Ruptured cerebral aneurysm: influence of specialist and trainee-performed operations on outcome

A systematic review of the impact of volume of surgery and specialization on patient outcome

BACKGROUND AND METHODS

Volume of surgery and specialization may affect patient outcome. Articles examining the effects of one or more of three variables (hospital volume of surgery, surgeon volume and specialization) on outcome (measured by length of hospital stay, mortality and complication rate) were analysed. Reviews, opinion articles and observational studies were excluded. The methodological quality of each study was assessed, a correlation between the variables analysed and the outcome accepted if it was significant.

RESULTS

The search identified 55,391 articles published between 1957 and 2002; 1075 were relevant to the study, of which 163 (9,904,850 patients) fulfilled the entry criteria. These 163 examined 42 different surgical procedures, spanning 13 surgical specialities. None were randomized and 40 investigated more than one variable. Hospital volume was reported in 127 studies; high-volume hospitals had significantly better outcomes in 74.2 per cent of studies, but this effect was limited in prospective studies (40 per cent). Surgeon volume was reported in 58 studies; high-volume surgeons had significantly better outcomes in 74 per cent of studies. Specialization was reported in 22 studies; specialist surgeons had significantly better outcomes than general surgeons in 91 per cent of studies. The benefit of high surgeon volume and specialization varied in magnitude between specialities.

CONCLUSION

High surgeon volume and specialization are associated with improved patient outcome, while high hospital volume is of limited benefit.

Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals?

OBJECT

Concern for patient safety, among other reasons, recently prompted sweeping changes in resident work policies in the US. Some have speculated that the arrival of new interns and residents at teaching hospitals each July might cause an annual transient increase in poor patient outcomes and inefficient care.

METHODS

Data were analyzed for 4323 craniotomies for tumor resection and 22,072 shunt operations performed in pediatric patients between 1988 and 2000 in US nonfederal hospitals (Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, Rockville, MD). In-hospital mortality rates, discharge outcome, complications, and efficiency measures (length of stay [LOS] and hospital charges) for patients treated in July and August were compared with similar data for patients in other months. There were no significant increases in any adverse end point for either tumor or shunt operations in July and August. Odds ratios (95% confidence interval [CI]) for outcome of tumor craniotomies performed in July and August compared with outcome for tumor craniotomies performed in other months were as follows: for mortality rate, 0.43 (0.14-1.32); for adverse discharge disposition, 1.03 (0.71-1.51); for neurological complications, 1.00 (0.63-1.59); for transfusion, 0.70 (0.41-1.19). Hospital charges were 0.5% lower (range -6 to 5%) in July and August, and LOS was 3% shorter (range -8 to 3%). Odds ratios (95% CI) for July or August shunt surgery compared with shunt surgery performed in other months were as follows: for mortality rate, 0.96 (0.58-1.60); for adverse discharge disposition, 0.85 (0.66-1.11); for neurological complications, 1.27 (0.75-2.16); for transfusion, 0.81 (0.48-1.37). Hospital charges were 0.2% higher in July and August (range -3 to 3%), and LOS was 3% shorter (range -5 to 0.5%).

CONCLUSIONS

Although moderate increases in some adverse end points could not be excluded, there was no evidence that brain tumor or shunt surgery performed in pediatric patients at US teaching hospitals during July and August is associated with more frequent adverse patient outcome or inefficient care than similar surgery performed during other months.

Effect of critical care medicine fellows on patient outcome in the intensive care unit

BACKGROUND

The impact that physician trainees have on patient outcomes in academic adult medical/surgical intensive care units (ICUs) has not been adequately assessed.

METHOD

All admissions to adult ICUs within the Calgary Health Region over a three-year period when a critical care medicine fellow (CCMF) was on service were compared to when an attending physician was alone on service. Primary outcomes were ICU and in-hospital mortality and length of stay (LOS).

RESULTS

CCMFs and attending physicians admitted 3,341 patients, while attending physicians alone admitted 3,224 patients. There was no difference in ICU or in-hospital mortality between the two groups; regression analysis determined CCMFs did not affect patient LOS.

CONCLUSION

In teaching hospitals with adult mixed medical/surgical ICUs, CCMFs do not have an effect on patient outcome or LOS. Improved patient outcomes at academic institutions previously attributed to the presence of CCMFs may instead be due to institution and patient-related factors.

Surgery for primary brain tumors at United States academic training centers: results from the Residency Review Committee for neurological surgery

OBJECT

Surgery for primary brain tumors has been an important index of the quality of neurosurgical training programs in the US. The scope of such cases and the proportion of surgeries performed transsphenoidally are an interesting means of tracking the effectiveness of residency education.

METHODS

Program Information Forms from the 94 American Council for Graduate Medical Education-approved US neurosurgical residency programs were reviewed for the period between 2000 and 2003. Particular attention was focused on an analysis of the cases requiring craniotomy for primary brain tumor and transsphenoidal surgery. The mean annual number of primary brain tumor cases per program was 195, with a range from 36 to 724 cases. The proportion of primary brain tumors accessed transsphenoidally was 20%. The mean annual number of transsphenoidal operations performed at academic training centers was 39. A wide range in the frequency of transsphenoidal cases from one program to another was also noted. Almost one third of training centers performed fewer than 20 transsphenoidal operations annually and 80% performed fewer than 50.

CONCLUSIONS

Most neurosurgical training programs provide residents with excellent experience in craniotomy for primary brain tumors. Practice with transsphenoidal surgery, however, is less well represented and tends to be clustered at several active centers. The implications for neurosurgical education are significant.

Safety of intracranial aneurysm surgery performed in a postgraduate training program: implications for training

OBJECT

Patient care and educational experience have long formed a dichotomy in modem surgical training. In neurosurgery, achieving a delicate balance between these two factors has been challenged by recent trends in the field including increased subspecialization, emerging technologies, and decreased resident work hours. In this study the authors evaluated the experience profiles of neurosurgical trainees at a large Canadian academic center and the safety of their practice on patient care.

METHODS

Two hundred ninety-three patients who underwent surgery for intracranial aneurysm clipping between 1993 and 1996 were selected. Prospective data were available in 167 cases, allowing the operating surgeon to be identified. Postoperative data and follow-up data were gathered retrospectively to measure patient outcomes. In 167 cases, a total of 183 aneurysms were clipped, the majority (91%) by neurosurgical trainees. Trainees performed dissections on aneurysms that were predominantly small (< 1.5 cm in diameter; 77% of patients) and ruptured (64% of patients). Overall mortality rates for the patients treated by the trainee group were 4% (two of 52 patients) and 9% (nine of 100 patients) for unruptured and ruptured aneurysm cases, respectively. Patient outcomes were comparable to those reported in historical data. Staff members appeared to be primary surgeons in a select subset of cases.

CONCLUSIONS

Neurosurgical trainees at this institution are exposed to a broad spectrum of intracranial aneurysms, although some case selection does occur. With careful supervision, intracranial aneurysm surgery can be safely delegated to trainees without compromising patient outcomes. Current trends in practice patterns in neurosurgery mandate ongoing monitoring of residents' operative experience while ensuring continued excellence in patient care.

In-hospital Mortality and Morbidity after Surgical Treatment of Unruptured Intracranial Aneurysms in the United States, 1996–2000: The Effect of Hospital and Surgeon Volume

OBJECTIVE

We sought to determine the risk of adverse outcome after contemporary surgical treatment of patients with unruptured intracranial aneurysms in the United States. Patient, surgeon, and hospital characteristics were tested as potential outcome predictors, with particular attention to the surgeon's and hospital's volume of care.

METHODS

We performed a retrospective cohort study with the Nationwide Inpatient Sample, 1996 to 2000. Multivariate logistic and ordinal regression analyses were performed with endpoints of mortality, discharge other than to home, length of stay, and total hospital charges.

RESULTS

We identified 3498 patients who were treated at 463 hospitals, and we identified 585 surgeons in the database. Of all patients, 2.1% died, 3.3% were discharged to skilled-nursing facilities, and 12.8% were discharged to other facilities. The analysis adjusted for age, sex, race, primary payer, four variables measuring acuity of treatment and medical comorbidity, and five variables indicating symptoms and signs. The statistics for median annual number of unruptured aneurysms treated were eight per hospital and three per surgeon. High-volume hospitals had fewer adverse outcomes than hospitals that handled comparatively fewer unruptured aneurysms: discharge other than to home occurred after 15.6% of operations at high-volume hospitals (20 or more cases/yr) compared with 23.8% at low-volume hospitals (fewer than 4 cases/yr) (P = 0.002). High surgeon volume had a similar effect (15.3 versus 20.6%, P = 0.004). Mortality was lower at high-volume hospitals (1.6 versus 2.2%) than at hospitals that handled comparatively fewer unruptured aneurysms, but not significantly so. Patients treated by high-volume surgeons had fewer postoperative neurological complications (P = 0.04). Length of stay was not related to hospital volume. Charges were slightly higher at high-volume hospitals, partly because arteriography was performed more frequently than at hospitals that handled comparatively fewer unruptured aneurysms.

CONCLUSION

For patients with unruptured aneurysms who were treated in the United States between 1996 and 2000, surgery performed at high-volume institutions or by high-volume surgeons was associated with significantly lower morbidity and modestly lower mortality.

Does the participation of a surgical trainee adversely impact patient outcomes? A study of major pancreatic resections in California

BACKGROUND

Some patients have concerns regarding the impact of surgical trainees on the quality of care that they receive in teaching hospitals. No population-based data exist that describe outcomes of surgical procedures in teaching and nonteaching hospitals; however, institutional data suggest that teaching hospitals provide high-quality care. We hypothesized that the presence of a general surgery residency program (GSRP) is associated with superior outcomes for pancreatic resection, a complex surgical procedure.

METHODS

A retrospective, population-based, risk-adjusted analysis of 5696 patients who underwent major pancreatic resection compares the outcomes of patients treated at hospitals with a GSRP (GSRP+) and those hospitals without a GSRP (GSRP-).

RESULTS

GSRP+ hospitals had a lower operative mortality rate (8.3% vs 11.0%; P <. 001), a lower percentage of patients discharged to another acute care hospital or skilled nursing facility (6.5% vs 13.0%; P <.001), and a longer length of stay compared with GSRP- hospitals (22.1 +/- 0.4 days vs 19.6 +/- 0.3 days; P <.001). The observed difference in hospital mortality rates was not significant after an adjustment was made for patient mix and hospital volume (9.7% vs 10.0%). However, superior outcomes were found in the university teaching hospitals, as compared with the affiliated teaching and the nonteaching hospitals (5.3% [P <.001] vs 11.4% vs 11.0%; risk adjusted, 8.0% [P <.05] vs 10.9% vs 10.0%).

CONCLUSIONS

The presence of surgical trainees does not have an adverse impact on the quality of care for One complex procedure, pancreatectomy, and is associated with superior operative mortality rate in university teaching hospitals.