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Fajardo OM, Grebenyuk E, Chaves KF, Zhao Z, Ding T, Curlin HL, Harvey LFB. Impact of trainees involvement on surgical outcomes of abdominal and laparoscopic myomectomy. J OBSTET GYNAECOL 2024; 44:2330697. [PMID: 38520272 DOI: 10.1080/01443615.2024.2330697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/05/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND To determine the association of trainees involvement with surgical outcomes of abdominal and laparoscopic myomectomy including operative time, rate of transfusion, and complications. METHODS A retrospective cohort study of 1145 patients who underwent an abdominal or laparoscopic myomectomy from 2008-2012 using the American College of Surgeons National Surgical Quality Improvement Program database (Canadian Task Force Classification II-2). RESULTS Overall, 64% of myomectomies involved trainees. Trainees involvement was associated with a longer operative time for abdominal myomectomies (mean difference 20.17 minutes, 95% Confidence Interval (CI) [11.37,28.97], p < 0.01) overall and when stratified by fibroid burden. For laparoscopic myomectomy, there was no difference in operative time between trainees vs no trainees involvement (mean difference 4.64 minutes, 95% CI [-18.07,27.35], p = 0.67). There was a higher rate of transfusion with trainees involvement for abdominal myomectomies (10% vs 2%, p < 0.01; Odds Ratio (OR) 5.62, 95% CI [2.53,12.51], p < 0.01). Trainees involvement was not found to be associated with rate of transfusion for laparoscopic myomectomy (4% vs 5%, p = 0.86; OR 0.82, 95% CI [0.16,4.14], p = 0.81). For abdominal myomectomy, there was a higher rate of overall complications (15% vs 5%, p < 0.01; OR 2.96, 95% CI [1.77,4.93], p < 0.01) and minor complications (14% vs 4%, p < 0.01; OR 3.71, 95% CI [2.09,6.57], p < 0.01) with no difference in major complications (3% vs 2%, p = 0.23). For laparoscopic myomectomy, there was no difference in overall (6% vs 10% p = 0.41; OR 0.59, 95% CI [0.18,2.01], p = 0.40), major (2% vs 0%, p = 0.38), or minor (5% vs 10%, p = 0.32; OR 0.52, 95% CI [0.15,1.79], p = 0.30) complications. CONCLUSION Trainees involvement was associated with increased operative time, rate of transfusion, and complications for abdominal myomectomy, however, did not impact surgical outcomes for laparoscopic myomectomy.
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Affiliation(s)
- Olga M Fajardo
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI, USA
| | - Ekaterina Grebenyuk
- Department of Obstetrics and Gynecology, Lankenau Medical Center, Wynnewood, PA, USA
| | - Katherine F Chaves
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Main Line Health, Wynnewood, PA, USA
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tan Ding
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Howard L Curlin
- Minimally Invasive Gynecologic Surgery Division, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lara F B Harvey
- Minimally Invasive Gynecologic Surgery Division, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
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Morgat C, Cellier J, Dinanian S, Juin C, Slama MS, Kalyana Sundar S, Extramiana F, Algalarrondo V. Impact of resident training on cardiac electrophysiological procedures. Arch Cardiovasc Dis 2024:S1875-2136(24)00283-3. [PMID: 39217006 DOI: 10.1016/j.acvd.2024.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 07/01/2024] [Accepted: 07/04/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Modern management of cardiac arrhythmias often requires interventions in which young physicians must acquire a high level of expertise. However, concerns have been raised about the increase in side effects during procedures performed with resident involvement. AIM This study aims to identify the effects of resident training on cardiac electrophysiological procedures within a university centre. METHODS In a single-centre study, cardiac arrhythmia procedures were reviewed retrospectively, and resident involvement was scrutinized. Univariate and multivariable models were built for the following outcomes: fluoroscopy time; operative time; length of hospitalization after procedure; and adverse events. RESULTS We reviewed 991 procedures, 574 without and 417 with resident involvement (650 cardiac pacemakers or defibrillators, 120 generator replacements, 188 electrophysiological studies and 153 radiofrequency ablations). Resident involvement was associated with an increase in fluoroscopy time: +1.7±0.4minutes (P<0.01) for pacemaker implantation; and +2.5±0.9minutes (P=0.01) for electrophysiological studies. Operative time was longer for electrophysiological studies (+10.8±4.9minutes; P=0.03) and pacing implantation (+8.4±2.2minutes; P<0.01). There was no significant association between resident training and adverse events (7.67 vs. 9.83%; P=0.28). CONCLUSIONS Cardiac electrophysiological procedures performed with resident involvement have a good safety profile. However, resident training modestly, but significantly, prolongs fluoroscopy time and operative time.
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Affiliation(s)
- Charles Morgat
- Service de cardiologie, hôpital Bichat-Claude Bernard, AP-HP, 46, boulevard Henri-Huchard, 75018 Paris, France; Université Paris-Cité, 75006 Paris, France
| | - Joffrey Cellier
- Service de cardiologie, hôpital Antoine-Béclère, AP-HP, 92140 Clamart, France
| | - Sylvie Dinanian
- Service de cardiologie, hôpital Antoine-Béclère, AP-HP, 92140 Clamart, France
| | - Christophe Juin
- Service de cardiologie, hôpital Antoine-Béclère, AP-HP, 92140 Clamart, France
| | - Michel S Slama
- Service de cardiologie, hôpital Bichat-Claude Bernard, AP-HP, 46, boulevard Henri-Huchard, 75018 Paris, France; Service de cardiologie, hôpital Antoine-Béclère, AP-HP, 92140 Clamart, France
| | - Shweta Kalyana Sundar
- Service de cardiologie, hôpital Bichat-Claude Bernard, AP-HP, 46, boulevard Henri-Huchard, 75018 Paris, France
| | - Fabrice Extramiana
- Service de cardiologie, hôpital Bichat-Claude Bernard, AP-HP, 46, boulevard Henri-Huchard, 75018 Paris, France; Université Paris-Cité, 75006 Paris, France
| | - Vincent Algalarrondo
- Service de cardiologie, hôpital Bichat-Claude Bernard, AP-HP, 46, boulevard Henri-Huchard, 75018 Paris, France; Université Paris-Cité, 75006 Paris, France; Service de cardiologie, hôpital Antoine-Béclère, AP-HP, 92140 Clamart, France.
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Okubo T, Nagoshi N, Kono H, Kobayashi Y, Tsuji O, Aoyama R, Isogai N, Ishihara S, Takeda K, Ozaki M, Suzuki S, Matsumoto M, Nakamura M, Watanabe K, Ishii K, Yamane J. Comparison of Surgical Outcomes After Posterior Decompression by Junior or Senior Surgeons for Patients With Cervical Ossification of the Posterior Longitudinal Ligament: Results From Retrospective Multicenter Cohort Study. Global Spine J 2024:21925682241260725. [PMID: 38831702 DOI: 10.1177/21925682241260725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
STUDY DESIGN Retrospective multicenter study. OBJECTIVES To investigate surgical outcomes following posterior decompression for cervical ossification of the posterior longitudinal ligament (OPLL) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons. METHODS We included 203 patients with cervical OPLL who were followed for a minimum of 1 year after surgery. Demographic information, medical history, and imaging findings were collected. Clinical outcomes were assessed preoperatively and at the final follow-up using the Japanese Orthopedic Association (JOA) score and the visual analog scale (VAS) for the neck. We compared outcomes between BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and NBCS surgeons. RESULTS BCS surgeons performed 124 out of 203 cases, while NBCS surgeons were primary in 79 cases, with 73.4% were directly supervised by a BCS surgeon. There was no statistically significant difference in surgical duration, estimated blood loss, and perioperative complication rates between the BCS and NBCS groups. Moreover, no statistically significant group differences were observed in each position of the C2-7 angle and cervical range of motion at preoperation and the final follow-up. Preoperative and final follow-up JOA scores, VAS for the neck, and JOA score recovery rate were comparable between the two groups. CONCLUSIONS Surgical outcomes, including functional recovery, complication rates, and cervical dynamics, were comparable between the BCS and NBCS groups. Consequently, posterior decompression for cervical OPLL is considered safe and effective when conducted by junior surgeons who have undergone training and supervision by experienced spine surgeons.
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Affiliation(s)
- Toshiki Okubo
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Hitoshi Kono
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Keiyu Orthopedic Hospital, Tatebayashi, Japan
| | - Yoshiomi Kobayashi
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Japan Red Cross Shizuoka Hospital, Shizuoka, Japan
- Department of Orthopedic Surgery, National Hospital Organization Murayama Medical Center, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Saitama Medical Center, Saitama, Japan
| | - Ryoma Aoyama
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Norihiro Isogai
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare (IUHW) Mita Hospital, Tokyo, Japan
| | - Shinichi Ishihara
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare (IUHW) Mita Hospital, Tokyo, Japan
- Department of Orthopedic Surgery, Subaru Health Insurance Society Ota Memorial Hospital, Ota, Japan
| | - Kazuki Takeda
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Masahiro Ozaki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Satoshi Suzuki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Ken Ishii
- Keio Spine Research Group (KSRG), Tokyo, Japan
- New Spine Clinic Tokyo, Tokyo, Japan
| | - Junichi Yamane
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, National Hospital Organization Murayama Medical Center, Tokyo, Japan
- Department of Orthopedic Surgery, Kanagawa Prefectural Police Association Keiyu Hospital, Yokohama, Japan
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Marcel AJ, Feinn RS, Myrick KM. Impact of Resident Involvement on 30-Day Postoperative Outcomes in Orthopedic Shoulder Surgery. Adv Orthop 2024; 2024:1550500. [PMID: 38586198 PMCID: PMC10999291 DOI: 10.1155/2024/1550500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/09/2024] Open
Abstract
The literature concerning resident involvement in shoulder surgery is limited. The purpose of this study was to examine whether resident involvement across all orthopedic shoulder surgeries is associated with adverse 30-day outcomes. Utilizing the American College of Surgeons National Surgical Quality Improvement Program database, patients who underwent shoulder surgery with or without a resident present were analyzed. Independent t-test and chi-square or Fischer's exact test were used appropriately. A logistic regression model was used to calculate adjusted odds ratios. This study examined 5,648 patients: 3,455 patients in the "Attending alone" group and 2,193 in the "Attending and resident in the operating room" group. Resident presence in the operating room was not associated with increased complications, except for bleeding transfusions (OR 1.71, CI 1.32-2.21, P ≤ 0.001). This study demonstrates that resident involvement in orthopedic shoulder surgery does not present an increased risk for 30-day complications when compared to surgeries performed with the attending surgeon alone.
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Affiliation(s)
- Aaron J. Marcel
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut, USA
| | - Richard S. Feinn
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut, USA
| | - Karen M. Myrick
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut, USA
- University of Saint Joseph, West Hartford, CT, USA
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Chintalapudi N, Hysong A, Posey S, Hsu JR, Kempton L, Phelps KD, Sims S, Karunakar M, Seymour RB, Medda S. Are Orthopaedic Trauma Surgeons Appropriately Compensated for Treating Acetabular Fractures? An Analysis of Operative Times and Relative Value Units. J Orthop Trauma 2024; 38:143-147. [PMID: 38117575 DOI: 10.1097/bot.0000000000002749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVES To evaluate the work relative value units (RVUs) attributed per minute of operative time (wRVU/min) in fixation of acetabular fractures, evaluate surgical factors that influence wRVU/min, and compare wRVU/min with other procedures. METHODS DESIGN Retrospective. SETTING Level 1 academic center. PATIENT SELECTION CRITERIA Two hundred fifty-one operative acetabular fractures (62 A, B, C) from 2015 to 2021. OUTCOME MEASURES AND COMPARISONS Work relative value unit per minute of operative time for each acetabular current procedural terminology (CPT) code. Surgical approach, patient positioning, total room time, and surgeon experience were collected. Comparison wRVU/min were collected from the literature. RESULTS The mean wRVU per surgical minute for each CPT code was (1) CPT 27226 (isolated wall fracture): 0.091 wRVU/min, (2) CPT 27227 (isolated column or transverse fracture): 0.120 wRVU/min, and (3) CPT 27228 (associated fracture types): 0.120 wRVU/min. Of fractures with single approaches, anterior approaches generated the least wRVU/min (0.091 wRVU/min, P = 0.0001). Average nonsurgical room time was 82.1 minutes. Surgeon experience ranged from 3 to 26 years with operative time decreasing as surgeon experience increased ( P = 0.03). As a comparison, the wRVU/min for primary and revision hip arthroplasty have been reported as 0.26 and 0.249 wRVU/min, respectively. CONCLUSIONS The wRVUs allocated per minute of operative time for acetabular fractures is less than half of other reported hip procedures and lowest for isolated wall fractures. There was a significant amount of nonsurgical room time that should be accounted for in compensation models. This information should be used to ensure that orthopaedic trauma surgeons are being appropriately supported for managing these fractures. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nainisha Chintalapudi
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
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Lee AJ, Kim SY, Jang EB, Hyun JA, Yang EJ, So KA, Lee SJ, Lee JY, Kim TJ, Kang SB, Shim SH. Impact of resident participation on surgical outcomes in laparoscopically assisted vaginal hysterectomy. Int J Gynaecol Obstet 2024; 164:587-595. [PMID: 37675800 DOI: 10.1002/ijgo.15087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/09/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE To compare surgical outcomes in patients with benign diseases who underwent laparoscopically assisted vaginal hysterectomy (LAVH) to determine the association between surgical outcomes and resident participation in the gynecologic field. METHODS A single-center retrospective study was conducted of patients diagnosed with benign gynecologic diseases who underwent LAVH between January 2010 and December 2015. Clinicopathologic characteristics and surgical outcomes were compared between the resident involvement and non-involvement groups. The primary endpoint was the 30-day postoperative morbidity. Observers were propensity matched for 17 covariates for resident involvement or non-involvement. RESULTS Of the 683 patients involved in the study, 165 underwent LAVH with resident involvement and 518 underwent surgery without resident involvement. After propensity score matching (157 observations), 30-day postoperative morbidity occurred in 6 (3.8%) and 4 (2.5%) patients in the resident involvement and non-involvement groups, respectively (P = 0.501). The length of hospital stay differed significantly between the two groups: 5 days in the resident involvement group and 4 days in the non-involvement group (P < 0.001). On multivariate analysis, Charlson Comorbidity Index >2 (odds ratio [OR] 8.01, 95% confidence interval [CI] 2.68-23.96; P < 0.001), operative time (OR 1.02, 95% CI 1.01-1.03; P < 0.001), and estimated blood loss (OR 1.00, 95% CI 1.00-1.00; P < 0.001) were significantly associated with 30-day morbidity, but resident involvement was not statistically significant. CONCLUSION There was no significant difference in the 30-day morbidity rate when residents participated in LAVH. These findings suggest that resident participation in LAVH may be a viable approach to ensure both residency education and patient safety.
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Affiliation(s)
- A Jin Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seo-Yeon Kim
- Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun Bi Jang
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jeong-Ah Hyun
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Eun Jung Yang
- Department of Obstetrics and Gynecology, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Kyeong A So
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Sun Joo Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Ji Young Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Tae Jin Kim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Soon-Beom Kang
- Department of Obstetrics and Gynecology, Hosan Women's Hospital, Gangnam-gu, Seoul, Republic of Korea
| | - Seung-Hyuk Shim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
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Biron DR, DalCortivo RL, Ahmed IH, Vosbikian MM. Resident involvement in hand and upper extremity surgery: An analysis of 30-day complications. J Clin Orthop Trauma 2023; 45:102281. [PMID: 38037635 PMCID: PMC10685008 DOI: 10.1016/j.jcot.2023.102281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/15/2023] [Accepted: 11/03/2023] [Indexed: 12/02/2023] Open
Abstract
Background Rotations in hand and upper extremity surgery are a core component of the Orthopaedic and Plastic Surgery resident training curriculums. This study compares short-term outcomes in hand and upper extremity procedures with and without resident involvement. Methods The National Surgical Quality Improvement Program database was queried from years 2005-2012 for all procedures distal to the shoulder. Patients were stratified based on whether a resident scrubbed for the procedure. Outcome measures were 30-day mortality, reoperation rate, minor complications, major complications, and length of stay (LOS). Chi-squared tests were used to determine significant variables. Significant variables were included in a binomial multivariate logistic regression model. Results A total of 7697 patients were included in the study. Of those, 4509 (59 %) had no resident, and 3188 (41 %) had a resident. Patients with resident involvement were less likely to be Caucasian, ASA classification 3 or higher, and outpatient. Cohorts were similar with respect to age, sex, and emergent status. Operative time was 15 min longer in resident cases. Work relative value units were higher in resident cases. In the multivariate logistic regression model, resident involvement had no statistically significant impact on LOS, mortality, reoperation rate, minor complications, or major complications. Subgroup analysis showed increased odds of superficial surgical site infections in resident cases, although this was statistically insignificant (OR 1.35, p = 0.24). Conclusions Hand and upper extremity procedures with resident involvement do not have any increase in overall adverse short-term outcomes. In appropriately selected cases, residents can participate without compromising patient safety.
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Affiliation(s)
- Dustin R. Biron
- Rutgers New Jersey Medical School Department of Orthopaedics, 140 Bergen Street, ACC D1610, Newark, NJ, 07103, United States
| | - Robert L. DalCortivo
- Rutgers New Jersey Medical School Department of Orthopaedics, 140 Bergen Street, ACC D1610, Newark, NJ, 07103, United States
| | - Irfan H. Ahmed
- Rutgers New Jersey Medical School Department of Orthopaedics, 140 Bergen Street, ACC D1610, Newark, NJ, 07103, United States
| | - Michael M. Vosbikian
- Rutgers New Jersey Medical School Department of Orthopaedics, 140 Bergen Street, ACC D1610, Newark, NJ, 07103, United States
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Jovan JD, Marcel AJ, Myrick KM, Feinn RS, Blaine T. Resident Involvement in Shoulder-Stabilization Procedures Is Not Associated With an Increased Risk of 30-Day Postoperative Complications. Arthrosc Sports Med Rehabil 2023; 5:100764. [PMID: 37533975 PMCID: PMC10391657 DOI: 10.1016/j.asmr.2023.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/14/2023] [Indexed: 08/04/2023] Open
Abstract
Purpose To examine the 30-day postoperative outcomes of resident involvement in shoulder-stabilization surgical procedures using the American College of Surgeons National Surgical Quality Improvement database. Methods We conducted a retrospective review of the National Surgical Quality Improvement database for all shoulder-stabilization procedures from 2010 to 2018. Procedures included arthroscopic Bankart, arthroscopic Bankart with SLAP repair, arthroscopic Bankart with Remplissage, open Bankart, anterior bone block, posterior bone block, Latarjet coracoid process transfer, and capsular shift/capsulorrhaphy for multidirectional instability. Data included preoperative demographics, comorbidities, and 30-day postoperative outcomes. Cases were categorized into 2 groups: "attending alone" and "attending and resident." Statistical analysis comparing groups on demographics and comorbidities included independent t-test for continuous variables and Pearson χ2 or Fischer exact for categorical variables. A logistic regression model including propensity score was used to calculate adjusted odds ratio for outcomes. Results A total of 3,954 patients undergoing shoulder-stabilization procedures were included in the study and 28.8% of patients had a resident involved in their procedure. Residents were more likely to be involved in procedure for patients who were of minority ethnicity (P < .001), a lower body mass index (P < .001) and less likely to have a history of chronic obstructive pulmonary disease (P = .029). Resident involvement resulted in statistically significant longer total operation time (91 vs 85 minutes, P < .001). In terms of postsurgical outcomes, complication rates were low for both groups (∼0.8%). Resident involvement was not associated with any significant increase in 30-day postsurgical complications. Conclusions Our results show that resident involvement in shoulder-stabilization surgery is associated with a significant increase in operative time without any significant increase in 30-day postsurgical complications. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- John D. Jovan
- Frank H. Netter M.D. School of Medicine, Quinnipiac University, North Haven, Connecticut, U.S.A
| | - Aaron J. Marcel
- Frank H. Netter M.D. School of Medicine, Quinnipiac University, North Haven, Connecticut, U.S.A
| | - Karen M. Myrick
- Frank H. Netter M.D. School of Medicine, Quinnipiac University, North Haven, Connecticut, U.S.A
| | - Richard S. Feinn
- Frank H. Netter M.D. School of Medicine, Quinnipiac University, North Haven, Connecticut, U.S.A
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McKinley SK, Wojcik BM, Witt EE, Hamdi I, Mansur A, Petrusa E, Mullen JT, Phitayakorn R. Inpatient Satisfaction With Surgical Resident Care After Elective General and Oncologic Surgery. Ann Surg 2023; 277:e1380-e1386. [PMID: 35856490 DOI: 10.1097/sla.0000000000005598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate inpatient satisfaction with surgical resident care. BACKGROUND Surgical trainees are often the primary providers of care to surgical inpatients, yet patient satisfaction with surgical resident care is not well characterized or routinely assessed. METHODS English-speaking, general surgery inpatients recovering from elective gastrointestinal and oncologic surgery were invited to complete a survey addressing their satisfaction with surgical resident care. Patients positively identified photos of surgical senior residents and interns before completing a modified version of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS). Adapted S-CAHPS items were scored using the "top-box" method. RESULTS Ninety percent of recruited patients agreed to participate (324/359, mean age=62.2, 50.3% male). Patients were able to correctly identify their seniors and interns 85% and 83% of the time, respectively ( P =0.14). On a 10-point scale, seniors had a mean rating of 9.23±1.27 and interns had a mean rating of 9.01±1.49 ( P =0.14). Ninety-nine percent of patients agreed it was important to help in the education of future surgeons. CONCLUSIONS Surgical inpatients were able to recognize their resident physicians with high frequency and rated resident care highly overall, suggesting that they may serve as a willing source of feedback regarding residents' development of core competencies such as interpersonal skills, communication, professionalism, and patient care. Future work should investigate how to best incorporate patient evaluation of surgical resident care routinely into trainee assessment to support resident development.
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Affiliation(s)
| | | | | | - Isra Hamdi
- Massachusetts General Hospital, Boston, MA
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10
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Marder RS, Shah NV, Naziri Q, Maheshwari AV. The impact of surgical trainee involvement in total knee arthroplasty: a systematic review of surgical efficacy, patient safety, and outcomes. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:255-298. [PMID: 35022881 DOI: 10.1007/s00590-021-03179-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/27/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Trainee involvement in patient care has raised concerns about the potential risk of adverse outcomes and harming patients. We sought to analyze the impact and potential consequence of surgical trainee involvement in total knee arthroplasty (TKA) procedures in terms of surgical efficacy, patient safety, and functional outcomes. METHODS We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in April 2021. Eligible studies reported on the impact of trainee participation in TKA procedures performed with and without such involvement. RESULTS Twenty-three publications met our eligibility criteria and were included in our study. These studies reported on 132,624 surgeries completed on 132,416 patients. Specifically, 23,988 and 108,636 TKAs were performed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 19,573) and without (n = 94,581) trainee involvement were 99.77 and 85.05 min, respectively. Both studies that reported data on cost of TKAs indicated a significant increase (p < 0.001) associated with procedures completed by teaching hospitals compared to private practices. Mean overall complication rates were 7.20% and 7.36% for TKAs performed with (n = 9,386) and without (n = 31,406) trainees. Lastly, the mean Knee Society Scale (KSS) knee scores for TKAs with (n = 478) and without (n = 806) trainee involvement were similar; 82.81 and 82.71, respectively. CONCLUSION Our systematic review concurred with previous studies that reported trainee involvement during TKAs increases the mean operative time. However, the overall complication rates and functional outcomes were similar. Larger studies with a better methodology and higher level of evidence are still needed for a resolute conclusion.
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Affiliation(s)
- Ryan S Marder
- Department of Orthopaedic Surgery and Rehabilitation Medicine, Downstate Medical Center, State University of New York (SUNY, 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA
| | - Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, Downstate Medical Center, State University of New York (SUNY, 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA
| | - Qais Naziri
- Department of Orthopaedic Surgery and Rehabilitation Medicine, Downstate Medical Center, State University of New York (SUNY, 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA
| | - Aditya V Maheshwari
- Department of Orthopaedic Surgery and Rehabilitation Medicine, Downstate Medical Center, State University of New York (SUNY, 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA.
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Alexander B, Sowers M, Jacob R, McGwin G, Maffulli N, Naranje S. The Impact of Resident Involvement on Patient Outcomes in Revision Total Hip Arthroplasty. Rev Bras Ortop 2023; 58:133-140. [PMID: 36969789 PMCID: PMC10038725 DOI: 10.1055/s-0041-1736469] [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: 02/21/2021] [Accepted: 09/02/2021] [Indexed: 10/19/2022] Open
Abstract
Objective The aim of the present study was to determine the influence of resident involvement on acute complication rates in revision total hip arthroplasty (THA). Methods Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, 1,743 revision THAs were identified from 2008 to 2012; 949 of them involved a resident physician. Demographic information including gender and race, comorbidities including lung disease, heart disease and diabetes, operative time, length of stay, and acute postoperative complications within 30 days were analyzed. Results Resident involvement was not associated with a significant increase in the risk of acute complications. Total operative time demonstrated a statistically significant association with the involvement of a resident (161.35 minutes with resident present, 135.07 minutes without resident; p < 0.001). There was no evidence that resident involvement was associated with a longer hospital stay (5.61 days with resident present, 5.22 days without resident; p = 0.46). Conclusion Involvement of an orthopedic resident during revision THA does not appear to increase short-term postoperative complication rates, despite a significant increase in operative times.
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Affiliation(s)
- Bradley Alexander
- Divisão de Cirurgia Ortopédica, Universidade do Alabama em Birmingham, Birmingham, Alabama, Estados Unidos
| | - Mackenzie Sowers
- Divisão de Cirurgia Ortopédica, Universidade do Alabama em Birmingham, Birmingham, Alabama, Estados Unidos
| | - Roshan Jacob
- Divisão de Cirurgia Ortopédica, Universidade do Alabama em Birmingham, Birmingham, Alabama, Estados Unidos
| | - Gerald McGwin
- Departamento de Epidemiologia, Universidade do Alabama em Birmingham, Universidade Boulevard Birmingham, Alabama, Estados Unidos
| | - Nicola Maffulli
- Departamento de Distúrbios Musculoesqueléticos, Faculdade de Medicina e Cirurgia, Universidade de Salerno, Baronissi, Itália
| | - Sameer Naranje
- Divisão de Cirurgia Ortopédica, Universidade do Alabama em Birmingham, Birmingham, Alabama, Estados Unidos
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Frenkel Rutenberg T, Vitenberg M, Daglan E, Kadar A, Shemesh S. Single Surgeon versus Co-Surgeons in Primary Total Joint Arthroplasty: Does "Two Is Better than One" Apply to Surgeons? J Pers Med 2022; 12:jpm12101683. [PMID: 36294821 PMCID: PMC9604737 DOI: 10.3390/jpm12101683] [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: 09/03/2022] [Revised: 09/26/2022] [Accepted: 10/08/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND As the demand for total joint arthroplasties (TJA) increases steadily, so does the pressure to train future surgeons and, at the same time, achieve optimal outcomes. We aimed to identify differences in operative times and short-term surgical outcomes of TJAs performed by co-surgeons versus a single attending surgeon. METHODS A retrospective analysis of 597 TJAs, including 239 total hip arthroplasties (THAs) and 358 total knee arthroplasties (TKAs) was conducted. All operations were performed by one of four fellowship-trained attending surgeons as the primary surgeon. The assisting surgeons were either attendings or residents. RESULTS In 51% of THA and in 38% of TKA, two attending surgeons were scrubbed in. An additional scrubbed-in attending was not found to be beneficial in terms of surgical time reduction or need for revision surgeries within the postoperative year. This was also true for THAs and for TKAs separately. An attending co-surgeon was associated with a longer hospital stay (p = 0.028). Surgeries performed by fewer surgeons were associated with a shorter surgical time (p = 0.036) and an increased need for blood transfusion (p = 0.033). Neither the rate of intraoperative complications nor revisions differed between groups, regardless of the number of attending surgeons scrubbed in or the total number of surgeons. CONCLUSION A surgical team comprised of more than a single attending surgeon in TJAs was not found to reduce surgical time, while the participation of residents was not related with worse patient outcomes.
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Affiliation(s)
- Tal Frenkel Rutenberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel
| | - Maria Vitenberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel
| | - Efrat Daglan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel
| | - Assaf Kadar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel
| | - Shai Shemesh
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel
- Correspondence:
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Effect of Fellow Involvement and Experience on Patient Outcomes in Spine Surgery. J Am Acad Orthop Surg 2022; 30:831-840. [PMID: 35421018 DOI: 10.5435/jaaos-d-21-01019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 03/06/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Investigations in spine surgery have demonstrated that trainee involvement correlates with increased surgical time, readmissions, and revision surgeries; however, the specific effects of spine fellow involvement remain unelucidated. This study aims to investigate the isolated effect of fellow involvement on surgical timing and patient-reported outcomes measures (PROMs) after spine surgery and evaluate how surgical outcomes differ by fellow experience. METHODS All patients aged 18 years or older who underwent primary or revision decompression or fusion for degenerative diseases and/or spinal deformity between 2017 and 2019 at a single academic institution were retrospectively identified. Patient demographics, surgical factors, intraoperative timing, transfusion status, length of stay (LOS), readmissions, revision rate, and preoperative and postoperative PROMs were recorded. Surgeries were divided based on spine fellow participation status and occurrence in the start or end of fellowship training. Univariate and multivariate analyses compared outcomes across fellow involvement and fellow experience groups. RESULTS A total of 1,108 patients were included. Age, preoperative diagnoses, number of fusion levels, and surgical approach differed markedly by fellow involvement. Fellow training experience groups differed by patient smoking status, preoperative diagnosis, and surgical approach. On univariate analysis, spine fellow involvement was associated with extended total theater time, induction start to cut time, cut to close time, and LOS. Increased spine fellow training was associated with reduced cut to close time and LOS. On regression, fellow involvement predicted cut to close extension while increased fellow training experience predicted reduction in cut to close time, both independent of surgical factors and assisting residents or physician assistants. Transfusions, readmissions, revision rate, and PROMs did not differ markedly by fellow involvement or experience. CONCLUSION Spine fellow participation predicted extended procedural duration. However, the presence of a spine fellow did not affect long-term postoperative outcomes. Furthermore, increased fellow training experience predicted decreased procedural time, underscoring a learning effect. AVAILABILITY OF DATA AND MATERIAL The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. LEVEL OF EVIDENCE Level 3.
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Condron NB, Cotter EJ, Naveen NB, Wang KC, Patel SS, Waterman BR, Cole BJ, Dodds JA. Increasing Patient Age, Ambulatory Surgery Center Setting, and Surgeon Experience Are Associated With Shorter Operative Duration for Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e1323-e1329. [PMID: 36033177 PMCID: PMC9402419 DOI: 10.1016/j.asmr.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 04/16/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose To identify variables associated with operative duration and intraoperative or perioperative complications after primary anterior cruciate ligament reconstruction (ACLR). Methods Surgeons who performed a minimum of 20 arthroscopic cases per month were recruited for participation through the Arthroscopy Association of North America from 2011 through 2013. All participants agreed to voluntarily submit data for 6 months of consecutive knee and shoulder arthroscopy cases. Only subjects coded for ACLR were analyzed, whereas revision cases were excluded. ACLRs were subdivided into isolated ACLR, ACLR with minor concomitant procedures, and ACLR with major concomitant procedures. Patient, surgeon, and surgical variables were analyzed for their effect on operative duration and complications. Results One hundred thirty-five orthopaedic surgeons participated, providing 1,180 primary ACLRs (399 isolated ACLRs, 441 ACLRs plus minor procedures, and 340 ACLRs plus major procedures). Most surgeons were in private practice (72.8%). Most patients were male patients (58.8%), and the mean body mass index (BMI) was 26.2 ± 5.1. The overall mean operative duration was 95.9 ± 42.0 minutes (isolated ACLRs, 88.4 ± 36.8 minutes; ACLRs plus minor concomitant procedures, 90.1 ± 37.6 minutes; and ACLRs plus major concomitant procedures, 118.5 ± 112.4 minutes; P < .001). Patient age was inversely correlated with operative duration (ρ = –0.221, P < .001). Surgical procedures performed in an ambulatory surgery center had a shorter mean operative duration (91.5 ± 40.4 minutes) compared with those performed in a hospital setting (105.0 ± 43.8 minutes, P < .001). There were 22 intraoperative and 47 early postoperative complications, with the most common being deep vein thrombosis (n = 15). Surgical volume (knee arthroscopy cases per month) correlated inversely with operative time (ρ = –0.200, P = .001) and complication rate (ρ = –0.112, P < .001). Patient BMI was associated with increased odds of early postoperative complications on multivariate analysis (odds ratio, 1.060; P = .044; 95% confidence interval, 1.002-1.121). Conclusions Increasing patient age, private practice, ambulatory surgery center setting, and surgeon experience are associated with a shorter operative duration for ACLR. Although an increasing number of arthroscopic knee procedures performed by surgeons correlated with fewer complications, only increasing patient BMI significantly predicted odds of complications. Level of Evidence Level IV, prognostic case series.
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Anis HK, Rothfusz CA, Eskildsen SM, Klika AK, Piuzzi NS, Higuera CA, Molloy RM. Does Surgical Trainee Participation Affect Infection Outcomes in Primary Total Knee Arthroplasty? JOURNAL OF SURGICAL EDUCATION 2022; 79:993-999. [PMID: 35300952 DOI: 10.1016/j.jsurg.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/10/2021] [Accepted: 02/06/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate whether the involvement of surgeons-in-training was associated with increased infection rates, including both prosthetic joint infection (PJI) and surgical site infection (SSI), following primary total knee arthroplasty (TKA). DESIGN This was a retrospective review of outcomes following primary total knee arthroplasty. Surgeries were divided into two groups: (a) attending-only and (b) trainee-involved. Association with PJI and SSI were evaluated with univariate analysis and multivariate analysis to adjust for sex, age, body mass index (BMI), Charlson Comorbidity Index (CCI), year of surgery, operative time, and hospital/surgeon volume. SETTING A single, large North-American integrated healthcare system between January 1, 2014 and December 31, 2017. PARTICIPANTS A total of 12,664 primary TKAs with a minimum of one-year (mean of 2-years, range 1-4.5) follow-up were evaluated. RESULTS Residents and fellows were more likely to participate in cases with longer operative times (p<0.001) than the attending-only group. A significant difference existed on univariate analysis between the trainee-involved group and attending-only group for PJI incidence (p=0.015) but not for SSI (p=0.840). After adjusting for patient- and procedure-related features, however, neither PJI nor SSI were independently associated with trainee involvement (PJI: p=0.089; SSI: p=0.998). CONCLUSIONS Trainee participation did not directly correlate with increased infection risk, despite their association with longer-operative times and increased medical complexity. Further approaches to mitigating the risk of SSI and PJI for patients with increased comorbidities and in complex TKA cases, which demand longer operative times, are still required.
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Affiliation(s)
- Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, Ohio
| | - Christopher A Rothfusz
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, Ohio
| | | | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, Ohio.
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation Florida, Weston Hospital, Weston, Florida
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, Ohio
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The impact of surgical trainee involvement in total hip arthroplasty: a systematic review of surgical efficacy, patient safety, and outcomes. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1365-1409. [PMID: 35662374 DOI: 10.1007/s00590-022-03290-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/05/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Concerns persist that trainee participation in surgical procedures may compromise patient care and potentiate adverse events and costs. We aimed to analyse the potential impact and consequences of surgical trainee involvement in total hip arthroplasty (THA) procedures in terms of surgical efficacy, patient safety, and functional outcomes. METHODS We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in October 2021. Eligible studies reported a direct comparison between THA cases performed with and without trainee involvement. RESULTS Eighteen publications met our eligibility criteria and were included in our study. The included studies reported on 142,450 THAs completed on 142,417 patients. Specifically, 48,155 and 94,295 surgeries were completed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 5,662) and without (n = 14,763) trainee involvement were 106.20 and 91.41 min, respectively. Mean overall complication rates were 6.43% and 5.93% for THAs performed with (n = 4842) and without (n = 12,731) trainees. Lastly, the mean Harris Hip Scores (HHS) for THAs performed with (n = 442) and without (n = 750) trainee participation were 89.61 and 86.97, respectively. CONCLUSION Our systematic review confirmed previous studies' reports of increased operative time for THA cases with trainee involvement. However, based on the overall similar complication rates and functional hip scores obtained, patients should be reassured concerning the relative safety of trainee involvement in THA. Future prospective studies with higher levels of evidence are still needed to reinforce the existing evidence.
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Simmonds A, Otoya D, Lavingia KS, Amendola MF. Assessing Resident Impact on Surgical Outcomes in Below-the-Knee Amputations Based on Operative Autonomy. Ann Vasc Surg 2022; 87:57-63. [PMID: 35472501 DOI: 10.1016/j.avsg.2022.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/14/2022] [Accepted: 04/18/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Gradual increases in resident autonomy with attending physician oversight is crucial to developing safe and competent surgeons1. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) follows surgical outcomes within the VA. We set forth to examine the VASQIP database to compare outcomes between resident independent cases and nonindependent cases during below-the-knee amputations (BKA). METHODS All VASQIP records for BKA from 2000 to 2020 were examined and categorized based on whether the attending was scrubbed during the case. Case matching was performed based on preoperative comorbidities; 30-day postoperative outcomes, including a return to the operating room, wound infection, and mortality, were assessed in addition to operative time, hospital length of stay, and transfusion requirements. Student's t-test and Fisher's Exact Test were utilized. RESULTS A total of 13,208 BKA VASQIP records were obtained. After case control matching, 2,688 cases remained. Cases were identified with the attending surgeon noted as being scrubbed during the case (n = 1,344), or not scrubbed (n = 1,344). Patients were similar in comorbidities across both groups. No statistically significant difference in operative time (1.52 hr ± 0.78 vs. 1.47 hr ± 0.75, P = 0.08), 30-day mortality (3.3% vs. 4.8%, P = 0.05), or complication rate (19.5% vs. 21.3%, P = 0.25). Resident independent cases were noted to have slightly longer postop length of stay (12.47 days ± 12.69 vs. 15.33 days ± 20.56, P < 0.01) and operative bleeding requiring more than 4 units transfused (0.3% vs. 1.3%, P ≤ 0.01). CONCLUSIONS Resident independent operating during below-the-knee amputation at VA hospitals is associated with an increased length of stay and blood transfusion. There was no statistically significant increase in operative time, 30-day mortality, or total complication rate. Further research is required to assess the risks associated with surgical training, resident supervision, and resident preparedness for independent practice.
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Affiliation(s)
- Alexander Simmonds
- Division of Vascular Surgery, Central Virginia Veterans Administration Health System, Richmond, VA
| | - Diana Otoya
- Division of Vascular Surgery, Central Virginia Veterans Administration Health System, Richmond, VA
| | - Kedar S Lavingia
- Division of Vascular Surgery, Central Virginia Veterans Administration Health System, Richmond, VA.
| | - Michael F Amendola
- Division of Vascular Surgery, Central Virginia Veterans Administration Health System, Richmond, VA
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Meyer MA, Tarabochia MA, Goh BC, Hietbrink F, Houwert RM, Dyer GSM. The Impact of Resident Involvement on Outcomes and Costs in Elective Hand and Upper Extremity Surgery. J Hand Surg Am 2022:S0363-5023(22)00121-6. [PMID: 35461739 DOI: 10.1016/j.jhsa.2022.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/15/2021] [Accepted: 02/02/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to assess the impact of resident involvement on periprocedural outcomes and costs after common procedures performed at an academic hand surgical practice. METHODS A retrospective review was performed in all patients undergoing 7 common elective upper extremity procedures between January 2008 and December 2018: carpal tunnel release, distal radius open reduction and internal fixation (ORIF), trigger finger release, thumb carpometacarpal arthroplasty, phalanx closed reduction and percutaneous pinning, cubital tunnel release, and olecranon ORIF. The medical record was reviewed to determine the impact of surgical assistants (resident, fellow, or physician assistant) on periprocedural outcomes, periprocedural costs, and 1-year postoperative outcomes. The involvement of surgical trainees operating under direct supervision was compared with the entire operation performed by the attending surgeon with a physician assistant present. RESULTS A total of 396 procedures met the inclusion criteria. Analysis of the whole study sample revealed low rates of intraoperative complications, wound complications, medical complications, readmissions, and mortality. Subgroup analysis of carpal tunnel releases revealed significantly greater tourniquet times for residents compared with physician assistants (7 ± 2 min, 6 ± 1 min), as well as longer overall operating room times for residents compared to fellows or physician assistants (17 ± 5 min, 13 ± 3 min, 12 ± 3 min). Operating room times for distal radius ORIF were significantly greater among residents compared to fellows or physician assistants (68 ± 19 min, 57 ± 17 min, 56 ± 14 min). There were no differences in any other perioperative metrics or periprocedural costs for the trigger finger release or cubital tunnel release cohorts. CONCLUSIONS Resident involvement in select upper extremity procedures can lengthen operative times but does not have an impact on blood loss or operating room costs. CLINICAL RELEVANCE Surgeons should be aware that having a resident assistant slightly increases operative times in elective hand surgery.
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Affiliation(s)
- Maximilian A Meyer
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | | | - Brian C Goh
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R Marijn Houwert
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - George S M Dyer
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
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Maheshwari AV, Garnett CT, Cheng TH, Buksbaum JR, Singh V, Shah NV. Does Resident Participation Influence Surgical Time and Clinical Outcomes? An Analysis on Primary Bilateral Single-Staged Sequential Total Knee Arthroplasty. Arthroplast Today 2022; 15:202-209.e4. [PMID: 35774880 PMCID: PMC9237261 DOI: 10.1016/j.artd.2022.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 02/08/2022] [Accepted: 02/26/2022] [Indexed: 12/01/2022] Open
Abstract
Background Although several studies have indirectly compared teaching and nonteaching hospitals, results are conflicting, and evaluation of the direct impact of trainee involvement is lacking. We investigated the direct impact of resident participation in primary total knee arthroplasties (TKAs). Material and methods Fifty patients undergoing single-staged sequential bilateral primary TKAs were evaluated. The more symptomatic side was performed by the attending surgeon first, followed by the contralateral side performed by a chief resident under direct supervision and assistance of the same attending surgeon. Surgery was subdivided into 8 critical steps on both sides. The overall time and critical stepwise surgical time and short-term clinical outcomes were then compared between the 2 sides. Results The attending surgeon completed the surgery (skin incision to dressing) significantly faster than the resident (70.2 vs 96.9 minutes) by a mean of 26.7 minutes (P < .05) and was also faster in all steps. The most significant differences in time were in “exposure” (9.5 vs 16.5 minutes) and “closure” steps (13.2 vs 24.9 minites), all P < .001. Adverse events occurred in 7 patients; 5 of these resolved uneventfully. There were no significant differences in surgical complications, objective outcome scores, or patient satisfaction scores between both sides. Conclusion Resident participation in TKA increased operative time without jeopardizing short-term patient clinical outcomes, satisfaction, and complications. This may alleviate concerns from patients and policymakers about TKA in an academic setting. Surgical “exposure” and “closure” were the most prolonged steps for the residents, and they may benefit with more focus and/or simulation studies during training.
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Bron DM, Wolterbeek N, Poolman RW, Kempen DHR, Delawi D. Resident training does not influence the complication risk in total knee and hip arthroplasty. Acta Orthop 2021; 92:689-694. [PMID: 34605337 PMCID: PMC8635675 DOI: 10.1080/17453674.2021.1979296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Gaining experience in the surgery room during residency is an important part of learning the skills needed to perform arthroplasties. However, in practice, patients are often not fully comfortable with trainee involvement in their own surgery. Therefore, we investigated complications, revision rates, mortality, and operative time of orthopedic surgeons and residents as primary surgeon performing total knee arthroplasties (TKAs) or total hip arthroplasties (THAs).Patients and methods - In this multi-center retrospective cohort study, 3,098 TKAs and 4,027 THAs performed between 2007 and 2013 were analyzed. Complications, revisions, mortality, and operative time were compared for patients operated on by the orthopedic surgeon or a resident as primary surgeon. An additional analysis was performed to determine whether the complication risk was affected by the postgraduate year of the resident.Results - Orthopedic complication rates were similar (TKA: orthopedic surgeon: 10%, resident: 11%; THA: 9% and 8%), revision rates (TKA: 3% and 2%, THA: 3% and 2%), or mortality rates (TKA: 0.1% and 0.3%, THA: 0.2% and 0.3%). For both procedures a higher non-orthopedic complication rate was found in the resident group (TKA: 8% and 10%; p = 0.03, THA: 8% and 10%; p = 0.01) and a slightly longer operative time (TKA: mean difference 9.0 minutes (8%); THA: 11.3 minutes (11%)).Interpretation - Complications, revisions, and mortality were similar in TKAs or THAs performed by the resident as primary surgeon compared with surgeries performed by an orthopedic surgeon. This data can be used in teaching hospitals and may help to reassure patients.
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Affiliation(s)
- Daphne M Bron
- Department of Orthopedic Surgery, St. Antonius Hospital, Nieuwegein;
| | - Nienke Wolterbeek
- Department of Orthopedic Surgery, St. Antonius Hospital, Nieuwegein;;,Correspondence:
| | - Rudolf W Poolman
- Department of Orthopedic Surgery, JointResearch OLVG, Amsterdam;;,Department of Orthopedic Surgery, LUMC, Leiden, The Netherlands
| | | | - Diyar Delawi
- Department of Orthopedic Surgery, St. Antonius Hospital, Nieuwegein;
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Kelly MA, Vukanic D, McAnena P, Quinlan JF. The opportunity cost of arthroplasty training in orthopaedic surgery. Surgeon 2021; 20:297-300. [PMID: 34801411 DOI: 10.1016/j.surge.2021.09.008] [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: 05/08/2021] [Revised: 08/23/2021] [Accepted: 09/30/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Training the next generation of surgeons is a crucial role fulfilled by consultant orthopaedic surgeons. However we are increasingly constrained by limited time and resources. We sought to compare operative time and length of stay (LOS) for total hip and total knee arthroplasties (THA, TKA) performed by a consultant orthopaedic surgeon with those performed by supervised trainees. MATERIALS AND METHODS A prospective database of arthroplasty procedures performed from 2015 to 2018 was collated. Primary surgeon grade was recorded. Patient demographics, ASA grade, LOS and operative time were recorded. For THA both cemented and uncemented arthroplasties were used. SPSS version 23 was used for statistical analysis. RESULTS 394 arthroplasty procedures were carried out during the study period. Trainee surgeons performed a high proportion of both THA (53.2%, n = 123) and TKA (44.8%, n = 73) surgeries. Trainees performed 57% of cemented THA procedures. LOS did not differ between consultant and trainee surgeons for THA (5.9 ± 4.8 days) or TKA (5.6 ± 4.1 days). Age had a significant effect on LOS (p < 0.001). For THA the mean operative time for trainees was 90.3 ± 19.23 min, 18.2 min longer than the consultant group. For TKA the mean operative time was 89.06 ± 18.87 min for trainees, 24.4 min longer than the consultant group. DISCUSSION At our institution trainee surgeons can be expected to take between 18 and 24 min longer to perform arthroplasty procedures. This should be factored into resource planning, as the training of orthopaedic surgeons is crucial to sustaining and improving health service provision.
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Affiliation(s)
- M A Kelly
- Specialist Registrar in Trauma & Orthopaedic Surgery, Tallaght University Hospital, Dublin, Ireland.
| | - D Vukanic
- Specialist Registrar in Trauma & Orthopaedic Surgery, Tallaght University Hospital, Dublin, Ireland.
| | - P McAnena
- Surgical Registrar & Clinical Researcher, Lambe Institute for Translational Research, University Hospital Galway, Ireland.
| | - J F Quinlan
- Consultant Trauma and Orthopaedic Surgeon, Tallaght University Hospital, Dublin, Ireland.
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Fowler TJ, Aquilina AL, Blom AW, Sayers A, Whitehouse MR. Association between surgeon grade and implant survival following hip and knee replacement: a systematic review and meta-analysis. BMJ Open 2021; 11:e047882. [PMID: 34758989 PMCID: PMC8587578 DOI: 10.1136/bmjopen-2020-047882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To investigate the association between surgeon grade (trainee vs consultant) and implant survival following primary hip and knee replacement. DESIGN A systematic review and meta-analysis of observational studies. DATA SOURCES MEDLINE and Embase from inception to 6 October 2021. SETTING Units performing primary hip and/or knee replacements since 1990. PARTICIPANTS Adult patients undergoing either a primary hip or knee replacement, predominantly for osteoarthritis. INTERVENTION Whether the surgeon recorded as performing the procedure was a trainee or not. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was net implant survival reported as a Kaplan-Meier survival estimate. The secondary outcome was crude revision rate. Both outcomes were reported according to surgeon grade. RESULTS Nine cohort studies capturing 4066 total hip replacements (THRs), 936 total knee replacements (TKRs) and 1357 unicompartmental knee replacements (UKRs) were included (5 THR studies, 2 TKR studies and 2 UKR studies). The pooled net implant survival estimates for THRs at 5 years were 97.9% (95% CI 96.6% to 99.2%) for trainees and 98.1% (95% CI 97.1% to 99.2%) for consultants. The relative risk of revision of THRs at 5 and 10 years was 0.88 (95% CI 0.46 to 1.70) and 0.68 (95% CI 0.37 to 1.26), respectively. For TKRs, the net implant survival estimates at 10 years were 96.2% (95% CI 94.0% to 98.4%) for trainees and 95.1% (95% CI 93.0% to 97.2%) for consultants. We report a narrative summary of UKR outcomes. CONCLUSIONS There is no strong evidence in the existing literature that trainee surgeons have worse outcomes compared with consultants, in terms of the net survival or crude revision rate of hip and knee replacements at 5-10 years follow-up. These findings are limited by the quality of the existing published data and are applicable to countries with established orthopaedic training programmes. PROSPERO REGISTRATION NUMBER CRD42019150494.
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Affiliation(s)
- Timothy J Fowler
- Musculoskeletal Research Unit, Learning and Research Building, Southmead Hospital, University of Bristol Medical School, Bristol, UK
| | - Alex L Aquilina
- Musculoskeletal Research Unit, Learning and Research Building, Southmead Hospital, University of Bristol Medical School, Bristol, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Learning and Research Building, Southmead Hospital, University of Bristol Medical School, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust, University of Bristol, National Institute for Health Research, Bristol, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, Learning and Research Building, Southmead Hospital, University of Bristol Medical School, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Learning and Research Building, Southmead Hospital, University of Bristol Medical School, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust, University of Bristol, National Institute for Health Research, Bristol, UK
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Dickinson KJ, Bass BL, Graviss EA, Nguyen DT, Pei KY. Independent Operating by General Surgery Residents: An ACS-NSQIP Analysis. JOURNAL OF SURGICAL EDUCATION 2021; 78:2001-2010. [PMID: 33879397 DOI: 10.1016/j.jsurg.2021.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/15/2021] [Accepted: 03/21/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Surgical resident autonomy during training is paramount to independent practice. We sought to determine prevalence of general surgery resident autonomy for surgeries commonly performed on emergency general surgery services and identify trends with time. DESIGN We queried ACS-NSQIP for patients undergoing one of 7 emergency general surgery operations. We evaluated trends in independent operating (defined as a resident operating alone, without attending having scrubbed) over the study period. Other outcomes of interest: operative time, 30-day-mortality and complications. SETTING The ACS-NSQIP database. PARTICIPANTS Patients undergoing one of 7 emergency general surgery operations. RESULTS Data regarding resident involvement was only available for the years 2005-2010. 90,790 operations were performed, 922 (1%) by residents operating independently. Appendectomy accounted for 61% independent cases. Independent resident operating was associated with a longer operative time (65 versus 58 minutes, p < 0.001), but lower risk of bleeding requiring transfusion (p < 0.001) and progressive renal insufficiency (p = 0.02). Independent operating was not associated with increased risk of complications/mortality. CONCLUSION Independent resident operating is rare, even with increasing attention to its importance, and is not associated with increased complications or mortality. National data on this subject is old and not currently collected. There is need for a national registry on resident involvement to understand the current effect of independent operating on outcomes.
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Affiliation(s)
- Karen J Dickinson
- Department of Surgery, Houston Methodist Hospital, Houston, Texas; Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | - Barbara L Bass
- George Washington University School of Medicine and Health Services, Washington DC
| | - Edward A Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, Texas; Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, Texas
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, Texas
| | - Kevin Y Pei
- Department of Graduate Medical Education, Parkview Health, Fort Wayne, Indiana
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Resident Involvement in Hip Arthroscopy Procedures Does Not Affect Short-Term Surgical Outcomes. Arthrosc Sports Med Rehabil 2021; 3:e1367-e1376. [PMID: 34712975 PMCID: PMC8527250 DOI: 10.1016/j.asmr.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/23/2021] [Indexed: 12/21/2022] Open
Abstract
Purpose To evaluate whether the presence of residents in hip arthroscopy (HA) procedures affects short-term surgical outcomes. Methods The 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. Results A 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. Conclusion Resident 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.
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Traven SA, McGurk KM, Althoff AD, Walton ZJ, Leddy LR, Potter BK, Slone HS. Resident Level Involvement Affects Operative Time and Surgical Complications in Lower Extremity Fracture Care. JOURNAL OF SURGICAL EDUCATION 2021; 78:1755-1761. [PMID: 33903063 DOI: 10.1016/j.jsurg.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 01/01/2021] [Accepted: 03/13/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The purpose of this study is to evaluate the effect of resident participation on operative time and surgical complications in isolated lower extremity fracture care. SETTING Patients who were treated at teaching hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database. PARTICIPANTS A total of 2,488 patients who underwent surgical fixation of isolated hip fractures, femoral or tibial shaft fractures, and ankle fractures. DESIGN Patients were stratified by surgical procedure and post-graduate year (PGY) of the resident involved. Total operative time and surgical complications were analyzed with respect to resident participation and seniority. Multivariable logistic regression analyses were used to adjust for potential confounders including case complexity, wound class, and patient comorbidity burden. RESULTS As PGY level increased, operative time increased for each procedure. The odds for a deep surgical site infection decreased as resident seniority increased, but the odds for wound dehiscence increased as resident seniority increased. We found no difference in the incidences of superficial infections or return to the OR with respect to PGY level. Academic quarter within the academic year did not correlate with any of the surgical complications. Furthermore, when cases performed with residents were compared to those performed without residents, there was no increased risk of superficial infections, deep infections, or return to the OR. CONCLUSIONS This nationally representative dataset demonstrates that operative times for lower extremity orthopedic trauma increased as resident seniority increased. Additionally, senior resident participation was associated with increased wound dehiscence, whereas junior resident participation was associated with an increased risk of deep surgical site infections. However, there was no associated "July effect" for residents at any level of training and there was no increased risk for surgical site infections or return to the OR in cases involving resident participation.
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Affiliation(s)
- Sophia A Traven
- Medical University of South Carolina, Charleston, South Carolina.
| | - Kathy M McGurk
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Zeke J Walton
- Medical University of South Carolina, Charleston, South Carolina
| | - Lee R Leddy
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Harris S Slone
- Medical University of South Carolina, Charleston, South Carolina
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26
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Kagan R, Hart C, Hiratzka SL, Mirarchi AJ, Mirza AJ, Friess DM. Does Resident Participation in the Surgical Fixation of Hip Fractures Increase Operative Time or Affect Outcomes? JOURNAL OF SURGICAL EDUCATION 2021; 78:1269-1274. [PMID: 33281076 DOI: 10.1016/j.jsurg.2020.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/20/2020] [Accepted: 11/20/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Surgical fixation of hip fractures is a common procedure at teaching hospitals with resident support and in community hospitals. OBJECTIVE We evaluated to what extent participation by residents in hip fracture fixation affects operative times or outcomes. SETTING Operations were performed by three surgeons who operate at a teaching hospital with resident support, and at a community hospital without residents in the same metropolitan area. PARTICIPANTS We performed a retrospective analysis of operative time and early post-operative outcomes on a series of 314 patients with hip fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association A1-3, B1-3) treated with surgical fixation between April 2012 and March 2015; 177 patients at the community hospital, and 137 at the teaching hospital. METHODS Multivariate regression assessed the effect of hospital type, adjusting for age, gender, American Society of Anesthesiologist classification, and Charlson comorbidity index. RESULTS We found lower median operative time at the community hospital than the teaching hospital (46 minutes, 95% confidence interval [CI] = [43, 52] versus 75 minutes, 95% CI = [70, 81]) and lower estimated blood loss (177.3 mL, 95% CI=[158.6, 195.1] versus 234.8 mL, 95% CI = [196.4, 273.6]), but no differences in transfusion requirement, length of stay, or discharge to skilled nursing facility. Adjusted odds ratio for thirty-day mortality at the teaching hospital was 5.44 (95% CI = [1.22, 24.1]). CONCLUSION We found longer operative times and elevated estimated blood loss with resident involvement in surgical fixation of hip fractures. There was a difference in 30-day mortality between the groups, although this cannot simply be attributed to resident involvement as there are many other factors related to mortality.
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Affiliation(s)
- Ryland Kagan
- Oregon Health and Science University, Department of Orthopaedics and Rehabilitation, Portland, Oregon.
| | - Christopher Hart
- University of California Los Angeles, Department of Orthopaedic Surgery, Los Angeles, California
| | - Shannon L Hiratzka
- Oregon Health and Science University, Department of Orthopaedics and Rehabilitation, Portland, Oregon
| | - Adam J Mirarchi
- Oregon Health and Science University, Department of Orthopaedics and Rehabilitation, Portland, Oregon
| | | | - Darin M Friess
- Oregon Health and Science University, Department of Orthopaedics and Rehabilitation, Portland, Oregon
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27
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Madanipour S, Singh P, Karia M, Bhamra JS, Abdul-Jabar HB. Trainee performed total knee arthroplasty is safe and effective: A systematic review and meta-analysis comparing outcomes between trainees and consultants. Knee 2021; 30:291-304. [PMID: 33984748 DOI: 10.1016/j.knee.2021.04.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 03/04/2021] [Accepted: 04/09/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND There are concerns that trainee performed knee arthroplasty (KA) may adversely affect patient outcomes. Demand for KA is projected to increase, and trainees must therefore be competent to perform it. METHODS A systematic literature search was performed identifying articles comparing outcomes following trainee versus consultant surgeon performed primary KA. Outcomes included rate of revision surgery, rate of infection, operation time, length of stay and functional outcomes. A meta-analysis was conducted using Odds ratios (ORs) and weighted mean differences (WMD). A quality assessment of studies and qualitative analysis was performed. RESULTS The analysis included 9 studies of 92,309 arthroplasties, 80,655 were performed by consultants, 11,654 by trainees. The mean age was 69.2. There was no significant difference between the two groups' rate of revision (OR 0.79; 95% CI 0.61-1.02; p = 0.07. Trainees were associated with a lower rate of infection (5 studies; OR 0.75; 95% CI 0.58-0.97; p = 0.03). There was no difference in the rate of neurological deficit, transfusion rate or thrombosis. There was no difference in operation time (5 studies; WMD 3.50; 95% CI -3.9-10.89; p = 0.35). The trainee group had less favourable functional outcome scores (7 studies; WMD -1.26; 95% CI -1.44--1.07; p < 0.01). However, this difference was not clinically significant. CONCLUSIONS The study suggests that supervised trainees can achieve similar outcomes to consultant surgeons andin selected cases, trainee performed supervised KA is therefore safe and effective.
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Affiliation(s)
- Suroosh Madanipour
- Department of Trauma and Orthopaedic Surgery, Barnet Hospital, Royal Free London NHS Trust, United Kingdom.
| | - Prashant Singh
- Department of Trauma and Orthopaedic Surgery, Imperial College Healthcare NHS Trust, United Kingdom
| | - Monil Karia
- Department of Trauma and Orthopaedic Surgery, Imperial College Healthcare NHS Trust, United Kingdom
| | - Jagmeet Singh Bhamra
- Department of Trauma and Orthopaedic Surgery, Imperial College Healthcare NHS Trust, United Kingdom
| | - Hani B Abdul-Jabar
- Department of Trauma and Orthopaedic Surgery, London North West University Healthcare NHS Trust, United Kingdom
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Lebedeva K, Bryant D, Docter S, Litchfield RB, Getgood A, Degen RM. The Impact of Resident Involvement on Surgical Outcomes following Anterior Cruciate Ligament Reconstruction. J Knee Surg 2021; 34:287-292. [PMID: 31461757 DOI: 10.1055/s-0039-1695705] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hands-on participation in the operating room (OR) is an integral component of surgical resident training. However, the implications of resident involvement in many orthopaedic procedures are not well defined. This study aims to assess the effect of resident involvement on short-term outcomes following anterior cruciate ligament reconstruction (ACLR). The National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who underwent ACLR from 2005 to 2012. Demographic variables, resident participation, 30-day complications, and intraoperative time parameters were assessed for all cases. Resident and nonresident cases were matched using propensity scores. Outcomes were analyzed using univariate and multivariate regression analyses, as well as stratified by resident level of training. Univariate analysis of 1,222 resident and 1,188 nonresident cases demonstrated no difference in acute postoperative complication rates between groups. There was no significant difference in the incidence of overall complications based on resident level of training (p = 0.109). Operative time was significantly longer for cases in which a resident was involved (109.5 vs. 101.7 minutes; p < 0.001). Multivariate analysis identified no significant predictors of major postoperative complications, while patient history of chronic obstructive pulmonary disease was the only independent risk factor associated with minor complications. Resident involvement in ACLR was not associated with 30-day complications despite a slight increase in operative time. These findings provide reassurance that resident involvement in ACLR procedures is safe, although future investigations should focus on long-term postoperative outcomes.
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Affiliation(s)
- Kate Lebedeva
- Department of Orthopedic Surgery, School of Physical Therapy, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Dianne Bryant
- Department of Orthopedic Surgery, School of Physical Therapy, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Shgufta Docter
- Department of Orthopedic Surgery, School of Physical Therapy, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Robert B Litchfield
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Ryan M Degen
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
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Impact of microsurgery skill acquisition on free flap ischaemia time and free flap outcomes. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01782-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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30
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Hoerlesberger N, Glehr M, Amerstorfer F, Hauer G, Leithner A, Sadoghi P. Residents' Learning Curve of Total Knee Arthroplasty Based on Radiological Outcome Parameters: A Retrospective Comparative Study. J Arthroplasty 2021; 36:154-159. [PMID: 32839061 DOI: 10.1016/j.arth.2020.07.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/21/2020] [Accepted: 07/17/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study aimed to plot the impact of a learning curve for a resident's first 103 total knee arthroplasties (TKAs) based on radiological deviations and incision to closure time (ICT), and to compare it to 103 matched TKAs performed by a senior surgeon. METHODS This is a retrospective comparative study comprising a total of 206 TKAs and evaluated the results based on radiographic outcome and ICT. Radiological evaluation was performed according to a predefined implemented radiological grading system (RGS). t-Tests compared ICT and RGS; data of mechanical axis were observed with Man-Whitey U-tests and Wilcoxon signed-rank-tests. RESULTS The study included 206 patients (mean age 73 years, mean body mass index of 30). Determining all the deviation points (DP) with the RGS, the deviation ratio for resident vs senior surgeon was 0.96:0.5 DP (P = .0002). The learning curve based on DP showed a decrease over time with statistical significance in the first (26 DP, P = .0001), second (21 DP, P = .0059), and fourth (20 DP, P = .0187) quintiles of implanted cases. The ICT of the resident showed a decrease within the quintiles from 79.45 minutes (first quintile) to 65.17 minutes (fifth quintile), for an improvement of 14.28 minutes. When the quintiles are viewed in relation to the mean operation time of the senior surgeon (mean ICT 66.04 minutes), the mean values of the first and the second quintiles remain statistically significant. CONCLUSION Supervised TKA showed statistical significance in the learning curves according to deviations documented with a predefined radiological outcome assessment system as well as to ICTs. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Nina Hoerlesberger
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Mathias Glehr
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Florian Amerstorfer
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Georg Hauer
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Patrick Sadoghi
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
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Basques BA, Saltzman BM, Korber SS, Bolia IK, Mayer EN, Bach BR, Verma NN, Cole BJ, Weber AE. Resident Involvement in Arthroscopic Knee Surgery Is Not Associated With Increased Short-term Risk to Patients. Orthop J Sports Med 2020; 8:2325967120967460. [PMID: 33403211 PMCID: PMC7747120 DOI: 10.1177/2325967120967460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/24/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Whether resident involvement in surgical procedures affects intra- and/or postoperative outcomes is controversial. Purpose/Hypothesis: The purpose of this study was to compare operative time, adverse events, and readmission rate for arthroscopic knee surgery cases with and without resident involvement. We hypothesized that resident involvement would not negatively affect these variables. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of the prospectively maintained National Surgical Quality Improvement Program was performed. Patients who underwent arthroscopic knee surgery between 2005 and 2012 were identified. Multivariate Poisson regression with robust error variance was used to compare the rates of postoperative adverse events and readmission within 30 days between cases with and without resident involvement. Multivariate linear regression was used to compare operative time between cohorts. Because of multiple statistical comparisons, a Bonferroni correction was used, and statistical significance was set at P < .004. Results: A total of 29,539 patients who underwent arthroscopic knee surgery were included in the study, and 11.3% of these patients had a resident involved with the case. The overall rate of adverse events was 1.62%. On multivariate analysis, resident involvement was not associated with increased rates of adverse events or readmission. Resident cases had a mean 6-minute increase in operative time (P < .001). Conclusion: Overall, resident involvement in arthroscopic knee surgery was not associated with an increased risk of adverse events or readmission. Resident involvement was associated with only a mean increased operative time of 6 minutes, a difference that is not likely to be clinically significant. These results support the safety of resident involvement with arthroscopic knee surgery.
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Affiliation(s)
| | - Bryan M. Saltzman
- OrthoCarolina Sports Medicine Center, Charlotte, North Carolina, USA
| | - Shane S. Korber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Ioanna K. Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Erik N. Mayer
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | | | | | - Brian J. Cole
- Midwest Orthopaedics at Rush, Chicago, Illinois, USA
| | - Alexander E. Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
- Alexander E. Weber, MD, USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, 1520 San Pablo Street #2000, Los Angeles, CA 90033, USA ()
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Rockov ZA, Etzioni DA, Schwartz AJ. The July Effect for Total Joint Arthroplasty Procedures. Orthopedics 2020; 43:e543-e548. [PMID: 32818288 DOI: 10.3928/01477447-20200812-08] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/24/2019] [Indexed: 02/03/2023]
Abstract
The "July effect" refers to the assumed increased risk of complications during the months when medical school graduates transition to residency programs. The actual existence of a July effect is controversial. With this study, the authors sought to determine whether evidence exists for the presence of a July effect among total joint arthroplasty (TJA) procedures. The 2013 and 2014 Nationwide Readmission Databases were combined and all index primary and revision arthroplasty procedures were identified, and then patients from December were excluded. Thirty-day readmission rates, time to readmission, and readmission costs were analyzed by index procedure month and index procedure type. A total of 1,193,034 procedures (index primary: n=1,107,657; revision arthroplasty: n=85,377) were identified. Among all procedure types, 46,674 (3.9%) 30-day readmissions were observed. Among all procedures, an index procedure with a discharge in July resulted in the highest monthly readmission rate of the year (4.2%), which was significantly higher than the mean annual readmission rate (P<.0001). This effect was most pronounced for primary total knee arthroplasty (3.9% vs 3.6%, P<.0001). When stratifying results into teaching vs nonteaching hospitals, the highest readmission rate occurred if the index procedure occurred at a nonteaching hospital in July (4.5%, P<.0001). These data provide evidence that a July effect appears to exist for TJA procedures and is most pronounced at nonteaching institutions. Based on published mean readmission costs, the total annualized cost variation attributable to the higher readmission rate for primary TJA procedures in July is approximately $18.6 million. [Orthopedics. 2020;43(6):e543-e548.].
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Pirruccio K, Mehta S, Sheth NP. The Association Between Newly Accredited Orthopedic Residency Programs and Teaching Hospital Complication Rates in Lower Extremity Total Joint Arthroplasty. JOURNAL OF SURGICAL EDUCATION 2020; 77:690-697. [PMID: 31786199 DOI: 10.1016/j.jsurg.2019.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 10/01/2019] [Accepted: 11/10/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The influence of residency programs on teaching hospital outcomes in total joint arthroplasty (TJA) has recently been debated. This study investigates how complication and readmission rates for primary elective total hip (THA) and total knee arthroplasty (TKA) changed before and after new orthopedic surgery residency programs meeting ACGME accreditation requirements were introduced at hospitals. DESIGN We conducted a retrospective cohort study using the CMS Hospital Compare database, which contains hospital-level data on risk-standardized complication and readmission rates (2013-2018) for primary elective THA and TKA in Medicare beneficiaries. Orthopedic surgery residency programs that were newly accredited during this time were identified using ACGME publicly available data. SETTING Eight primary adult teaching hospitals with complication and readmission data in the CMS database available prior to the first full year its affiliated residency program was implemented, and with subsequent program data also available. PARTICIPANTS Six ACGME accredited orthopedic surgery residency programs. RESULTS Even after controlling for annual variation in surrounding hospital rates, the at-risk patient volume, and variation in starting rates for a given hospital in the first available year, multivariate linear regression demonstrated that complication rates for lower extremity TJA in Medicare beneficiaries decreased by 0.20 per year (R2 = 0.78, p = 0.005) after hospitals introduced new orthopedic surgery residency programs meeting ACGME accreditation requirements. There were no significant differences in readmission rates after the addition of newly accredited programs to these same hospitals (R2 = 0.51; p = 0.706). CONCLUSIONS Starting an orthopedic surgery residency program meeting ACGME accreditation requirements was associated with significantly reduced complication rates for primary elective lower extremity TJA in Medicare beneficiaries at teaching hospitals where these programs began rotating residents. These findings raise awareness regarding the potential for residency programs to contribute to improved patient care outside of the operating room as well as through direct resident involvement in procedures.
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Affiliation(s)
- Kevin Pirruccio
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Samir Mehta
- Division of Orthopaedic Trauma and Fracture Care, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil P Sheth
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Phan K, Phan P, Stratton A, Kingwell S, Hoda M, Wai E. Impact of resident involvement on cervical and lumbar spine surgery outcomes. Spine J 2019; 19:1905-1910. [PMID: 31323330 DOI: 10.1016/j.spinee.2019.07.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Resident involvement in the operating room is a vital component of their medical education. Conflicting and limited research exists regarding the effects of surgical resident participation on spine surgery patient outcomes. PURPOSE To determine the effect of resident involvement on surgery duration, length of hospital stay and 30-day postoperative complication rates in common spinal surgery using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database. STUDY DESIGN Multicenter retrospective cohort study. PATIENT SAMPLE A total of 1,441 patients met the inclusion criteria: 1,142 patients had surgeries with an attending physician alone and 299 patients had surgeries with trainee involvement. All anterior cervical or posterior lumbar surgery patients were identified. Patients who had missing trainee involvement information, surgery for cancer, preoperative infection or dirty wound classification, spine fractures, traumatic spinal cord injury, intradural surgery, thoracic surgery, and emergency surgery were excluded. OUTCOME MEASURES The main outcomes of interest analyzed from the ACS-NSQIP database included surgical complications, medical complications, length of hospital stay, and surgery duration. METHODS Propensity score for risk of any complication was calculated to account for baseline characteristic differences between the attending alone and trainee present group. Multivariate logistic regression was used to investigate the impact of resident involvement on surgery duration, length of hospital stay, and 30-day postoperative complication rates. RESULTS After adjusting using the calculated propensity score, the multivariate analysis demonstrated that there was no significant difference in any complication rates between surgeries involving trainees compared to surgeries with attending surgeons alone. Surgery times were found to be significantly longer for surgeries involving trainees. To further explore this relationship, separate analyses were performed for tertiles of predicted surgery duration, cervical or lumbar surgery, fusion or nonfusion, and inpatient or outpatient surgery. The effect of trainee involvement on increasing surgery time remained significant for medium predicted surgery duration, longer predicted surgery duration, cervical surgery, lumbar surgery, fusion surgery, and inpatient surgery. There were no significant differences reported for any other factors. CONCLUSIONS After adjusting for confounding, we demonstrated in a national database that resident involvement in surgeries did not increase complication rates. We demonstrated that surgeries with more complex features may lead to an increase in operative time when trainees are involved. Further study is required to determine how to efficiently integrate resident involvement in surgeries without affecting their medical education.
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Affiliation(s)
- Kim Phan
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Philippe Phan
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alexandra Stratton
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stephen Kingwell
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Mohamad Hoda
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Eugene Wai
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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The impact of anesthesia and surgical provider characteristics on outcomes after spine surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2112-2121. [PMID: 31267212 DOI: 10.1007/s00586-019-06055-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 06/19/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Information regarding the impact of provider characteristics on perioperative outcomes in the spine surgery setting is limited. Existing studies primarily consider the impact of surgical provider volume. This analysis sought to identify the impact of anesthesiologist and surgeon volume and experience as well as anesthesia care team composition on adverse outcomes following anterior cervical discectomy and fusions (ACDF) and posterior lumbar fusions (PLF). METHODS We identified 5900 patients who underwent ACDF or PLF procedures at a high-volume orthopedic institution from 2005 to 2014. Provider characteristics of interest were anesthesiologist and surgeon volume and experience along with anesthesia care team composition. Multivariable logistic regression models were used to evaluate the outcomes of any complication, cardiopulmonary complication, and prolonged length of stay (> 7 days). Intraclass correlation coefficients were calculated to determine how much variation in outcomes could be explained by provider characteristics. RESULTS There were no significant relationships between provider characteristics and perioperative outcomes among ACDF patients. Within the PLF cohort, surgeon annual case volume > 25 was associated with decreased odds of prolonged length of stay, while anesthesia resident involvement was associated with increased odds of prolonged length of stay. Surgeon characteristics explained the greatest proportion of variation in outcomes while anesthesiologist characteristics explained the least. CONCLUSIONS Anesthesia provider volume and experience did not significantly impact the odds of adverse outcome for ACDF and PLF patients. Higher surgeon volume was exclusively associated with decreased odds of prolonged length of stay following PLF. Further study is necessary to determine if these relationships persist in a less-specialized setting. These slides can be retrieved under Electronic Supplementary Material.
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Giordano L, Oliviero A, Peretti GM, Maffulli N. The presence of residents during orthopedic operation exerts no negative influence on outcome. Br Med Bull 2019; 130:65-80. [PMID: 31049559 DOI: 10.1093/bmb/ldz009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 02/05/2019] [Accepted: 03/26/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Operative procedural training is a key component of orthopedic surgery residency. It is unclear how and whether residents participation in orthopedic surgical procedures impacts on post-operative outcomes. SOURCES OF DATA A systematic search was performed to identify articles in which the presence of a resident in the operating room was certified, and was compared with interventions without the presence of residents. AREAS OF AGREEMENT There is a likely beneficial role of residents in the operating room, and there is only a weak association between the presence of a resident and a worse outcome for orthopedic surgical patients. AREAS OF CONTROVERSY Most of the studies were undertaken in USA, and this represents a limit from the point of view of comparison with other academic and clinical realities. GROWING POINT The data provide support for continued and perhaps increased involvement of resident in orthopedic surgery. AREAS OF RESEARCH To clarify the role of residents on clinically relevant outcomes in orthopedic patients, appropriately powered randomized control trials should be planned.
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Affiliation(s)
- Lorenzo Giordano
- Department of Musculoskeletal Disorder, Faculty of Medicine and Surgery, University of Salerno, Salerno Italy
| | - Antonio Oliviero
- Department of Musculoskeletal Disorder, Faculty of Medicine and Surgery, University of Salerno, Salerno Italy
| | | | - Nicola Maffulli
- Department of Musculoskeletal Disorder, Faculty of Medicine and Surgery, University of Salerno, Salerno Italy.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK.,Institute of Science and Technology in Medicine, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, UK
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Ourian AJ, Doval AF, Zavlin D, Chegireddy V, Echo A. Evaluating Patient Outcomes in Breast and Abdominal Cosmetic Plastic Surgery Procedures Involving Residents. Aesthet Surg J 2019; 39:572-578. [PMID: 30561504 DOI: 10.1093/asj/sjy329] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hands-on training and exposure to cosmetic surgery is an integral part of plastic surgery residency. However, resident participation in cosmetic surgical cases is often limited in many training programs. Furthermore, the effect of resident participation in cosmetic surgery is poorly defined. OBJECTIVES The aim of this study was to analyze the impact of resident involvement on outcomes in cosmetic plastic surgery procedures, with a focus on breast and abdominal surgeries. METHODS A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed to identify all patients undergoing cosmetic breast and abdominal surgical procedures by plastic surgeons over a 4-year period (2009-2012). Multivariate regression models were constructed to determine any association between resident participation and surgical outcomes. RESULTS A total of 6982 patients were included in the analysis. Cases with resident involvement had higher rates of superficial surgical site infection (P < 0.0001), wound dehiscence (P = 0.014), and an increase in mean length of hospital stay (P = 0.001). Multivariate analysis revealed that the increased rate of superficial surgical site infection was associated with a higher body mass index and with the involvement of a resident during the surgical procedure. CONCLUSIONS This study provides further evidence to support the claim that resident involvement in cosmetic surgery is safe, with little effect on the rates of major complications. Any increase in minor complication rates must be critically analyzed with respect to the valuable surgical experience gathered by the next generation of surgeons. LEVEL OF EVIDENCE: 2
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Affiliation(s)
- Ariel J Ourian
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX
| | - Andres F Doval
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX
| | - Dmitry Zavlin
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX
| | - Vishwanath Chegireddy
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX
| | - Anthony Echo
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX
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Malyar M, Peymani A, Johnson AR, Chen AD, Van Der Hulst RRWJ, Lin SJ. The Impact of Resident Postgraduate Year Involvement in Body-Contouring and Breast Reduction Procedures. Ann Plast Surg 2019; 82:310-315. [DOI: 10.1097/sap.0000000000001714] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Singh P, Madanipour S, Fontalis A, Bhamra JS, Abdul-Jabar HB. A systematic review and meta-analysis of trainee- versus consultant surgeon-performed elective total hip arthroplasty. EFORT Open Rev 2019; 4:44-55. [PMID: 30931148 PMCID: PMC6404792 DOI: 10.1302/2058-5241.4.180034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Total hip arthroplasty (THA) is one of the most commonly performed orthopaedic procedures. Some concern exists that trainee-performed THA may adversely affect patient outcomes. The aim of this meta-analysis was to compare outcomes following THA performed by surgical trainees and consultant surgeons. A systematic search was performed to identify articles comparing outcomes following trainee- versus consultant-performed THA. Outcomes assessed included rate of revision surgery, dislocation, deep infection, mean operation time, length of hospital stay and Harris Hip Score (HHS) up to one year. A meta-analysis was conducted using odds ratios (ORs) and weighted mean differences (WMDs). A subgroup analysis for supervised trainees versus consultants was also performed. The final analysis included seven non-randomized studies of 40 810 THAs, of which 6393 (15.7%) were performed by trainees and 34 417 (84.3%) were performed by consultants. In total, 5651 (88.4%) THAs in the trainee group were performed under supervision. There was no significant difference in revision rate between the trainee and consultant groups (OR 1.09; p = 0.51). Trainees took significantly longer to perform THA compared with consultants (WMD 12.9; p < 0.01). The trainee group was associated with a lower HHS at one year compared with consultants (WMD -1.26; p < 0.01). There was no difference in rate of dislocation, deep infection or length of hospital stay between the two groups. The present study suggests that supervised trainees can achieve similar clinical outcomes to consultant surgeons, with a slightly longer operation time. In selected patients, trainee-performed THA is safe and effective.
Cite this article: EFORT Open Rev 2019;4:44-55. DOI: 10.1302/2058-5241.4.180034.
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Effect of Resident and Fellow Involvement in Adult Spinal Deformity Surgery. World Neurosurg 2019; 122:e759-e764. [DOI: 10.1016/j.wneu.2018.10.135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/18/2018] [Accepted: 10/20/2018] [Indexed: 11/18/2022]
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Surgical training in spine surgery: safety and patient-rated outcome. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:807-816. [DOI: 10.1007/s00586-019-05883-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
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Basques BA, Saltzman BM, Mayer EN, Bach BR, Romeo AA, Verma NN, Cole BJ, Weber AE. Resident Involvement in Shoulder Arthroscopy Is Not Associated With Short-term Risk to Patients. Orthop J Sports Med 2018; 6:2325967118816293. [PMID: 30622998 PMCID: PMC6302272 DOI: 10.1177/2325967118816293] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Shoulder arthroscopy is a commonly performed, critical component of orthopaedic residency training. However, it is unclear whether there are additional risks to patients in cases associated with resident involvement. Purpose To compare shoulder arthroscopy cases with and without resident involvement via a large, prospectively maintained national surgical registry to characterize perioperative risks. Study Design Cohort study; Level of evidence, 3. Methods The prospectively maintained American College of Surgeons National Surgical Quality Improvement Program registry was queried to identify patients who underwent 1 of 12 shoulder arthroscopy procedures from 2005 through 2012. Multivariate Poisson regression with robust error variance was used to compare the rates of postoperative adverse events and readmission within 30 days between cases with and without resident involvement. Multivariate linear regression was used to compare operative time between cohorts. Results A total of 15,774 patients with shoulder arthroscopy were included in the study, and 12.3% of these had a resident involved with the case. The overall rate of adverse events was 1.09%. On multivariate analysis, resident involvement was not associated with increased rates of any aggregate or individual adverse event. There was also no association between resident involvement and risk of readmission within 30 days. Resident involvement was not associated with any difference in operative time (P = .219). Conclusion Resident involvement in shoulder arthroscopy was not associated with increased risk of adverse events, increased operative time, or readmission within 30 days. The results of this study suggest that resident involvement in shoulder arthroscopy cases is a safe method for trainees to learn these procedures.
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Affiliation(s)
- Bryce A Basques
- Midwestern Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Bryan M Saltzman
- Midwestern Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Erik N Mayer
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, USA
| | - Bernard R Bach
- Midwestern Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Anthony A Romeo
- Midwestern Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Nikhil N Verma
- Midwestern Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian J Cole
- Midwestern Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Alexander E Weber
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, USA
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Casp AJ, Patterson BM, Yarboro SR, Tennant JN. The Effect of Time During the Academic Year or Resident Training Level on Complication Rates After Lower-Extremity Orthopaedic Trauma Procedures. J Bone Joint Surg Am 2018; 100:1919-1925. [PMID: 30480596 DOI: 10.2106/jbjs.18.00279] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Few studies have evaluated the effect of resident participation on morbidity and mortality after orthopaedic trauma surgery. The goal of this study was to evaluate whether complications after orthopaedic trauma procedures involving residents correlate with the level of resident training and the timing in the academic year. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent operative fixation of proximal femoral fractures, femoral shaft fractures, and tibial shaft fractures from 2005 to 2012. A total of 1,851 cases with resident involvement were identified, and complication rates were calculated and analyzed with respect to resident level of training (postgraduate year [PGY] 1 through 6) and the academic quarter in which the procedure took place. RESULTS The composite complication rates in the first academic quarter for serious adverse events (10.96%), any adverse events (18.57%), and surgical complications (9.62%) did not significantly differ from those during the remainder of the year (11.40%, 17.81%, and 7.19%, respectively). The rates of any adverse event were significantly higher for senior-level residents (quarter 1, 20.58%; quarter 2, 20.05%) than for junior residents (quarter 1, 11.76%; quarter 2, 12.44%) during the first half of the academic year (quarter 1, p = 0.044; quarter 2, p = 0.024). CONCLUSIONS This evaluation of the composite complication rates found no "July effect" in lower-extremity orthopaedic trauma surgery. There was evidence for a July effect for superficial surgical site infections, in that there was a significantly higher rate in the first academic quarter. Senior residents may benefit from more oversight or instruction during the first portion of the academic year.
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Affiliation(s)
- Aaron J Casp
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Seth R Yarboro
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Josh N Tennant
- Department of Orthopaedics, University of North Carolina, Chapel Hill, North Carolina
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Wojcik BM, Lee JM, Peponis T, Amari N, Mendoza AE, Rosenthal MG, Saillant NN, Fagenholz PJ, King DR, Phitayakorn R, Velmahos G, Kaafarani HM. Do Not Blame the Resident: the Impact of Surgeon and Surgical Trainee Experience on the Occurrence of Intraoperative Adverse Events (iAEs) in Abdominal Surgery. JOURNAL OF SURGICAL EDUCATION 2018; 75:e156-e167. [PMID: 30195664 DOI: 10.1016/j.jsurg.2018.07.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/10/2018] [Accepted: 07/25/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Intraoperative adverse events (iAEs) are defined as inadvertent injuries that occur during an operation and are associated with increased mortality, morbidity, and health care costs. We sought to study the impact of attending surgeon experience as well as resident training level on the occurrence of iAEs. DESIGN The institutional American College of Surgeons-National Surgical Quality Improvement Program and administrative databases for abdominal surgeries were linked and screened for iAEs using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "accidental puncture/laceration." Each flagged record was systematically reviewed to confirm iAE occurrence and determine the number of years of independent practice of the attending surgeon and the postgraduate year (PGY) of the assisting resident at the time of the operation. The attending surgeon experience was divided into quartiles (<6 years, 6-13 years, 13-20 years, >20 years). The resident experience level was defined as Junior (PGY-1 to PGY-3) or Senior (PGY-4 or PGY-5). Univariate/bivariate then multivariable logistic regression analyses adjusting for patient demographics, comorbidities, and operation type and/or complexity (using RVUs as a proxy) were performed to assess the independent impact of resident and attending surgeon experience on the occurrence of iAEs. SETTING A large tertiary care teaching hospital. PARTICIPANTS Patients included in the 2007-2012 ACS-NSQIP that had an abdominal surgery performed by both an attending surgeon and a resident. RESULTS A total of 7685 operations were included and iAEs were detected in 159 of them (2.1%). Junior residents participated in 1680 cases (21.9%), while senior residents were involved in 6005 (78.1%). The iAE rates for attending surgeons with <6, 6-13, 13-20, and >20 years of experience were 2.7%, 1.7%, 2.4%, and 1.4%, respectively. In multivariable analyses, the risk of occurrence of an iAE was significantly decreased for surgeons with >20 years of experience compared to those with <6 years of experience (odds ratio=0.52, 95% confidence interval 0.32-0.86, p = 0.011). On bivariate analyses, iAEs occurred in 1.2% of junior resident cases, while senior residents had an iAE rate of 2.3%. However, after risk adjustment on multivariable analyses, the resident experience level did not significantly impact the rate of iAEs. CONCLUSIONS The surgeon's level of experience, but not the resident's, is associated with the occurrence of iAEs in abdominal surgery. Efforts to improve patient safety in surgery should explore the value of pairing junior surgeons with the more experienced ones thru formalized coaching programs, rather than focus on curbing resident operative autonomy.
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Affiliation(s)
- Brandon M Wojcik
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jae Moo Lee
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas Peponis
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Noor Amari
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - April E Mendoza
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Martin G Rosenthal
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Noelle N Saillant
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter J Fagenholz
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David R King
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Roy Phitayakorn
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - George Velmahos
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Radomski SB, Ruzhynsky V, Wallis CJ, Herschorn S. Complications and Interventions in Patients with an Artificial Urinary Sphincter: Long-Term Results. J Urol 2018; 200:1093-1098. [DOI: 10.1016/j.juro.2018.05.143] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Sidney B. Radomski
- Division of Urology and University of Toronto Research Program in Functional Urology, University of Toronto, Toronto, Ontario, Canada
| | - Vladimir Ruzhynsky
- Division of Urology and University of Toronto Research Program in Functional Urology, University of Toronto, Toronto, Ontario, Canada
| | - Christopher J.D. Wallis
- Division of Urology and University of Toronto Research Program in Functional Urology, University of Toronto, Toronto, Ontario, Canada
| | - Sender Herschorn
- Division of Urology and University of Toronto Research Program in Functional Urology, University of Toronto, Toronto, Ontario, Canada
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Rajakumar C, Mallick R, Posner G, Schramm D, Singh SS, Lortie K, Pascali D, Chen I. Effect of Surgical Trainee Presence on Vaginal Hysterectomy Outcomes. J Minim Invasive Gynecol 2018; 25:1088-1093. [PMID: 29496583 DOI: 10.1016/j.jmig.2018.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/13/2018] [Accepted: 02/17/2018] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVE Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications. DESIGN Retrospective, multicenter, cohort study (Canadian Task Force classification II-2). SETTING Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites. PATIENTS Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012. INTERVENTION ACS-NSQIP database. MEASUREMENTS AND MAIN RESULTS Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p < .001), urinary tract infection (5.27% vs 2.64%, p < .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p < .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality. CONCLUSION Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.
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Affiliation(s)
- Chandrew Rajakumar
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | | | - Glenn Posner
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - David Schramm
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Otolaryngology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sukhbir S Singh
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Karine Lortie
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Dante Pascali
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Innie Chen
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada.
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Aisen CM, James M, Chung DE. The Impact of Teaching on Fundamental General Urologic Procedures: Do Residents Help or Hurt? Urology 2018; 121:44-50. [PMID: 30092301 DOI: 10.1016/j.urology.2018.05.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/06/2018] [Accepted: 05/29/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To examine the effects of trainee involvement on fundamental urology procedures. METHODS Current Procedural Terminology codes were used to identify patients within the National Surgical Quality Improvement Program database who underwent a selection of fundamental general urology procedures (2005-2013). Operative time and perioperative complications (30-day) were compared between cases with and without trainee involvement. RESULTS 29,488 patients had general urology procedures with information regarding trainee involvement, 13,251 (44.9%) with trainee involvement, and 16,237 (55.1%) without. Overall patients who underwent procedures with trainee involvement were younger and had fewer comorbidities (Table 1). Trainee involvement showed significant increase in operative time in all procedures included in the study (Table 2). On multivariate analysis trainee involvement increased the risk of complications (Odds Ratio (OR) 1.61, 95% CI 1.45-1.78, P < .001). Other factors that increased the risk of complications were: American Society of Anesthesiologists (ASA) class 3-4 (OR 2.01, 95% CI 1.46-2.77, P < .001), partially or totally dependent functional status (OR 2.22, 95% CI 1.68-2.94, P < .001), diabetes mellitus (OR 1.21, 95% CI 1.05-1.39, P = .008), heart disease (OR 1.19, 95% CI 1.02-1.38, P = .027), and respiratory disease (OR 1.33, 95% CI 1.09-1.63, P = .027). CONCLUSION While trainees are valuable members of the urology team at teaching hospitals and training is necessary, their involvement in urologic surgery appears to increase operative time for all procedures and complications in certain procedures. Further research needs to be done on how to mitigate these effects while preserving surgical education quality.
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Affiliation(s)
- Carrie M Aisen
- Department of Urology, Columbia University, New York, NY.
| | - Maxwell James
- Department of Urology, Columbia University, New York, NY
| | - Doreen E Chung
- Department of Urology, Columbia University, New York, NY
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Balancing training and outcomes in total knee replacement: A ten-year review. Surgeon 2018; 16:227-231. [DOI: 10.1016/j.surge.2017.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/17/2017] [Accepted: 10/26/2017] [Indexed: 11/21/2022]
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Bao MH, Keeney BJ, Moschetti WE, Paddock NG, Jevsevar DS. Resident Participation is Not Associated With Worse Outcomes After TKA. Clin Orthop Relat Res 2018; 476:1375-1390. [PMID: 29480888 PMCID: PMC6437564 DOI: 10.1007/s11999.0000000000000002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/05/2017] [Accepted: 11/03/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Approximately one-half of all US surgical procedures, and one-third of orthopaedic procedures, are performed at teaching hospitals. However, the effect of resident participation and their level of training on patient care for TKA postoperative physical function, operative time, length of stay, and facility discharge are unclear. QUESTIONS/PURPOSES (1) Are resident participation, postgraduate year (PGY) training level, and number of residents associated with absolute postoperative Patient-Reported Outcomes Measurement Information System (PROMIS®-10) global physical function score (PCS), and achieving minimum clinically important difference (MCID) PCS improvement, after TKA? (2) Are resident participation, PGY, and number of residents associated with increased TKA operative time? (3) Are resident participation, PGY, and number of residents associated with increased length of stay after TKA? (4) Are resident participation, PGY, and number of residents associated with higher odds of patients being discharged to another inpatient facility, rather than to their home (facility discharge)? METHODS We performed a retrospective study using a longitudinally maintained institutional registry of TKAs that included 1626 patients at a single tertiary academic institution from April 2011 through July 2016. All patients who underwent primary, elective unilateral TKA were included with no exclusions. All patients were included in the operative time, length of stay, and facility discharge models. The PCS model required postoperative PCS score (n = 1417; 87%; mean, 46.4; SD, 8.5) and the MCID PCS model required pre- and postoperative PCS (n = 1333; 82%; 55% achieved MCID). Resident participation was defined as named residents being present in the operating room and documented in the operative notes, and resident PGY level was determined by the date of TKA and its duration since the resident entered the program and using the standard resident academic calendar (July - June). Multivariable regression was used to assess PCS scores, operative time, length of stay, and facility discharge in patients whose surgery was performed with and without intraoperative resident participation, accounting for PGY training level and number of residents. We defined the MCID PCS score improvement as 5 points on a 100-point scale. Adjusting variables included surgeon, academic year, age, sex, race-ethnicity, Charlson Comorbidity Index, preoperative PCS, and patient-reported mental function, BMI, tobacco use, alcohol use, and postoperative PCS time for the PCS models. We had postoperative PCS for 1417 (87%) surgeries. RESULTS Compared with attending-only TKAs (5% of procedures), no postgraduate year or number of residents was associated with either postoperative PCS or MCID PCS improvement (PCS: PGY-1 = -0.98, 95% CI, -6.14 to 4.17, p = 0.708; PGY-2 = -0.26, 95% CI, -2.01to 1.49, p = 0.768; PGY-3 = -0.32, 95% CI, -2.16 to 1.51, p = 0.730; PGY-4 = -0.28, 95% CI, -1.99 to 1.43, p = 0.746; PGY-5 = -0.47, 95% CI, -2.13 to 1.18, p = 0.575; two residents = 0.28, 95% CI, -1.05 to 1.62, p = 0.677) (MCID PCS: PGY-1 = odds ratio [OR], 0.30, 95% CI, 0.07-1.30, p = 0.108; PGY-2 = OR, 0.86, 95% CI, 0.46-1.62, p = 0.641; PGY-3 = OR, 0.97, 95% CI, 0.49-1.89, p = 0.921; PGY-4 = OR, 0.73, 95% CI, 0.39-1.36, p = 0.325; PGY-5 = OR, 0.71, 95% CI, 0.39-1.29, p = 0.259; two residents = OR, 1.23, 95% CI, 0.80-1.89, p = 0.337). Longer operative times were associated with all PGY levels except for PGY-5 (attending surgeon only [reference] = 85.60 minutes, SD, 14.5 minutes; PGY-1 = 100. 13 minutes, SD, 21.22 minutes, +8.44 minutes, p = 0.015; PGY-2 = 103.40 minutes, SD, 23.01 minutes, +11.63 minutes, p < 0.001; PGY-3 = 97.82 minutes, SD, 18.24 minutes, +9.68 minutes, p < 0.001; PGY-4 = 96.39 minutes, SD, 18.94 minutes, +4.19 minutes, p = 0.011; PGY-5 = 88.91 minutes, SD, 19.81 minutes, -0.29 minutes, p = 0.853) or the presence of multiple residents (+4.39 minutes, p = 0.024). There were no associations with length of stay (PGY-1 = +0.04 days, 95% CI, -0.63 to 0.71 days, p = 0.912; PGY-2 = -0.08 days, 95% CI, -0.48 to 0.33 days, p = 0.711; PGY-3 = -0.29 days, 95% CI, -0.66 to 0.09 days, p = 0.131; PGY-4 = -0.30 days, 95% CI, -0.69 to 0.08 days, p = 0.120; PGY-5 = -0.28 days, 95% CI, -0.66 to 0.10 days, p = 0.145; two residents = -0.12 days, 95% CI, -0.29 to 0.06 days, p = 0.196) or facility discharge (PGY-1 = OR, 1.03, 95% CI, 0.26-4.08, p = 0.970; PGY-2 = OR, 0.61, 95% CI, 0.31-1.20, p = 0.154; PGY-3 = OR, 0.98, 95% CI, 0.48-2.02, p = 0.964; PGY-4 = OR, 0.83, 95% CI, 0.43-1.57, p = 0.599; PGY-5 = OR, 0.7, 95% CI, 0.41-1.40, p = 0.372; two residents = OR, 0.93, 95% CI, 0.56-1.54, p = 0.766) for any PGY or number of residents. CONCLUSIONS Our findings should help assure patients, residents, physicians, insurers, and hospital administrators that resident participation, after adjusting for numerous patient and clinical factors, does not have any association with key medical and financial metrics, including postoperative PCS, MCID PCS, length of stay, and facility discharge. Future research in this field should focus on whether residents affect knee-specific patient-reported outcomes such as the Knee Injury and Osteoarthritis Score and additional orthopaedic procedures, and determine how resident medical education can be further enhanced without compromising patient care and safety.Level of Evidence Level III, therapeutic study.
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Affiliation(s)
- Mike H Bao
- M. H. Bao, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA B. J. Keeney, W. E. Moschetti, N. G. Paddock, D. S. Jevsevar, Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA B. J. Keeney, W. E. Moschetti, D. S. Jevsevar, Department of Orthopaedics, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA B. J. Keeney, Berkley Medical Management Solutions, a W.R. Berkley Company, Overland Park, KS, USA
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Weber M, Worlicek M, Voellner F, Woerner M, Benditz A, Weber D, Grifka J, Renkawitz T. Surgical training does not affect operative time and outcome in total knee arthroplasty. PLoS One 2018; 13:e0197850. [PMID: 29856769 PMCID: PMC5983555 DOI: 10.1371/journal.pone.0197850] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 05/09/2018] [Indexed: 12/19/2022] Open
Abstract
Training the next generation of orthopaedic surgeons in total knee arthroplasty (TKA) is crucial, but might affect operative time and outcome. We hypothesized that the learning curve of residents in TKA has an impact on (1) operative time, (2) complication rates and (3) early postoperative outcome. In a retrospective analysis of 738 primary TKAs from our institutional joint registry, operative time, complication rates, patient-reported outcome measures (EQ-5D, WOMAC) within the first year and responder rates for positive outcome as defined by the OMERACT-OARSI criteria were compared between trainee and senior surgeons differentiating between conventional and navigated TKA. Mean operative time was 69.5±18.5min for trainees compared to 77.3±25.8min for senior surgeons (95%CI of the difference 1.5-13.9min, p = 0.02) in conventional TKA and 80.4±22.1min to 84.1±27.6min (95%CI of the difference -0.9-8.2min, p = 0.12) for navigated TKA, respectively. Intraoperative fracture (p≥0.36), thrombosis (p≥0.90), neurological deficits (p≥0.90) and infection rates (p≥0.28) were comparably low in both groups. Patient-reported outcome measures one year after TKA were similar for trainee and senior surgeons with EQ-5D 0.83±0.17 to 0.80±0.21 (p = 0.25) and WOMAC 74.85±18.60 to 72.77±20.12 (p = 0.44) for conventional TKA and EQ-5D 0.80±0.20 to 0.82±0.18 (p = 0.23) and WOMAC 72.71±18.52 to 75.77±17.78 (p = 0.07) for navigated TKA, respectively. Similarly, responder rates for positive outcome were comparable between trainees and senior surgeons (90.7% versus 87.0% p = 0.39 for conventional TKA, 88.7% versus 89.4% p = 0.80 for navigated TKA). Supervised TKA is a safe procedure during the learning curve of young orthopaedic surgeons.
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Affiliation(s)
- Markus Weber
- Department of Orthopaedic Surgery, Regensburg University, Medical Center, Bad Abbach, Germany
- * E-mail:
| | - Michael Worlicek
- Department of Orthopaedic Surgery, Regensburg University, Medical Center, Bad Abbach, Germany
| | - Florian Voellner
- Department of Orthopaedic Surgery, Regensburg University, Medical Center, Bad Abbach, Germany
| | - Michael Woerner
- Department of Orthopaedic Surgery, Regensburg University, Medical Center, Bad Abbach, Germany
| | - Achim Benditz
- Department of Orthopaedic Surgery, Regensburg University, Medical Center, Bad Abbach, Germany
| | - Daniela Weber
- Department of Hematology and Oncology, Regensburg University, Medical Center, Regensburg, Germany
| | - Joachim Grifka
- Department of Orthopaedic Surgery, Regensburg University, Medical Center, Bad Abbach, Germany
| | - Tobias Renkawitz
- Department of Orthopaedic Surgery, Regensburg University, Medical Center, Bad Abbach, Germany
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