Association of increasing surgeon age with decreasing in-hospital mortality after coronary artery bypass graft surgery

The association between physician sex and patient outcomes: a systematic review and meta-analysis

BACKGROUND

Some prior studies have found that patients treated by female physicians may experience better outcomes, as well as lower healthcare costs than those treated by male physicians. Physician-patient sex concordance may also contribute to better patient outcomes. However, other studies have not identified a significant difference. There is a paucity of pooled evidence examining the association of physician sex with clinical outcomes.

METHODS

This random-effects meta-analysis was conducted according to the PRISMA guidelines and prospectively registered on PROSPERO. MEDLINE and EMBASE were searched from inception to October 4th, 2023, and supplemented by a hand-search of relevant studies. Observational studies enrolling adults (≥ 18 years of age) and assessing the effect of physician sex across surgical and medical specialties were included. The risk of bias was assessed using ROBINS-I. A priori subgroup analysis was conducted based on patient type (surgical versus medical). All-cause mortality was the primary outcome. Secondary outcomes included complications, hospital readmission, and length of stay.

RESULTS

Across 35 (n = 13,404,840) observational studies, 20 (n = 8,915,504) assessed the effect of surgeon sex while the remaining 15 (n = 4,489,336) focused on physician sex in medical/anesthesia care. Fifteen studies were rated as having a moderate risk of bias, with 15 as severe, and 5 as critical. Mortality was significantly lower among patients of female versus male physicians (OR 0.95; 95% CI: 0.93 to 0.97; PQ = 0.13; I2 = 26%), which remained consistent among surgeon and non-surgeon physicians (Pinteraction = 0.60). No significant evidence of publication bias was detected (PEgger = 0.08). There was significantly lower hospital readmission among patients receiving medical/anesthesia care from female physicians (OR 0.97; 95% CI: 0.96 to 0.98). In a qualitative synthesis of 9 studies (n = 7,163,775), patient-physician sex concordance was typically associated with better outcomes, especially among female patients of female physicians.

CONCLUSIONS

Patients treated by female physicians experienced significantly lower odds of mortality, along with fewer hospital readmissions, versus those with male physicians. Further work is necessary to examine these effects in other care contexts across different countries and understand underlying mechanisms and long-term outcomes to optimize health outcomes for all patients.

REVIEW REGISTRATION

PROSPERO - CRD42023463577.

Comparison of Postoperative Outcomes Among Patients Treated by Male Versus Female Surgeons: A Systematic Review and Meta-analysis

OBJECTIVE

To compare clinical outcomes of patients treated by female surgeons versus those treated by male surgeons.

BACKGROUND

It remains unclear as to whether surgical performance and outcomes differ between female and male surgeons.

METHODS

We conducted a meta-analysis to compare patients' clinical outcomes-including patients' postoperative mortality, readmission, and complication rates-between female versus male surgeons. MEDLINE, Embase, CENTRAL, ICTRP, and ClinicalTrials.gov were searched from inception to September 8, 2022. The update search was conducted on July 19, 2023. We used random-effects models to synthesize data and GRADE to evaluate the certainty.

RESULTS

A total of 15 retrospective cohort studies provided data on 5,448,121 participants. We found that patients treated by female surgeons experienced a lower postoperative mortality compared with patients treated by male surgeons [8 studies; adjusted odds ratio (aOR), 0.93; 95% CI, 0.88-0.97; I2 =27%; moderate certainty of the evidence]. We found a similar pattern for both elective and nonelective (emergent or urgent) surgeries, although the difference was larger for elective surgeries (test for subgroup difference P =0.003). We found no evidence that female and male surgeons differed for patient readmission (3 studies; aOR, 1.20; 95% CI, 0.83-1.74; I2 =92%; very low certainty of the evidence) or complication rates (8 studies; aOR, 0.94; 95% CI, 0.88-1.01; I2 =38%; very low certainty of the evidence).

CONCLUSION

This systematic review and meta-analysis suggests that patients treated by female surgeons have a lower mortality compared with those treated by male surgeons.

Effect of Surgeons' Years of Experience on Outcomes of Acute Type A Aortic Dissection

Background The effect of surgeons' years of experience on the outcomes of acute type A aortic dissection (ATAAD) repair has not yet been studied. This study aimed to evaluate the association between the surgeon's years in practice and the outcomes of ATAAD repair. Methods Surgical records of ATAAD repairs performed at Saga University Hospital between 2004 and 2020 were reviewed. Surgeons were divided into two groups based on their surgical experience: late-career surgeons (LCSs) and early-career surgeons (ECSs) with ≥16 years and <16 of practice, respectively. The surgeons were designated as the primary surgeons or first assistants and grouped as follows: LCS-LCS, LCS-ECS, ECS-LCS, and ECS-ECS. Results During the study period, 25 primary surgeons performed 203 ATAAD repairs with 31 different first assistants: LCS-LCS, 50 repairs; LCS-ECS, 82 repairs; ECS-LCS, 55 repairs; and ECS-ECS, 16 repairs. The mean years in practice as a primary surgeon was 19.8 ± 3.3 for LCSs and 13.0 ± 1.8 for ECSs (p < 0.01). The unadjusted in-hospital mortality rates were 10.0%, 12.2%, 5.5%, and 6.3% for the LCS-LCS, LCS-ECS, ECS-LCS, and ECS-ECS groups, respectively (p = 0.63). Multivariable regression analysis showed that the surgeon's years of experience in practice were not a risk factor for in-hospital mortality. Furthermore, the long-term survival rate did not differ between the groups (p = 0.62). Conclusions The surgeons' years in practice had no effect on the outcomes of ATAAD repair. These investigations could aid in on-call coverage for ATAAD in medium-sized centers.

Duration of consultant experience and patient outcome following acute medical unit admission: an observational cohort study

BACKGROUND

The effect of the duration of consultant experience on clinical outcomes in the acute medical unit (AMU) model remains unknown.

METHODS

Unscheduled AMU admissions (n=66,929) admitted by 56 consultant physicians between 2017 and 2020 to two large teaching hospital AMUs in Lothian, Scotland were examined. The associations of consultant experience on AMU with patient discharge, mortality, readmission and postdischarge death were calculated adjusting for clinical acuity, pathology and comorbidity.

RESULTS

Increasing consultant experience was associated with a continuous increase in likelihood of early AMU discharge (odds ratio (OR) 1.08; 95% confidence interval (CI) 1.07-1.10; p<0.001 per 5 years' experience), which persisted after adjustment for confounders (OR 1.06; 95% CI: 1.01-1.11; p=0.01). There was no association with early readmission, death after discharge or 30-day inpatient mortality. The marginal effect estimate translates into 31 (95% CI: 25-36), 41 (95% CI: 30-53) and 52 (95% CI: 35-71) additional safe discharges per 1,000 admissions for clinicians of 15, 20 and 25 years' experience, respectively compared with those recently completing training.

CONCLUSIONS

Increasing consultant physician experience associates with early safe discharge after AMU admission. These data suggest that the support and retention of experienced clinicians is vital if escalating pressures on unscheduled medical care are to be addressed.

Do older surgeons have safer hands? A retrospective cohort study

Background

For complex surgical procedures a volume-outcome relationship can often be demonstrated implicating multiple factors at a unit and surgeon specific level. This study aims to investigate this phenomenon in lung transplantation over a 30-year period with particular reference to surgeon age and experience, cumulative unit activity and time/day of transplant.

Methods

Prospective databases identified adult patients undergoing isolated lung transplantation at a single UK centre between June 1987 and October 2017. Mortality data was acquired from NHS Spine. Individual surgeon demographics were obtained from the General Medical Council. Student t-test, Pearson’s Chi-squared, Logistic Regression, and Kaplan–Meier Survival analyses were performed using Analyse-it package for MicrosoftExcel and STATA/IC.

Results

954 transplants (55.9% male, age 44.4 ± 13.8 years, 67.9% bilateral lung) were performed, with a median survival to follow-up of 4.37 years. There was no difference in survival by recipient gender (p = 0.661), between individual surgeons (p = 0.224), or between weekday/weekend procedures (p = 0.327).

Increasing centre experience with lung transplantation (OR1.001, 95%CI: 1.000–1.001, p = 0.03) and successive calendar years (OR1.028, 95%CI: 1.005–1.052, p = 0.017) was associated with improved 5-year survival.

Advancing surgeon age at the time of transplant (mean, 48.8 ± 6.6 years) was associated with improved 30-day survival (OR1.062, 95%CI: 1.019 to1.106, p = 0.003), which persisted 5 years post-transplant (OR1.043, 95%CI: 1.014–1.073, p = 0.003).

Individual surgeon experience, measured by the number of previous lung transplants performed, showed a trend towards improved outcomes at 30 days (p = 0.0413) with no difference in 5-year survival (p = 0.192).

Conclusions

Our study demonstrates a relationship between unit volume, increasing surgeon age and survival after lung transplantation. A transplant volume: outcome relationship was not seen for individual surgeons.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01943-2.

The burden of performing minimal access surgery: ergonomics survey results from 462 surgeons across Germany, the UK and the USA

This international study aimed to understand, from the perspective of surgeons, their experience of performing minimal access surgery (MAS), to explore causes of discomfort while operating and the impact of poor ergonomics on surgeon welfare and career longevity across different specialties and techniques. A quantitative online survey was conducted in Germany, the UK and the USA from March to April 2019. The survey comprised 17 questions across four categories: demographics, intraoperative discomfort, effects on performance and anticipated consequences. In total, 462 surgeons completed the survey. Overall, 402 (87.0%) surgeons reported experiencing discomfort while operating at least ‘sometimes’. The peak professional performance age was perceived to be 45–49 years by 30.7% of surgeons, 50–54 by 26.4% and older than 55 by 10.1%. 86 (18.6%) surgeons felt it likely they would consider early retirement, of whom 83 were experiencing discomfort. Our findings highlight the continued unmet needs of surgeons performing MAS, with the overwhelming majority experiencing discomfort, frequently in the back, neck and shoulders, and many likely to consider early retirement consequently. Innovative solutions are needed to alleviate this physical burden and, in turn, prevent economic and societal impacts on healthcare systems resulting from MAS limiting surgeon longevity.

Physicians' clinical experience and its association with healthcare quality: a systematised review

BACKGROUND AND PURPOSE

There is conflicting evidence regarding whether physicians' clinical experience affects healthcare quality. Knowing whether an association exists and which dimensions of quality might be affected can help healthcare services close quality gaps by tailoring improvement initiatives according to physicians' clinical experience. Here, we present a systematised review that aims to assess the potential association between physicians' clinical experience and different dimensions of healthcare quality.

METHODS

We conducted a systematised literature review, including the databases MEDLINE, Embase, PsycINFO and PubMed. The search strategy involved combining predefined terms that describe physicians' clinical experience with terms that describe different dimensions of healthcare quality (ie, safety, clinical effectiveness, patient-centredness, timeliness, efficiency and equity). We included relevant, original research published from June 2004 to November 2020.

RESULTS

Fifty-two studies reporting 63 evaluations of the association between physicians' clinical experience and healthcare quality were included in the final analysis. Overall, 27 (43%) evaluations found a positive or partially positive association between physicians' clinical experience and healthcare quality; 22 (35%) found no association; and 14 (22%) evaluations reported a negative or partially negative association. We found a proportional association between physicians' clinical experience and quality regarding outcome measures that reflect safety, particularly in the surgical fields. For other dimensions of quality, no firm evidence was found.

CONCLUSION

We found no clear evidence of an association between measures of physicians' clinical experience and overall healthcare quality. For outcome measures related to safety, we found that physicians' clinical experience was proportional with safer care, particularly in surgical fields. Our findings support efforts to secure adequate training and supervision for early-career physicians regarding safety outcomes. Further research is needed to reveal the potential subgroups in which gaps in quality due to physicians' clinical experience might exist.

The relationship between cardiac surgeon experience and average patient risk profile: CA and NY statewide analysis

BACKGROUND

It is unknown how high and low-risk cases are distributed among cardiac surgeons of different experience levels. The purpose of this study was to determine if high and low-risk coronary artery bypass grafting (CABG) cases are distributed among surgeons in such a way that would optimize outcomes in light of recent studies that show mid-career surgeons may obtain better patient outcomes on more complex cases.

METHODS

We performed a cross-sectional study using aggregated New York (NY) and California (CA) statewide surgeon-level outcome data, including 336 cardiac surgeons who performed 43,604 CABGs. The surgeon observed and expected mortality rates (OMR and EMR) were collected and the number of years-in-practice was determined by searching for surgeon training history on online registries. Loess and linear regression models were used to characterize the relationship between surgeon EMR and surgeon years-in-practice.

RESULTS

The median number of surgeon years-in-practice was 20 (interquartile range [IQR] 11-28) with a median annual case volume of 46 (IQR 19, 70.25). The median surgeon observed to expected mortality (O:E) ratio was 0.87 (IQR 0.19-1.4). Median EMR for CA surgeons was 2.42% and 1.44% for NY surgeons. Linear regression models showed EMR was similar across years in practice. Regression models also showed surgeon O:E ratios were similar across years-in-practice.

CONCLUSION

High and low-risk CABG cases are relatively equally distributed among surgeons of differing experience levels. This equal distribution of high and low-risk cases does not reflect a triaging of more complex cases to more experienced surgeons, which prior research shows may optimize patient outcomes.

Association Between Cardiac Surgeons' Number of Years in Practice and Surgical Outcomes in New York Cardiac Centers

IMPORTANCE

More than half of US cardiothoracic surgeons are older than 55 years, and the association between surgeon number of years in practice and surgical outcomes remains unclear.

OBJECTIVE

To assess the association between cardiac surgeons' time in practice and operative outcomes for coronary artery bypass grafting (CABG) and valve surgery.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis performed of surgeon-level outcomes data from the 2014-2016 New York State Cardiac Data Reporting System across the 38 New York cardiac surgery centers. Years in practice were characterized as early career (<10 years) and late career (≥10 years). Participants were 120 cardiothoracic surgeons who performed CABG and 112 cardiothoracic surgeons who performed valve procedures between 2014 and 2016. Data were analyzed in April 2020. Surgeons who trained outside of the United States or had unclear training history were excluded.

MAIN OUTCOMES AND MEASURES

Risk-adjusted operative mortality rate (RAMR). Mortality was defined as all-cause death within 30 days of surgery or within the index hospitalization, whichever was longer. Risk adjustment was performed by a multivariable risk model developed by the New York State Department of Public Health. Restricted cubic spline curve identified the association between risk-adjusted mortality rate and surgeon number of years in practice. Linear regression models adjusted for surgeons' annual case volumes.

RESULTS

A total of 112 CABG surgeons and 120 valve surgeons performed 39 436 CABG and 18 596 valve procedures between 2014 and 2016. The median number of surgeon years in practice was 20.0 (interquartile range [IQR], 12.0-28.5) years. The median surgeon annual case volume was 160.0 (IQR, 92.5-245.0) for CABG procedures and 104.0 (IQR, 43.0-210.0) for valve procedures. The median RAMR was 1.3% (IQR, 0.2%-2.2%) for CABG procedures and 3.1% (IQR, 1.7%-5.1%) for valve procedures. Surgeons with less than 10 years of practice had higher RAMR for valve procedures compared with surgeons with more than 10 years of practice (4.0 [IQR, 1.5-7.7] vs 2.9 [IQR, 1.7-4.7]; P = .20), but the finding was not statistically signficant. The RAMR for surgeons with less than 10 years of practice was similar compared with surgeons with more than 10 years of practice for CABG procedures (1.3 [IQR, 0.3-2.1] vs 1.3 [IQR, 0.0-2.2]; P = .73). A lower number of years in practice was significantly associated with higher RAMR for valve procedures (RAMR estimates for linear term: -1.144; 95% CI, -1.955 to -0.332; P = .006; quadratic term: 0.059; 95% CI, 0.015 to 1.102; P = .008; and cubic term: -0.001; 95% CI, -0.002 to 0.000; P = .01). This association was not observed for CABG.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, compared with late-career cardiac surgeons, early-career cardiac surgeons were associated with worse risk-adjusted outcomes for valve operations but not for CABG. This finding suggests certain competence deficiency for valve surgery early after finishing training in cardiac surgery.

Association of Cataract Surgical Outcomes With Late Surgeon Career Stages: A Population-Based Cohort Study

Importance

Evidence suggests that the quality of some aspects of care provided by physicians may decrease during their late career stage. However, to our knowledge, data regarding the association of advancing surgeon career phase with cataract surgical outcomes have been lacking.

Objective

To investigate whether an increase in cataract surgical adverse events occurs during later surgeon career stages.

Design, Setting, and Participants

This population-based study of 499 650 cataract operations performed in Ontario, Canada, between January 1, 2009, and December 31, 2013, investigated the association between late surgeon career stage and the risk of surgical adverse events. Linked health care databases were used to study cataract surgical complications while controlling for patient-, surgeon-, and institution-level covariates. All ophthalmologists who performed cataract surgery in Ontario within the study period were included in the analysis.

Exposures

Isolated cataract surgery performed by surgeons at early, mid, and late career stages.

Main Outcomes and Measures

Four serious adverse events were evaluated: dropped lens fragments, posterior capsule rupture, suspected endophthalmitis, and retinal detachment.

Results

Of 416 502 participants, 244 670 (58.7%) were women, 90 429 (21.7%) were age 66 to 70 years, 111 530 (26.8%) were age 71 to 75 years, 90 809 (21.8%) were age 76 to 80 years, and 123 734 (29.7%) were 81 years or older. Late-career surgeons performed 143 108 of 499 650 cataract operations (28.6%) during the study period. Late surgeon career stage was not associated with an increased overall risk of surgical adverse events (odds ratio [OR] vs midcareer, 1.06; 95% CI, 0.85-1.32). In a sensitivity analysis with surgeon volume removed from the model, late career stage was still not associated with overall adverse surgical events (OR, 1.10; 95% CI, 0.88-1.38). Among individual complications, late surgeon career stage was associated with an increased risk of dropped lens fragment (OR, 2.30; 95% CI, 1.50-3.54) and suspected endophthalmitis (OR, 1.41; 95% CI, 1.01-1.98). These corresponded with small absolute risk differences of 0.11% (95% CI, 0.085%-0.130%) and 0.045% (95% CI, 0.028%-0.063%) for dropped lens fragment and suspected endophthalmitis, respectively.

Conclusions and Relevance

These findings suggest that later-career surgeons are performing a substantial proportion of cataract operations with overall low surgical adverse event rates. Future studies might extend evaluations to the frequency of secondary surgical interventions as additional measures of surgical care quality.

Age and sex of surgeons and mortality of older surgical patients: observational study

OBJECTIVE

To investigate whether patients' mortality differs according to the age and sex of surgeons.

DESIGN

Observational study.

SETTING

US acute care hospitals.

PARTICIPANTS

100% of Medicare fee-for-service beneficiaries aged 65-99 years who underwent one of 20 major non-elective surgeries between 2011 and 2014.

MAIN OUTCOME MEASURE

Operative mortality rate of patients, defined as death during hospital admission or within 30 days of the operative procedure, after adjustment for patients' and surgeons' characteristics and indicator variables for hospitals.

RESULTS

892 187 patients who were treated by 45 826 surgeons were included. Patients' mortality was lower for older surgeons than for younger surgeons: the adjusted operative mortality rates were 6.6% (95% confidence interval 6.5% to 6.7%), 6.5% (6.4% to 6.6%), 6.4% (6.3% to 6.5%), and 6.3% (6.2% to 6.5%) for surgeons aged under 40 years, 40-49 years, 50-59 years, and 60 years or over, respectively (P for trend=0.001). There was no evidence that adjusted operative mortality differed between patients treated by female versus male surgeons (adjusted mortality 6.3% for female surgeons versus 6.5% for male surgeons; adjusted odds ratio 0.97, 95% confidence interval 0.93 to 1.01). After stratification by sex of surgeon, patients' mortality declined with age of surgeon for both male and female surgeons (except for female surgeons aged 60 or older); female surgeons in their 50s had the lowest operative mortality.

CONCLUSION

Using national data on Medicare beneficiaries in the US, this study found that patients treated by older surgeons had lower mortality than patients treated by younger surgeons. There was no evidence that operative mortality differed between male and female surgeons.