Dataset Information

Association of Resident Independence With Short-term Clinical Outcome in Core General Surgery Procedures.

ABSTRACT:

Importance

Prior studies evaluating the effect of resident independence on operative outcome draw from case mixes that cross disciplines and overrepresent cases with low complexity. The association between resident independence and clinical outcome in core general surgical procedures is not well defined.

Objective

To evaluate the level of autonomy provided to residents during their training, trends in resident independence over time, and the association between resident independence in the operating room and clinical outcome.

Design, setting, and participants

Using the Veterans Affairs Surgical Quality Improvement Program database from 2005 to 2021, outcomes in resident autonomy were compared using multivariable logistic regression and propensity score matching. Data on patients undergoing appendectomy, cholecystectomy, partial colectomy, inguinal hernia, and small-bowel resection in a procedure with a resident physician involved were included.

Exposures

Resident independence was graded as the attending surgeon scrubbed into the operation (AS) or the attending surgeon did not scrub (ANS).

Main outcomes and measures

Outcomes of interest included rates of postoperative complication, severity of complications, and death.

Results

Of 109 707 patients who met inclusion criteria, 11 181 (10%) underwent operations completed with ANS (mean [SD] age of patients, 61 [14] years; 10 527 [94%] male) and 98 526 (90%) operations completed with AS (mean [SD] age of patients, 63 [13] years; 93 081 [94%] male). Appendectomy (1112 [17%]), cholecystectomy (3185 [11%]), and inguinal hernia (5412 [13%]) were more often performed with ANS than small-bowel resection (527 [6%]) and colectomy (945 [4%]). On multivariable logistic regression adjusting for procedure type, age, body mass index, functional status, comorbidities, American Society of Anesthesiologists class, wound class, case priority, admission status, facility type, and year, factors associated with a complication included increasing age (adjusted odds ratio [aOR], 1.19 [95% CI, 1.16-1.22]), emergent case priority (aOR, 1.41 [95% CI, 1.33-1.50]), and resident independence (aOR, 1.12 [95% CI, 1.03-1.22]). On propensity score matching, AS cases were score matched 1:1 to ANS cases based on the variables listed above. Comparing matched cohorts, there was no difference in complication rates (817 [7%] vs 784 [7%]) or death (91 [1%] vs 102 [1%]) based on attending physician involvement.

Conclusions and relevance

Core general surgery cases performed by senior-level trainees in such a way that the attending physician is not scrubbed into the case are being done safely with no significant difference in rates of postoperative complication.

SUBMITTER: Tonelli CM

PROVIDER: S-EPMC9996403 | biostudies-literature | 2023 Mar

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Association of Resident Independence With Short-term Clinical Outcome in Core General Surgery Procedures.

Tonelli Celsa M CM Cohn Tyler T Abdelsattar Zaid Z Luchette Frederick A FA Baker Marshall S MS

JAMA surgery 20230301 3

<h4>Importance</h4>Prior studies evaluating the effect of resident independence on operative outcome draw from case mixes that cross disciplines and overrepresent cases with low complexity. The association between resident independence and clinical outcome in core general surgical procedures is not well defined.<h4>Objective</h4>To evaluate the level of autonomy provided to residents during their training, trends in resident independence over time, and the association between resident independen ...[more]

PMID: 36723925

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Project description:PurposeTo evaluate whether the presence of residents in hip arthroscopy (HA) procedures affects short-term surgical outcomes.MethodsThe American College of Surgeons National Surgical Quality Improvement Program Database was used to identify patients who underwent HA from 2006 to 2012. Demographic and 30-day outcome variables were compared between cohorts of patients with and without residents. Multivariate logistic regression was used to identify whether resident involvement was an independent risk factor for adverse outcomes. Propensity score matching was performed to control for all demographic and intraoperative variables.ResultsA total of 869 patients (59.7% female) were included in this study, 626 of which reported data on resident involvement. Patients were mostly White (73.4% of cases without a resident, 51.8% with a resident, P < .05). Those with residents were younger (P = .016), had lower modified 5-item frailty index (mFI-5) scores (P = .028), and had fewer cardiac comorbidities (P = .008). There was no difference in diabetic status, dyspnea symptoms, history of chronic obstructive pulmonary disease, renal comorbidity, neurologic comorbidity, cumulative comorbidities, history of bleeding disorders, inpatient vs. outpatient treatment, preoperative functional status, smoking history, and steroid use for chronic conditions. There was no difference in all complications, operative time, length of stay, reoperation, readmission, wound complication, venous thromboembolism, blood transfusions, or sepsis. Propensity score match for demographic and intraoperative differences found no association between resident involvement and increased complications. Resident involvement was not an independent risk factor for all complications studied.ConclusionResident involvement in HA procedures was not a risk factor for 30-day complications between 2006 and 2012. Resident involvement did not increase the risk of adverse outcomes, readmission, reoperation, or length of stay, nor did it significantly increase operative times.

Project description:ImportancePrevious studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear.ObjectivesTo determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate.Design, setting, and participantsThis multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses.Main outcomes and measuresFive-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared.ResultsThe 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: "I feel that it is my responsibility as a program director to redirect residents who should not be surgeons."Conclusions and relevanceThe overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.

Project description:ObjectivesTo assess the incremental prognostic value of right ventricular free wall longitudinal strain over conventional risk scores in predicting the peri-operative mortality in patients with severe tricuspid regurgitation (TR) undergoing isolated tricuspid valve (TV) surgery.MethodsWe retrospectively enrolled 110 consecutive patients with severe TR who underwent isolated TV surgery between November 2016 and July 2022 at San Raffaele Hospital, Milan, Italy. Exclusion criteria were previous TV surgery, urgent surgery, complex congenital heart disease, active endocarditis and inadequate acoustic window. Baseline clinical data were included, as well as laboratory tests and clinical risk score, as TRI-SCORE and MELD-XI. The clinical outcome was peri-operative mortality, defined as all-cause mortality within 30 days.ResultsThe final cohort included 79 patients. The end-point occurred in 7 patients (9%), who died within 30 days after isolated TV surgery. Receiver operator characteristic curves analysis showed that, among parameters of right ventricular function, right ventricular free wall longitudinal strain was the best parameter to predict peri-operative mortality (AUC: 0.854, 95% CI 0.74-0.96, P = 0.005, sensitivity 68%, specificity 100%). At univariable analysis, left ventricular ejection fraction, diabetes mellitus, creatinine, estimated glomerular filtration rate, serum sodium, MELD-XI, TRI-SCORE, right ventricular areas, right ventricular global longitudinal strain, right ventricular free wall longitudinal strain, fractional area change and the ratio between right ventricular free wall longitudinal strain/pulmonary arterial systolic pressure were significantly associated with the end-point. The combination of TRI-SCORE and right ventricular Strain, evaluating right ventricular systolic function with speckle-tracking echocardiography, outperformed classic TRI-SCORE in outcome prediction (AUC 0.874 vs 0.787, P = 0.05).ConclusionsRight ventricular free wall longitudinal strain has an incremental prognostic value over conventional parameters and significantly improves the ability of clinical scores to predict peri-operative mortality in patients undergoing isolated TV surgery.

Project description:IntroductionInformed consent is essential in ensuring patients' understanding of their medical condition, treatment, and potential risks. The objective of this study was to investigate the impact of utilizing a video consent compared to standard consent for patient knowledge and satisfaction in selected general surgical procedures.Methods and proceduresWe included 118 patients undergoing appendectomy, cholecystectomy, inguinal hernia repair, and fundoplication at two hospitals in Omaha, NE. Patients were randomized to either a standard consent or a video consent. Outcomes included a pretest and posttest objective knowledge assessment of their procedure, as well as a satisfaction survey which was completed immediately after consent and following discharge. Given the pre-post design, a linear mixed-effect model was estimated for both outcomes. A two-way interaction effect was of primary interest to assess whether pre-to-post change in the outcome differed between patients randomized to standard or video consent.ResultsBaseline characteristics were mostly similar between groups except for patient sex, p = 0.041. Both groups showed a statistically significant increase in knowledge from pretest to posttest (standard group: 0.25, 95% CI 0.01 to 0.51, p = 0.048; video group: 0.68, 95% CI 0.36 to 1.00, p < 0.001), with the video group showing significantly greater change (interaction p = 0.043) indicating that incorporating a video into the consent process resulted in a better improvement in patient's knowledge of the proposed procedure. Further, both groups showed a decrease in satisfaction post-discharge, but no statistically significant difference in the magnitude of decrease between the groups (interaction p = 0.309).ConclusionVideo consent lead to a significant improvement in a patient's knowledge of the proposed treatment. Although the patient satisfaction survey didn't show a significant difference, it did show a trend. We propose incorporating videos into the consent process for routine general surgical procedures.

Project description:ImportanceThe treatment of oropharyngeal cancer has undergone a paradigm shift in the past 2 decades, with an increase in the use of nonoperative treatment owing to poor functional outcomes associated with traditional surgical approaches. Transoral robotic surgery (TORS) allows surgical resection of oropharyngeal cancer (OPC) with less morbidity through a minimally invasive approach.ObjectiveTo investigate the relationship among TORS and short- and long-term outcomes and costs in surgically treated patients with OPC.Design, setting, and participantsRetrospective cross-sectional analysis of 3573 patients who underwent an ablative procedure for OPC in 2010 to 2012 using the MarketScan Commercial Claim and Encounters database.Main outcomes and measuresThe association between TORS and short- and long-term outcomes, length of hospitalization, and treatment-related costs was analyzed using descriptive statistics and multivariate regression modeling.ResultsTransoral robotic surgery was performed in 304 surgical cases (8.5%); 94.7% of patients were 40 to 64 years old, and 70.7% were male. The use of TORS increased from 4.1% of surgical cases in 2010 to 13.2% of surgical cases in 2012. Patients who underwent TORS had a lower rate of tracheotomy during treatment (3.9% vs 11.4%), and posttreatment gastrostomy tube use (21.9% vs 34.2%), compared with patients undergoing non-TORS procedures. On multivariate analysis, TORS was not associated with significant differences in postoperative complications or length of hospitalization. There was no significant difference in the odds of receiving postoperative radiation therapy between patients who underwent TORS and those who did not; however, among patients receiving radiation therapy, chemoradiation was significantly less likely following TORS (odds ratio [OR], 0.52; 95% CI, 0.29-0.90). TORS was associated with significantly decreased odds of posttreatment gastrostomy (OR, 0.54; 95% CI. 0.30-0.95) and tracheostomy during treatment (OR, 0.17; 95% CI, 0.06-0.55) at 1 year, and was associated with significantly decreased overall treatment-related costs of care (mean incremental cost, -$22 724).Conclusions and relevanceThe use of TORS for surgical resection of OPC is increasing in the United States and is associated with significantly lower use of adjuvant chemoradiation, late gastrostomy and tracheostomy dependence, and lower overall treatment-related costs of care. These data have implications for discussions of value in OPC care at a time of health care reform.

Project description:ImportanceIntraoperative anesthesiology care is crucial to high-quality surgical care. The clinical expertise and experience of anesthesiologists may decrease the risk of adverse outcomes.ObjectiveTo examine the association between anesthesiologist volume and short-term postoperative outcomes for complex gastrointestinal (GI) cancer surgery.Design, setting, and participantsThis population-based cohort study used administrative health care data sets from various data sources in Ontario, Canada. Adult patients who underwent esophagectomy, pancreatectomy, or hepatectomy for GI cancer from January 1, 2007, to December 31, 2018, were eligible. Patients with an invalid identification number, a duplicate surgery record, and missing primary anesthesiologist information were excluded.ExposuresPrimary anesthesiologist volume was defined as the annual number of procedures of interest (esophagectomy, pancreatectomy, and hepatectomy) supported by that anesthesiologist in the 2 years before the index surgery. Volume was dichotomized into low-volume and high-volume categories, with 75th percentile or 6 or more procedures per year selected as the cutoff point.Main outcome and measuresThe primary outcome was a composite of 90-day major morbidity (with a Clavien-Dindo classification grade 3-5) and readmission. Secondary outcomes were individual components of the primary outcome. The association between exposure and outcomes was examined using multivariable logistic regression models, accounting for potential confounders.ResultsOf the 8096 patients included, 5369 were men (66.3%) and the median (interquartile range [IQR]) age was 65 (57-72) years. Operations were supported by 842 anesthesiologists and performed by 186 surgeons, and the median (IQR) anesthesiologist volume was 3 (1.5-6) procedures per year. A total of 2166 patients (26.7%) received care from high-volume anesthesiologists. Primary outcome occurred in 36.3% of patients in the high-volume group and 45.7% of patients in the low-volume group. After adjustment, care by high-volume anesthesiologists was independently associated with lower odds of the primary outcome (adjusted odds ratio [aOR], 0.85; 95% CI, 0.76-0.94), major morbidity (aOR, 0.83; 95% CI, 0.75-0.91), unplanned intensive care unit admission (aOR, 0.84; 95% CI, 0.76-0.94), but not readmission (aOR, 0.87; 95% CI, 0.73-1.05) or mortality (aOR, 1.05; 95% CI, 0.84-1.31). E-values analysis indicated that an unmeasured variable would unlikely substantively change the observed risk estimates.Conclusions and relevanceThis study found that, among adults who underwent complex gastrointestinal cancer surgery, those who received care from high-volume anesthesiologists had a lower risk of adverse postoperative outcomes compared with those who received care from low-volume anesthesiologists. These findings support organizing perioperative care to increase anesthesiologist volume to optimize patient outcomes.

Dataset Information

Association of Resident Independence With Short-term Clinical Outcome in Core General Surgery Procedures.

Importance

Objective

Design, setting, and participants

Exposures

Main outcomes and measures

Results

Conclusions and relevance

Publications

Association of Resident Independence With Short-term Clinical Outcome in Core General Surgery Procedures.

Similar Datasets

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