Safety of a Cardiac Surgical Training Program over a Twelve-Year Period

Outcomes of cardiac surgical procedures performed by trainees versus consultants: A systematic review with meta-analysis

OBJECTIVES

Cardiac surgery is highly demanding and the ideal teaching method to reach competency is widely debated. Some studies have shown that surgical trainees can safely perform full operations with equivocal outcomes compared with their consultant colleagues while under supervision. We aimed to compare outcomes after cardiac surgery with supervised trainee involvement versus consultant-led procedures.

METHODS

We systematically reviewed databases (PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar) and reference lists of relevant articles for studies that compared outcomes of cardiac surgery performed by trainees versus consultants. Primary end points included: operative mortality, coronary events, neurological/renal complications, reoperation, permanent pacemaker implantation, and sternal complications. Secondary outcomes included cardiopulmonary bypass and aortic cross-clamp times and intensive care/in-hospital length of stay. Random effects meta-analysis was performed.

RESULTS

Thirty-three observational studies that reported on a total of 81,616 patients (trainee: 20,154; consultant: 61,462) were included. There was a difference favoring trainees in terms of operative mortality in the main analysis and in an analysis restricted to propensity score-matched samples, whereas other outcomes were not consistently different in both analyses. Overall cardiopulmonary bypass and aortic cross-clamp times were longer in the trainee group but did not translate in longer intensive care unit or hospital stay.

CONCLUSIONS

In the right conditions, good outcomes are possible in cardiac surgery with trainee involvement. Carefully designed training programs ensuring graduated hands-on operative exposure as primary operator with appropriate supervision is fundamental to maintain high-quality training in the development of excellent cardiac surgeons.

Is It Safe to Let Trainees Operate on High Risk Cardiac Surgery Cases?

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.

Comparative Outcomes of Resident vs Attending Performed Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine whether outcomes are different when surgery is performed by resident or attending surgeons, and which variables may affect outcomes.

DESIGN

MEDLINE, EMBASE, and the Cochrane Library were searched from inception to May 2014 alongside the bibliographies of all included or relevant studies. Any study comparing outcomes from surgery performed by resident vs attending surgeons was eligible for inclusion. The main outcome measures were surgical complications (classified by Clavien-Dindo grade), death, operative time, and length of stay. Data were extracted independently by 2 authors and analyzed using the random-effects model.

RESULTS

The final analysis included 182 eligible studies that enrolled 141 555 patients. Resident performed surgery took longer by 10.2 minutes (95% confidence interval (CI): 8.38-11.95), and had more Clavien-Dindo grade 1 (rate ratio = 1.14, 95% CI: 1.02-1.29) and grade 3a complications (rate ratio = 1.22, 95% CI: 1.04-1.44). Resident performed surgery resulted in fewer deaths (risk ratio = 0.83, 95% CI: 0.70-0.999) with a shorter length of stay of -0.49 days (95% CI: -0.77 to -0.21). Significant heterogeneity was present in 7 of 10 outcomes, which persisted during multiple subgroup analyses.

CONCLUSIONS

Resident performed surgery appears to be safe in carefully selected patients. The significant amount of heterogeneity present in the study outcomes prevents generalizability of these results to specific clinical contexts.

Safety and efficiency assessment of training Canadian cardiac surgery residents to perform aortic valve surgery

BACKGROUND

Research has demonstrated equivalent patient safety outcomes for various cardiac procedures when the primary surgeon was a supervised trainee. However, cardiac surgery cases have become more complex, and the Canadian cardiac surgery education model has undergone some changes. We sought to compare patient safety and efficiency of aortic valve replacement (AVR) between Canadian patients treated by senior cardiac trainees and those treated by certified cardiac surgeons.

METHODS

We completed a single-centre, case-matched, prospectively collected and retrospectively analyzed study of AVR. Patients were matched between trainees and consultants for age, sex, New York Heart Association and Canadian Cardiovascular Society status, urgency of operation and diabetes status.

RESULTS

We analyzed 1102 procedures: 624 isolated AVRs and 478 AVRs with coronary artery bypass graft (CABG). For isolated AVR, there was no significant difference in 30-d mortality (p = 0.13) or in major adverse events (p = 0.38) between the groups. In the AVR+CABG group, there was no significant difference in 30-day mortality (p = 0.10) or in the rates of major adverse events (p = 0.37) between the groups. Secondary outcomes (hospital and intensive care unit lengths of stay, valve size and type) did not differ significantly between the groups for isolated AVR or AVR+CABG.

CONCLUSION

Despite a higher-risk patient population and changes in the cardiac surgery training model, it appears that outcomes are not negatively affected when a senior trainee acts as the primary surgeon in cases of AVR.

Safety of training and assessment in operating theatres--a systematic review and meta-analysis

OBJECTIVE

Procedural outcomes can be used to assess the performance of specialists and trainees. This article establishes a systematic evidence base for the safety of training in the operating theatre. It also explores the possibility of using early, intermediate and late procedural outcomes of cardiac surgical operations to evaluate the performance of the clinicians and the healthcare system.

METHODS

Medline, EMBASE and PsycINFO databases were searched. Comparative studies evaluating quality indicators of cardiac surgical procedures (coronary artery bypass grafting (CABG) and valve surgery) were included. guidelines from the preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used.

RESULTS

Fourteen studies met the inclusion criteria. For CABG, meta-analysis of outcomes did not show any significant differences between the technical and non-technical skills of trainees versus specialists apart from bypass time (less for specialists) and intensive care unit (ICU) length of stay (less for trainees). Studies reporting outcomes on valve surgery also did not report any statistically significant differences amongst the outcomes.

CONCLUSION

This systematic review did not discern any significant differences between the procedural outcomes of trainees and specialists, which indicates that trainees are safe to operate under senior supervision. In addition, this article recommends that various procedural outcomes can be used to evaluate the performance of clinicians and healthcare systems. Prospective studies need to be performed, taking into account the specific contribution of trainees and specialists during the procedure. This will give a clearer indication of safety and performance of trainees and specialists in the operating theatre.

The July effect: impact of the beginning of the academic cycle on cardiac surgical outcomes in a cohort of 70,616 patients

BACKGROUND

Because surgical residents' level of experience may be at its nadir early in the academic year, academic seasonality-or the "July effect"-could affect cardiac surgical outcomes.

METHODS

Prospectively collected data from the Department of Veterans Affairs Continuous Improvement in Cardiac Surgery Program were used to identify 70,616 consecutive cardiac surgical procedures performed between October 1997 and October 2007. Morbidity and mortality rates were compared between early (July 1 to August 31, n = 11,975) and late (September 1 to June 30, n = 58,641) periods in the academic year. A prediction model was constructed by using stepwise logistic regression modeling.

RESULTS

The two patient groups had similar demographic and risk variables. Isolated coronary artery bypass grafting accounted for 76.7% of early-period procedures and 75.8% of later-period procedures (p = 0.03). Morbidity rates did not differ significantly between the early (14.0%) and later periods (14.2%; odds ratio [OR], 1.01; 95% confidence interval [CI], 0.96 to 1.07; p = 0.67) and operative mortality was similar, 3.7% vs 3.9% (OR, 0.99; 95% CI, 0.89 to 1.11; p = 0.90). The early portion of the year was associated with longer cardiac ischemia times (84 +/- 40 vs 83 +/- 42 minutes), cardiopulmonary bypass times (126 +/-52 vs 124 +/-56 minutes), and total surgical times (295 +/- 90 vs 288 +/- 90 minutes; p < 0.05 for all).

CONCLUSIONS

The early part of the academic year was associated with slightly longer operative times; however, risk-adjusted outcomes were similar in both periods. This finding should lessen concerns about the quality of cardiac surgical care at the beginning of the academic year.

Short- and midterm outcomes of coronary artery bypass surgery performed by surgeons in training

OBJECTIVE

The effect of training on outcomes in cardiac surgery is poorly studied. We aimed to study the results of coronary artery bypass grafting procedures performed by surgeons in training across our state with respect to short- and midterm postoperative outcomes.

METHODS

All coronary artery bypass grafting surgeries performed by trainee surgeons between July 2001 and December 2006 were compared with those performed by consultant surgeons using mandatory prospectively collected statewide data. Early mortality; prolonged ventilation or intensive care unit stay; return to operating theater for bleeding, stroke, myocardial infarction, or renal failure; and 5-year survival were compared using propensity score analysis.

RESULTS

A total of 7745 surgeries were included in this study. Trainees performed 983 (13%) surgeries. Trainee surgeries had longer perfusion and crossclamp times. Crude early postoperative outcomes were similar between trainee and consultant surgeries. After propensity score adjustment, early outcomes remained similar, with the exception of myocardial infarction (0.8% in trainee surgeries vs 0.4% in consultant surgeries, P = .046). Adjusted 1-, 3-, and 5-year survivals were similar between trainee and consultant surgeries: 95.3% versus 95.5%, 90.8% versus 92.0%, and 86.3% versus 87.1%, respectively.

CONCLUSION

Coronary artery bypass grafting performed by trainee surgeons within a supervised program is safe with acceptable short- and midterm outcomes.

The July effect and cardiac surgery: the effect of the beginning of the academic cycle on outcomes

BACKGROUND

The effect of the time of the academic year on cardiac surgical outcomes is unknown.

METHODS

Using prospectively collected data, we identified all (n = 1,673) cardiac surgical procedures performed at our institution between October 1997 and April 2007. Morbidity and mortality rates were compared between 2 periods of the academic year, one early (July 1-August 31, n = 242) and one later in the year (September 1-June 30, n = 1,431). A prediction model was constructed by using stepwise logistic regression modeling.

RESULTS

Morbidity rates did not differ significantly between the early (12.8%) and later periods (15.4%) (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.54-1.28; P = 0.3). Additionally, there was no significant difference in operative mortality between the early (1.2%) and later periods (3.5%) (OR, 0.28; 95% CI, 0.07-1.19; P = 0.06).

CONCLUSIONS

The early and later parts of the academic year were associated with similar risk-adjusted outcomes. Further studies are needed to determine whether our findings are applicable to other academic cardiac centers.