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Kashner TM, Greenberg PB, Birnbaum AD, Byrne JM, Sanders KM, Wilson MA, Bowman MA. Patient Surgical Outcomes When Surgery Residents Are the Primary Surgeon by Intensity of Surgical Attending Supervision in Veterans Affairs Medical Centers. ANNALS OF SURGERY OPEN 2023; 4:e351. [PMID: 38144505 PMCID: PMC10735144 DOI: 10.1097/as9.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 09/25/2023] [Indexed: 12/26/2023] Open
Abstract
Objective Using health records from the Department of Veterans Affairs (VA), the largest healthcare training platform in the United States, we estimated independent associations between the intensity of attending supervision of surgical residents and 30-day postoperation patient outcomes. Background Academic leaders do not agree on the level of autonomy from supervision to grant surgery residents to best prepare them to enter independent practice without risking patient outcomes. Methods Secondary data came from a national, systematic 1:8 sample of n = 862,425 teaching encounters where residents were listed as primary surgeon at 122 VA medical centers from July 1, 2004, through September 30, 2019. Independent associations between whether attendings had scrubbed or not scrubbed on patient 30-day all-cause mortality, complications, and 30-day readmission were estimated using generalized linear-mixed models. Estimates were tested for any residual confounding biases, robustness to different regression models, stability over time, and validated using moderator and secondary factors analyses. Results After accounting for potential confounding factors, residents supervised by scrubbed attendings in 733,997 nonemergency surgery encounters had fewer deaths within 30 days of the operation by 14.2% [0.3%, 29.9%], fewer case complications by 7.9% [2.0%, 14.0%], and fewer readmissions by 17.5% [11.2%, 24.2%] than had attendings not scrubbed. Over the 15 study years, scrubbed surgery attendings may have averted an estimated 13,700 deaths, 43,600 cases with complications, and 73,800 readmissions. Conclusions VA policies on attending surgeon supervision have protected patient safety while allowing residents in selected teaching encounters to have limited autonomy from supervision.
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Affiliation(s)
- T. Michael Kashner
- From the Office of Academic Affiliations, Department of Veterans Affairs, Washington, DC
- Department of Medicine, Loma Linda University Medical School, Loma Linda, CA
| | - Paul B. Greenberg
- VA Providence Healthcare System, Providence, RI
- Department of Surgery (Ophthalmology), The Warren Alpert Medical School of Brown University, Providence, RI
| | - Andrea D. Birnbaum
- From the Office of Academic Affiliations, Department of Veterans Affairs, Washington, DC
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - John M. Byrne
- From the Office of Academic Affiliations, Department of Veterans Affairs, Washington, DC
- Department of Medicine, Loma Linda University Medical School, Loma Linda, CA
| | - Karen M. Sanders
- From the Office of Academic Affiliations, Department of Veterans Affairs, Washington, DC
- Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Mark A. Wilson
- Department of Veterans Affairs, National Director of Surgery, National Office of Surgery (11SURG), Washington, DC
| | - Marjorie A. Bowman
- From the Office of Academic Affiliations, Department of Veterans Affairs, Washington, DC
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Family Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH
- Chief Academic Affiliations Officer, Department of Veterans Affairs, Washington, DC
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Comanici M, Salmasi MY, Schulte KL, Raja SG, Attia RQ. Are there differences in cardiothoracic surgery performed by trainees versus fully trained surgeons? J Card Surg 2022; 37:3776-3798. [PMID: 36098376 DOI: 10.1111/jocs.16925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons. METHODS EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. Eight hundred and ninety-two results were obtained, 27 represented best evidence (2-meta-analyses, 1-RCT, and 24 retrospective cohort studies). RESULTS In all 474,160 operative outcomes were assessed for 434,535 coronary artery bypass grafting (CABG) (431,329 on-pump vs. 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital, and 4797 thoracic procedures. In all 398,058 cases were performed by trainees and 75,943 by consultants. One hundred fifty-nine cases were indeterminate. There were no statistically significant differences in the patients' preoperative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function, and reoperation cases that were undertaken by consultants. There were no differences in cardiopulmonary bypass and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the postoperative outcomes including perioperative myocardial infarction, resternotomy for bleeding, stroke, renal failure, intensive therapy unit length of stay, and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or midterm mortality out to 5-years. DISCUSSION Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.
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Affiliation(s)
- Maria Comanici
- Department of Cardiac Surgery, Harefield Hospital, London, UK.,Faculty of Medicine and Pharmacy, Dunarea de Jos University of Galati, Galați, Romania
| | | | | | - Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, UK
| | - Rizwan Q Attia
- Department of Cardiac Surgery, Harefield Hospital, London, UK
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Mehaffey JH, Kron I. General Principles of Teaching Cardiac Surgery. J Thorac Cardiovasc Surg 2022; 164:e487-e490. [DOI: 10.1016/j.jtcvs.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/05/2022] [Accepted: 07/18/2022] [Indexed: 11/26/2022]
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Escorel Neto AC, Sá MP, Van den Eynde J, Rotbi H, Do-Nguyen CC, Olive JK, Cavalcanti LRP, Torregrossa G, Sicouri S, Ramlawi B, Hussein N. Outcomes of cardiac surgical procedures performed by trainees versus consultants: A systematic review with meta-analysis. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01817-1. [PMID: 35065825 DOI: 10.1016/j.jtcvs.2021.12.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/06/2021] [Accepted: 12/10/2021] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Antonio C Escorel Neto
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Brazil; University of Pernambuco - UPE, Recife, Brazil
| | - Michel Pompeu Sá
- Department of Cardiothoracic Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pa; Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pa
| | - Jef Van den Eynde
- Department of Cardiovascular Diseases, Unit of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Hajar Rotbi
- Faculty of Medicine, Radboud University, Nijmegen, The Netherlands; Radboud Institute for Health Sciences, Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chi Chi Do-Nguyen
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Jacqueline K Olive
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Luiz Rafael P Cavalcanti
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Brazil; University of Pernambuco - UPE, Recife, Brazil
| | - Gianluca Torregrossa
- Department of Cardiothoracic Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pa
| | - Serge Sicouri
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pa
| | - Basel Ramlawi
- Department of Cardiothoracic Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pa; Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pa
| | - Nabil Hussein
- Department of Congenital Cardiac Surgery, Yorkshire Heart Centre, Leeds General Infirmary, England, United Kingdom.
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Abstract
PURPOSE OF REVIEW Rheumatic heart disease (RHD) affects over 30 million people worldwide. Substantial variation exists in the surgical treatment of patients with RHD. Here, we aim to review the surgical techniques to treat RHD with a focus on rheumatic mitral valve (MV) repair. We introduce novel educational paradigms to embrace repair-oriented techniques in cardiac centers. RECENT FINDINGS Due to the low prevalence of RHD in high-income countries, limited expertise in MV surgery for RHD, technical complexity of MV repair for RHD and concerns about durability, most surgeons elect for MV replacement. However, in some series, MV repair is associated with improved outcomes, fewer reinterventions, and avoidance of anticoagulation-related complications. In low- and middle-income countries, the RHD burden is large and MV repair is more commonly performed due to high rates of loss-to-follow-up and barriers associated with anticoagulation, international normalized ratio monitoring, and risk of reintervention. SUMMARY Increased consideration for MV repair in the setting of RHD may be warranted, particularly in low- and middle-income countries. We suggest some avenues for increased exposure and training in rheumatic valve surgery through international bilateral partnership models in endemic regions, visiting surgeons from endemic regions, simulation training, and courses by professional societies.
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Brandão CMDA, Dallan LRP, Dinato FJ, Monteiro R, Fiorelli AI, Jatene FB. Evaluation method of training simulation on biological models for cardiovascular surgery residents. J Card Surg 2021; 36:2247-2252. [PMID: 33797794 DOI: 10.1111/jocs.15524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The goal of this study was to describe and evaluate our simulation training program on biological models for the cardiovascular surgery residency program at our institution. MATERIAL AND METHODS Since 2016, with the purpose to develop better practical performance and evaluate the improvement of resident's surgical skills, a simulation training program was implemented, composed of some elemental procedures in cardiovascular surgery. It was established with one wet lab session weekly lasting 2 h, coached by two expert cardiovascular surgeons. Bovine and porcine hearts were used as biological models. At the end of the hands-on program, an objective assessment consisting of two practical modules was applied and performance was rated by way of a 5-point scale. In addition, to provide a subjective assessment, each resident filled out a questionnaire consisting of three items reviewing the overall quality of the workshops on a 10-point scale. RESULTS The objective evaluation applied at the end of the training program consisted of valve replacement and coronary artery bypass grafting (CABG) modules. The mean performance rating scores for the valve replacement module ranged from 4.2 to 4.79, and CABG, from 4.33 to 4.87. Regarding subjective assessment, all items evaluated, such as expert's didactics, simulation performance, and biological simulator fidelity, received high grades (above 9 on a 10-point scale). CONCLUSIONS Simulator training on biological models for cardiac surgery medical residents is a simple and effective learning method of surgical skills.
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Affiliation(s)
- Carlos M de A Brandão
- Cardiovascular Surgery Department, Heart Institute, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Luis R P Dallan
- Cardiovascular Surgery Department, Heart Institute, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Fabrício J Dinato
- Cardiovascular Surgery Department, Heart Institute, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Rosangela Monteiro
- Cardiovascular Surgery Department, Heart Institute, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Alfredo I Fiorelli
- Cardiovascular Surgery Department, Heart Institute, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Fabio B Jatene
- Cardiovascular Surgery Department, Heart Institute, University of Sao Paulo Medical School, São Paulo, SP, Brazil
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Di Tommaso E, Rapetto F, Guida GA, Zakkar M, Bruno VD. Benefits of mitral valve repair over replacement in the elderly: a systematic review and meta-analysis. J Card Surg 2021; 36:2524-2530. [PMID: 33783032 DOI: 10.1111/jocs.15506] [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: 01/13/2021] [Accepted: 02/09/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Mitral valve (MV) repair has demonstrated excellent short- and long-term outcomes, however, its merit in the elderly population is still debated. We conducted a meta-analysis of studies that have compared the MV repair to replacement in the elderly population. METHODS A systematic literature search was conducted for any study published on MV surgery on elderly patients (≥75 years old). A pooled risk-ratio meta-analysis was done to evaluate short-term mortality, postoperative complications, surgical timings, and long-term survival rates. RESULTS A total of nine retrospective observational studies were included in the quantitative meta-analysis. Pooled meta-analysis showed a reduced risk of short-term mortality for the MV repair group (risk ratio [RR] = 0.41 [0.24-0.71], p-value = .005). Postoperative neurological complications were in favor of repair, although not significantly (RR = 0.49 [0.21-1.11], p-value = .07). Operative timings (cardiopulmonary bypass and crossclamp time) were not different between the groups although no data were available on the complexity of the repairs. Long-term survival rates were in favor of the repairs (pooled treatment effect of -0.47 [-0.64; -0.29], p = .005). CONCLUSIONS MV surgery is a safe and effective procedure for the elderly. MV repair demonstrated better short-term outcomes compared to replacement. Long-term survival rates are significantly better after repair.
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Affiliation(s)
- Ettorino Di Tommaso
- Bristol Medical School, Translational Health Science, University of Bristol, Bristol, UK
| | - Filippo Rapetto
- Bristol Heart Institute, University Hospital Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Gustavo A Guida
- Bristol Heart Institute, University Hospital Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, Clinical Sciences Wing, Glenfield General Hospital, University of Leicester, Leicester, UK
| | - Vito D Bruno
- Bristol Medical School, Translational Health Science, University of Bristol, Bristol, UK
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