons at a single institution. Overlapping surgery was defined as the practice in which the attending surgeon performed a separate procedure in another room with an overlapping room time of at least 30 minutes. Patient baseline characteristics and 90-day rates of complications, readmissions, and reoperations were compared between overlapping and non-overlapping procedures. Subanalyses also were done on patients with a body mass index (BMI) of ≥30 kg/m2 and those with an American Society of Anesthesiologists (ASA) score of 3 or 4. The level of significance was set at 0.05.

RESULTS

Of the 2,833 procedures that met the inclusion criteria, 57% (1,610) were overlapping and 43% (1,223) were non-overlapping. Baseline demographics, BMI, and ASA scores were similar between the groups. No significant differences were found between the overlapping and non-overlapping procedures in terms of the 90-day rates of complications (5.2% vs. 6.6%, respectively; p = 0.104), unplanned readmissions (3.4% vs. 4.3%; p = 0.235), or reoperations (3.1 vs. 3.1; p = 1.0) in the analysis of the entire cohort or in subgroup analyses of obese patients and patients with an ASA score of 3 or 4. The total mean operating room time was 5.8 minutes higher for overlapping procedures.

CONCLUSIONS

Overlapping procedures showed no increase in terms of the 90-day rates of complications, readmissions, or reoperations when compared with non-overlapping procedures. There was just over a 5-minute increase in mean operating room time for overlapping procedures. Our data suggest that overlapping surgery does not lead to detrimental outcomes following total knee arthroplasty or total hip arthroplasty. Future investigations evaluating patient-oriented outcomes and satisfaction are warranted.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running Two Rooms" Does Not Compromise Outcomes or Patient Safety in Joint Arthroplasty

BACKGROUND

Scrutiny from the federal government and the media regarding the safety of 1 surgeon doing cases in 2 operating rooms (ORs) on the same day, prompted us to examine our own institutional data. Over the past 11 years, surgeons at our facility have operated consecutively in 1 OR on a given day or used 2 alternating ORs. This study compares these cases with a focus on revisions and complications in both groups.

METHODS

Six surgeons performed a total of 16,916 primary hip and knee arthroplasties from 2006-2016. 7002 cases (41%) were consecutive cases (CCs) and 9914 cases (59%) were overlapping cases (OCs). Intraoperative complications, component revisions, and postoperative complications within 90 days of surgery were compared between the CC and OC groups.

RESULTS

There was no difference in intraoperative complication rates between the two groups (CC 1.6% vs. OC 1.7%, relative risk 1.082, 95% confidence interval 0.852 to 1.375, P = .52). There was no difference in 90-day component revision rates among the CC and OC groups (0.66% vs. 0.85% respectively, relative risk = 1.290, 95% confidence interval 0.901 to 1.845, P = .19). There was also no difference in 90-day complication rates among the CC and OC groups (1.33% vs. 1.45% respectively, relative risk = 1.094, 95% confidence interval 0.844 to 1.417, P = .54).

CONCLUSION

This large study of a single institution with multiple surgeons over an 11-year period shows no compromise in patient safety or outcomes when comparing cases done in either consecutive or overlapping rooms.

Involvement of Residents Does Not Increase Postoperative Complications After Open Reduction Internal Fixation of Ankle Fractures: An Analysis of 3251 Cases

Ankle fractures are common injuries frequently treated by foot and ankle surgeons. Therefore, it has become a core competency for orthopedic residency training. Surgical educators must balance the task of training residents with optimizing patient outcomes and minimizing morbidity and mortality. The present study aimed to determine the effect of resident involvement on the 30-day postoperative complication rates after open reduction and internal fixation of ankle fractures. A second objective of the present study was to determine the independent risk factors for complications after this procedure. We identified patients in the American College of Surgeons National Surgical Quality Improvement Program database who had undergone open reduction internal fixation for ankle fractures from 2005 to 2012. Propensity score matching was used to help account for a potential selection bias. We performed univariate and multivariate analyses to identify the independent risk factors associated with short-term postoperative complications. A total of 3251 open reduction internal fixation procedures for ankle fractures were identified, of which 959 (29.4%) had resident involvement. Univariate (2.82% versus 4.54%; p = .024) and multivariate (odds ratio 0.71; p = .75) analyses demonstrated that resident involvement did not increase short-term complication rates. The independent risk factors for complications after open reduction internal fixation of ankle fractures included insulin-dependent diabetes, increasing age, higher American Society of Anesthesiologists score, and longer operative times.

Can Residents Be Trained and Safety Maintained?

INTRODUCTION

Teaching hospitals and faculty need to balance the educational mission for training residents with patient safety. There are no data studying the change in trauma patient outcomes before and after implementation of a surgical residency. The objective of this study was to compare trauma center outcomes before and after the advent of a surgical training program. We predicted that patient-centric outcome metrics would not be affected by the integration of surgical residents into trauma patient care.

METHODS

A retrospective review was performed using the Crimson Continuum of Care (CCC) dataset and the Trauma Injury Severity Scores (TRISS) for the year before implementation of a surgical residency, compared to the 6 months following initiation of the residency. Severity and risk-adjusted performance measures included mortality, readmissions, complications, and length of stay. Using TRISS, actual, and predicted mortality was compared.

RESULTS

There were 1535 trauma admissions to the acute Care Trauma Service the year before starting the residency, and 856 admissions for the 6 months following the implementation of the program. The demographics were similar between the 2 groups. There was no clinically significant difference in observed mortality after the initiation of a surgery residency, based on CCC dataset variables and TRISS datasets. There were also no significant differences in complications and readmission rates.

CONCLUSIONS

We found that initiating a surgical training program did not affect mortality rates or complications of trauma patients. Training of general surgery residents in a high-performing trauma center can be effectively implemented without compromising patient safety.

Overlapping Surgery in the Ambulatory Orthopaedic Setting

BACKGROUND

The practice of a surgeon performing procedures in two operating rooms during overlapping time frames has been described as concurrent surgery if critical portions occur simultaneously, or overlapping surgery if they do not. Although recent media reports have focused on the potential adverse effects of these practices, to our knowledge, there has been no previous research investigating outcomes of overlapping procedures in orthopaedic surgery.

METHODS

A retrospective review of an institutional clinical database from 2012 to 2015 was utilized to collect data from all surgical cases (including sports medicine, hand, and foot and ankle) performed at an ambulatory orthopaedic surgery center. Patient demographic characteristics, types of procedures, operating room time, procedure time, and 30-day outcomes including complications, unplanned hospital readmissions, unplanned reoperations, and emergency department visits were collected. The amount of overlap time between cases was also analyzed. Pearson chi-square tests, Student t tests, and logistic regression were used for statistical analysis.

RESULTS

Of 3,640 cases performed, 68% were overlapping procedures and 32% were non-overlapping. There was no difference in the mean age, sex, body mass index, American Society of Anesthesiologists rating, or Charlson Comorbidity Index between patients who had overlapping procedures and those who did not. Comparison of overlapping surgery cases and non-overlapping surgery cases revealed no difference in the mean procedure time (70.7 minutes compared with 72.8 minutes; p = 0.116) or total operating room time (105.4 minutes compared with 105.5 minutes; p = 0.949). Complications were tracked for 30 days after procedures and yielded a rate of 1.1% for overlapping surgeries and 1.3% for non-overlapping surgeries (p = 0.811). Stratification based on subspecialty surgery also demonstrated no difference in complications between the cohorts. Fifty percent of overlapping cases overlapped by <1 hour of operating room time, but 7% overlapped by >2 hours. The rate of complications was found to have no association with the amount of overlap between cases (p = 0.151).

CONCLUSIONS

Overlapping surgery yields equivalent patient operating room time, procedure time, and 30-day complication rates as non-overlapping surgery in the ambulatory orthopaedic setting. Further investigation is warranted for inpatient orthopaedic procedures and across all orthopaedic subspecialties.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The impact of resident involvement on outcomes in orthopedic trauma: An analysis of 20,090 cases

BACKGROUND

Involvement in patient care is critical in training orthopedic surgery residents for independent practice. As the focus on outcomes and quality measures intensifies, the impact of resident intraoperative involvement on patient outcomes will be increasingly scrutinized. We sought to determine the impact of residents' intraoperative participation on 30-day post-operative outcomes in the orthopedic trauma population.

METHODS

A total of 20,090 patients from the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2013 were identified. Patient demographics and comorbidities, surgical variables, and 30-day post-operative (wound, minor, and major) complications were collected. Chi-squared and analysis of variance statistical methods were used to compare the 30-day outcomes of patients with and without a resident's intraoperative involvement.

RESULTS

Resident involvement had no effect in the incidence of wound and minor complications among all three anatomic sites of orthopedic trauma procedures (hip, lower extremity [LE], and upper extremity [UE]). There was no statistically significant difference in the incidence of major complications in the hip and LE groups. The UE group, however, demonstrated an increase in the rate of major complications (2.60% vs. 1.89%, p = 0.046). There was no difference in mortality or readmission rates.

CONCLUSIONS

Resident involvement in orthopedic trauma cases did not significantly impact the 30-day outcomes in nearly all domains. Our findings support continued resident involvement in the care of the orthopedic trauma patient.

Resident involvement and experience do not affect perioperative complications following robotic prostatectomy

PURPOSE

Most urologic training programs use robotic prostatectomy (RP) as an introduction to teach residents appropriate robotic technique. However, concerns may exist regarding differences in RP outcomes with resident involvement. Our objective was therefore to evaluate whether resident involvement affects complications, operative time, or length of stay (LOS) following RP.

METHODS

Using the National Surgical Quality Improvement Program database (2005-2011), we identified patients who underwent RP, stratified them by resident presence or absence during surgery, and compared hospital LOS, operative time, and postoperative complications using bivariable and multivariable analyses. A secondary analysis comparing outcomes of interest across postgraduate year (PGY) levels was also performed.

RESULTS

A total of 5,087 patients who underwent RPs were identified, in which residents participated in 56%, during the study period. After controlling for potential confounders, resident present and absent groups were similar in 30-day mortality (0.0 vs. 0.2%, p = 0.08), serious morbidity (1.8 vs. 2.1%, p = 0.33), and overall morbidity (5.1 vs. 5.4%, p = 0.70). While resident involvement did not affect LOS, operative time was longer when residents were present (median 208 vs. 183 min, p < 0.001). Similar findings were noted when assessing individual PGY levels.

CONCLUSIONS

Regardless of PGY level, resident involvement in RPs appears safe and does not appear to affect postoperative complications or LOS. While resident involvement in RPs does result in longer operative times, this is necessary for the learning process.

The impact of resident involvement on surgical outcomes among patients undergoing hepatic and pancreatic resections

BACKGROUND

Resident participation during hepatic and pancreatic resections varies. The impact of resident participation on surgical outcomes in hepatic and pancreatic operations is poorly defined.

METHODS

We identified 25,511 patients undergoing a hepatic or pancreatic resection between 2006 and 2012 using the American College of Surgeons National Surgical Quality Improvement Program database. Multivariate regression models were constructed to determine any association between resident participation and surgical outcomes.

RESULTS

Pancreatic resections (n = 16,045; 62.9%) were more common than liver resections (n = 9,466; 37%). Residents participated in the majority of cases (n = 21,857; 86%), with most involvement at the senior level (postgraduate year ≥ 3, n = 21,147; 97%). Resident participation resulted in slightly longer mean operative times (hepatic, 9 minutes; pancreatic, 22 minutes; both P < .01). Need for perioperative transfusion, hospital duration of stay, and reoperation rates were unaffected by resident participation (all P > .05). Resident participation resulted in a higher risk of overall morbidity (odds ratio [OR], 1.14; 95% CI, 1.05-1.24; P = .001), but not major morbidity (OR, 1.05; 95% CI, 0.93-1.20; P = .40) after liver and pancreas resection. Resident participation resulted in lower odds of 30-day mortality after liver and pancreas resections (OR, 0.75; 95% CI, 0.60-0.94; P = .01).

CONCLUSION

Although resident participation resulted in slightly longer operative times and a modest increase in overall complications after liver and pancreatic resection, other metrics such as duration of stay, major morbidity, and mortality were unaffected. These data have important implications for educating patients regarding resident participation in these complex cases.

Impact of resident involvement in neurosurgery: an analysis of 8748 patients from the 2011 American College of Surgeons National Surgical Quality Improvement Program database

OBJECT

This study evaluates the impact of resident presence in the operating room on postoperative outcomes in neurosurgery.

METHODS

The authors retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified all cases treated in a neurosurgery service in 2011. Propensity scoring analysis and multiple logistic regression models were used to reduce patient bias and to assess independent effect of resident involvement.

RESULTS

Of the 8748 neurosurgery cases identified, residents were present in 4529 cases. Residents were more likely to be involved in complex procedures with longer operative duration. The multivariate analysis found that resident involvement was not a statistically significant factor for overall complications (OR 1.116, 95% CI 0.961-1.297), surgical complications (OR 1.132, 95% CI 0.825-1.554), medical complications (OR 1.146, 95% CI 0.979-1.343), reoperation (OR 1.250, 95% CI 0.984-1.589), mortality (OR 1.164, 95% CI 0.780-1.737), or unplanned readmission (OR 1.148, 95% CI 0.946-1.393).

CONCLUSIONS

In this multicenter study, the authors demonstrated that resident involvement in the operating room was not a significant factor for postoperative complications in neurosurgery service. This analysis also showed that much of the observed difference in postoperative complication rates was attributable to other confounding factors. This is a quality indicator for resident trainees and current medical education. Maintaining high standards in postgraduate training is imperative in enhancing patient care and reducing postoperative complications.

Resident involvement does not influence complication after total hip arthroplasty: an analysis of 13,109 cases

Our study aimed to determine the impact of resident involvement on the 30-day postoperative complication rates following primary total hip arthroplasty (THA). Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, 13,109 primary THAs were identified, of which 3462 (26.4%) had resident involvement. Neither univariate (4.45% vs 4.52%, P = 0.86) nor multivariate (OR 1.04, P = 0.75) analyses demonstrated an increased complication rate with resident involvement following THA. We did find, however, that increased operative time, comorbidities, age, obesity, prior history of stroke and/or cardiac surgery were all independent risk factors for short-term complication. Our findings suggest that resident involvement does not increase 30-day complication rates following primary THA.

Impact of Resident Involvement on Orthopaedic Surgery Outcomes: An Analysis of 30,628 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

Operative procedural training is a key component of orthopaedic surgery residency. The influence of intraoperative resident participation on the outcomes of surgery has not been studied extensively using large, population-based databases.

METHODS

We identified 30,628 patients who underwent orthopaedic procedures from the 2011 American College of Surgeons National Surgical Quality Improvement Program. Outcomes as measured by perioperative complications, readmission rates, and mortality within thirty days were compared for cases with and without intraoperative resident involvement.

RESULTS

Logistic regression with propensity score analysis revealed that intraoperative resident participation was associated with decreased rates of overall complications (odds ratio, 0.717 [95% confidence interval, 0.657 to 0.782]), medical complications (odds ratio, 0.723 [95% confidence interval, 0.661 to 0.790]), and mortality (odds ratio, 0.638 [95% confidence interval, 0.427 to 0.951]). Resident presence in the operating room was not predictive of wound complications (odds ratio, 0.831 [95% confidence interval, 0.656 to 1.053]), readmission (odds ratio, 0.962 [95% confidence interval, 0.830 to 1.116]), or reoperation (odds ratio, 0.938 [95% confidence interval, 0.758 to 1.161]). A second analysis by propensity score stratification into quintiles grouped by similar probability of intraoperative resident presence showed resident involvement to correlate with decreased rates of overall and medical complications in three quintiles, but increased rates of overall and medical complications in one quintile. All other outcomes were equivalent across quintiles.

CONCLUSIONS

Orthopaedic resident involvement during surgical procedures is associated with lower risk of perioperative complications and mortality in the National Surgical Quality Improvement Program database. The results support resident participation in the operative care of orthopaedic patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does resident involvement impact post-operative complications following primary total knee arthroplasty? An analysis of 24,529 cases

Little is known about the impact of resident involvement on complication rates following total knee arthroplasty (TKA). The goal of our study was to determine the impact of resident involvement on complications following primary TKA. Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2005-2012) we identified 24,529 patients who underwent primary TKA. Of these, 5960 (24.3%) had a resident involved in a primary TKA. Using a multivariate logistic regression which incorporated propensity score adjustment, no differences were seen in morbidity and mortality following those cases with resident involvement (OR: 1.15, P = 0.129). In the first large scale, comprehensive analysis of resident impact on short-term morbidity and mortality, no increase in complications was observed with resident involvement in primary TKA.

Does resident experience affect outcomes in complex abdominal surgery? Pancreaticoduodenectomy as an example

OBJECTIVES

Understanding the factors contributing to improved postoperative patient outcomes remains paramount. For complex abdominal operations such as pancreaticoduodenectomy (PD), the influence of provider and hospital volume on surgical outcomes has been described. The impact of resident experience is less well understood.

METHODS

We reviewed perioperative outcomes after PD at a single high-volume center between 2006 and 2012. Resident participation and outcomes were collected in a prospectively maintained database. Resident experience was defined as postgraduate year (PGY) and number of PDs performed.

RESULTS

Forty-three residents and four attending surgeons completed 686 PDs. The overall complication rate was 44 %; PD-specific complications (defined as pancreatic fistula, delayed gastric emptying, intraabdominal abscess, wound infection, and bile leak) occurred in 28 % of patients. The overall complication rates were similar when comparing PGY 4 to PGY 5 residents (55.3 vs. 43.0 %; p > 0.05). On univariate analysis, there was a difference in PD-specific complications seen between a PGY 4 as compared to a PGY 5 resident (44 vs. 27 %, respectively; p = 0.016). However, this was not statistically significant when adjusted for attending surgeon. Logistic regression demonstrated that as residents perform more cases, PD-specific complications decrease (OR = 0.97; p < 0.01). For a resident's first PD case, the predicted probability of a PD-specific complication is 27 %; this rate decreases to 19 % by resident case number 15.

CONCLUSIONS

Complex cases, such as PD, provide unparalleled learning opportunities and remain an important component of surgical training. We highlight the impact of resident involvement in complex abdominal operations, demonstrating for the first time that as residents build experience with PD, patient outcomes improve. This is consistent with volume-outcome relationships for attending physicians and high-volume hospitals. Maximizing resident repetitive exposure to complex procedures benefits both the patient and the trainee.

The impact of resident involvement on post-operative morbidity and mortality following orthopaedic procedures: a study of 43,343 cases

BACKGROUND

Few studies have addressed the role of residents' participation in morbidity and mortality after orthopaedic surgery. The present study utilized the 2005-2010 National Surgical Quality Improvement Program (NSQIP) dataset to assess the risk of 30-day post-operative complications and mortality associated with resident participation in orthopaedic procedures.

METHODS

The NSQIP dataset was queried using codes for 12 common orthopaedic procedures. Patients identified as having received one of the procedures had their records abstracted to obtain demographic data, medical history, operative time, and resident involvement in their surgical care. Thirty-day post-operative outcomes, including complications and mortality, were assessed for all patients. A step-wise multivariate logistic regression model was constructed to evaluate the impact of resident participation on mortality- and complication-risk while controlling for other factors in the model. Primary analyses were performed comparing cases where the attending surgeon operated alone to all other case designations, while a subsequent sensitivity analysis limited inclusion to cases where resident participation was reported by post-graduate year.

RESULTS

In the NSQIP dataset, 43,343 patients had received one of the 12 orthopaedic procedures queried. Thirty-five percent of cases were performed with resident participation. The mortality rate, overall, was 2.5 and 10 % sustained one or more complications. Multivariate analysis demonstrated a significant association between resident participation and the risk of one or more complications [OR 1.3 (95 % CI 1.1, 1.4); p < 0.001] as well as major systemic complications [OR 1.6 (95 % CI 1.3, 2.0); p < 0.001] for primary joint arthroplasty procedures only. These findings persisted even after sensitivity testing.

CONCLUSIONS

A mild to moderate risk for complications was noted following resident involvement in joint arthroplasty procedures. No significant risk of post-operative morbidity or mortality was appreciated for the other orthopaedic procedures studied.

LEVEL OF EVIDENCE

II (Prognostic).

In-hospital versus postdischarge adverse events following carotid endarterectomy

OBJECTIVE

Most studies based on state and nationwide registries evaluating perioperative outcome after carotid endarterectomy (CEA) rely on hospital discharge data only. Therefore, the true 30-day complication risk after carotid revascularization may be underestimated.

METHODS

We used the National Surgical Quality Improvement Program database 2005-2010 to assess the in-hospital and postdischarge rate of any stroke, death, cardiac event (new Q-wave myocardial infarction or cardiac arrest), and combined stroke/death and combined adverse outcome (S/D/CE) at 30 days following CEA. Multivariable analyses were used to identify predictors for in-hospital and postdischarge events separately, and in particular, those that predict postdischarge events distinctly.

RESULTS

A total of 35,916 patients who underwent CEA during 2005-2010 were identified in the National Surgical Quality Improvement Program database; 59% were male, median age was 72 years, and 44% had a previous neurologic event. Thirty-day stroke rate was 1.6% (n = 591), death rate was 0.8% (n = 272), cardiac event rate was 1.0% (n = 350), stroke or death rate was 2.2% (n = 794), and combined S/D/CE rate was 2.9% (n = 1043); 33% of strokes, 53% of deaths, 32% of cardiac events, 40% of combined stroke/death, and 38% of combined S/D/CE took place after hospital discharge. Patients with a prior stroke or transient ischemic attack had similar proportions of postdischarge events compared with patients without prior symptoms. Independent predictors for postdischarge events, but not for in-hospital events were female sex (stroke [odds ratio (OR), 1.6; 95% confidence interval (CI), 1.2-2.1] and stroke/death [OR, 1.4; 95% CI, 1.1-1.7]), renal failure (stroke [OR, 3.0; 95% CI, 1.4-6.2]) and chronic obstructive pulmonary disease (death [OR, 2.5; 95% CI, 1.6-3.7], stroke/death [OR, 1.8; 95% CI, 1.4-2.4], and S/D/CE [OR 1.8, 95% CI 1.4-2.3]).

CONCLUSIONS

With 38% of perioperative adverse events after CEA happening posthospitalization, regardless of symptoms status, we need to be alert to the ongoing risks after discharge particularly in women, patients with renal failure, or chronic obstructive pulmonary disease. This emphasizes the need for reporting and comparing 30-day adverse event rates when evaluating outcomes for CEA, or comparing carotid stenting to CEA.

Outcomes associated with resident involvement in partial colectomy

BACKGROUND

Surgical cases that include trainees are associated with worse outcomes in comparison with those that include attending surgeons alone.

OBJECTIVE

This study aimed to identify whether resident involvement in partial colectomy was associated with worse outcomes when evaluated by surgical approach and resident experience.

DESIGN

This is a retrospective study using the National Surgical Quality Improvement Program database.

SETTINGS

This study evaluates cases included in the National Surgical Quality Improvement Program database.

PATIENTS

All patients were included who underwent partial colectomy including both open and laparoscopic approaches.

INTERVENTIONS

Residents were involved.

MAIN OUTCOME MEASURES

The primary outcome measures were the association of resident involvement and major complication events, minor complication events, unplanned return to operating room, and operative time.

RESULTS

Cases with residents were associated with major complications (OR 1.18, CI 1.09-1.27, p < 0.001) on multivariate analysis. However, after including operative time in the model only open cases involving fifth year residents were still associated with major complications (OR 1.13, p = 0.037). Resident involvement was associated with increased likelihood of minor complications (OR 1.3, p < 0.001) and an increased risk of unplanned return to the operating room (OR 1.20, p < 0.001). Operative time was longer for cases with residents on average by 33.7 minutes and 27 minutes for open and laparoscopic cases.

LIMITATIONS

This study was limited by its retrospective design and lack of data on teachings status, case complexity, and intraoperative evaluation of technique.

CONCLUSIONS

Resident involvement in partial colectomies is associated with an increased major complications, minor complications, likelihood of return to the operating room, and operative time.