Does overlapping surgery result in worse surgical outcomes? A systematic review and meta-analysis

Critical Portions of a Foot or Ankle Surgical Procedure From Patient and Surgeon Perspectives

BACKGROUND

Over the past decade, overlapping procedures in orthopaedic surgery have come under increased public scrutiny. Central to this discussion is what should constitute a "critical portion" of any surgical procedure-a definition which may differ between patients and surgeons. This study therefore aimed to assess which components of three common foot and ankle procedures are considered "critical" from both the patient and surgeon perspectives.

METHODS

For this survey-based study, questionnaires were administered to patients who presented to an orthopaedic foot and ankle clinic and separately administered to foot and ankle surgeons through e-mail. The questionnaires broached all steps involved in three common foot and ankle procedures: open reduction and internal fixation of ankle fracture, Achilles tendon repair, and ankle arthroscopy. Respondents were asked to characterize each step as "always critical," "often critical," sometimes critical," rarely critical," or "never critical." A combined "always critical" and "often critical" response rate of greater than 50% was used to define a step as genuinely critical. Patient and surgeon responses were thereafter compared using Mann-Whitney U and Kruskal-Wallis tests ( P -value <0.05 was considered significant).

RESULTS

Notably, both patients and surgeons considered informed consent, preoperative marking of the surgical site, preoperative time-out, surgical soft-tissue dissection, and certain procedure-specific steps (critical portions) of these procedures. By contrast, only patients considered skin incision and wound closure to be critical steps.

CONCLUSION

Patients and surgeons were largely in agreement as to what should comprise the critical portions of several common foot and ankle procedures. Certain discrepancies did exist, however, such as skin incision and closure, and both groups were also in general agreement regarding what was not considered a critical component of these operations. Such findings highlight a potential opportunity for improved preoperative patient education and patient-physician communication.

LEVEL OF EVIDENCE

Level IV: Evidence from well-designed case-control or cohort studies.

Impact of the Percentage of Overlapping Surgery on Patient Outcomes: A Retrospective Cohort Study of 87,000 Surgical Cases

OBJECTIVES

The primary objective of this study was to analyze the relationship of percentage of surgical overlap with patient outcomes to determine if a detrimental level of overlap exists.

BACKGROUND

Overlapping surgery is defined as 1 attending physician supervising 2 or more operative cases simultaneously, without the critical portions of the cases occurring concurrently. To date, no study has examined the relationship of percent overlap, or the percentage of 1 case that is spent overlapping with another, to outcomes, efficiency, safety, and complications.

METHODS

This study is a retrospective cohort study conducted at a large tertiary referral center. The primary outcomes of interest included operative duration, in-hospital mortality, 30-day readmission, and patient safety indicators (PSIs). The Cochran-Armitage test for trend was used to evaluate the outcomes of interest. P values of ≤0.05 were considered statistically significant.

RESULTS

A total of 87,426 cases were included in this study. There were 62,332 cases without overlap (Group 0), 10,514 cases with 1% to 25% overlap (Group 1), 5303 cases with 26% to 50% overlap (Group 2), 4296 cases with 51% to 75% overlap (Group 3), and 4981 cases with >75% overlap (Group 4). In-hospital mortality decreased as overlap increased ( Ptrend <0.0001). Operative time increased with increasing overlap ( Ptrend <0.0001) while readmission rates showed no statistical significance between groups ( Ptrend =0.5078). Rates of PSIs were lower for Groups 1, 2, and 3 (1.69%, 2.01%, and 2.08%) when compared to Group 0 (2.24%). Group 4 had the highest rate of PSIs at 2.35% ( P =0.0086).

CONCLUSION

Overlapping surgery was shown to have reduced in-hospital mortality and similar PSI and readmission rates when compared to nonoverlapping cases. Operative time was shown to increase in overlapping surgeries when compared to nonoverlapping surgeries. The results from this study indicate that the percentage of surgical overlap does not detrimentally affect most patient outcomes, especially with overlap of <75%.

Association of Anesthesiologist Staffing Ratio With Surgical Patient Morbidity and Mortality

Importance

Recent studies have investigated the effect of overlapping surgeon responsibilities or nurse to patient staffing ratios on patient outcomes, but the association of overlapping anesthesiologist responsibilities with patient outcomes remains unexplored to our knowledge.

Objective

To examine the association between different levels of anesthesiologist staffing ratios and surgical patient morbidity and mortality.

Design, Setting, and Participants

A retrospective, matched cohort study consisting of major noncardiac inpatient surgical procedures performed from January 1, 2010, to October 31, 2017, was conducted in 23 US academic and private hospitals. A total of 866 453 adult patients (aged ≥18 years) undergoing major inpatient surgery within the Multicenter Perioperative Outcomes Group electronic health record registry were included. Anesthesiologist sign-in and sign-out times were used to calculate a continuous time-weighted average staffing ratio variable for each operation. Propensity score-matching methods were applied to create balanced sample groups with respect to patient-, operative-, and hospital-level confounders and resulted in 4 groups based on anesthesiologist staffing ratio. Groups consisted of patients receiving care from an anesthesiologist covering 1 operation (group 1), more than 1 to no more than 2 overlapping operations (group 1-2), more than 2 to no more than 3 overlapping operations (group 2-3), and more than 3 to no more than 4 overlapping operations (group 3-4). Data analysis was performed from October 2019 to October 2021.

Exposure

Undergoing a major inpatient surgical operation that involved an anesthesiologist providing care for up to 4 overlapping operations.

Main Outcomes and Measures

The primary composite outcome was 30-day mortality and 6 major surgical morbidities (cardiac, respiratory, gastrointestinal, urinary, bleeding, and infectious complications) derived from International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision discharge diagnosis codes.

Results

In all, 578 815 adult patients (mean [SD] age, 55.7 [16.2] years; 55.1% female) were analyzed. After matching operations according to anesthesiologist staffing ratio, 48 555 patients were in group 1; 247 057, group 1-2; 216 193, group 2-3; and 67 010, group 3-4. Increasing anesthesiologist coverage responsibilities was associated with an increase in risk-adjusted surgical patient morbidity and mortality. Compared with patients in group 1-2, those in group 2-3 had a 4% relative increase in risk-adjusted mortality and morbidity (5.06% vs 5.25%; adjusted odds ratio [AOR], 1.04; 95% CI, 1.01-1.08; P = .02) and those in group 3-4 had a 14% increase in risk-adjusted mortality and morbidity (5.06% vs 5.75%; AOR, 1.15; 95% CI, 1.09-1.21; P < .001).

Conclusions and Relevance

This study's findings suggest that increasing overlapping coverage by anesthesiologists is associated with increased surgical patient morbidity and mortality. Therefore, the potential effects of staffing ratios in perioperative team models should be considered in clinical coverage efforts.

Overlapping surgery in arthroplasty - a systematic review and meta-analysis

BACKGROUND

Planned overlapping surgery can improve efficiency, reduce costs and help manage long waiting lists; yet, this practice has been questioned due to patient safety concerns. A systematic review and meta-analysis were performed to answer the question: (1) are there any differences in the risk of postoperative adverse outcomes; and (2) are there any differences in length of stay or length of surgery, in elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed either as non-overlapping surgery (NOS) or overlapping surgery (OS).

PATIENTS AND METHODS

A systematic search of literature in the databases of MEDLINE, PubMed, Embase and Cochrane from dates of inception was performed. All studies published in English were included. Risk of Bias in Non-randomised Studies-of Interventions (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05.

RESULTS

A total of nine studies with 120,625 patients were included for analyses. There were no statistically significant differences for overall rates of postoperative complications, dislocations, fractures, infections, readmissions or revision surgery nor with length of stay or length of surgery (p>0.05). Patient characteristics between groups were similar (p>0.05).

DISCUSSION

There were no differences in postoperative adverse outcomes for elective orthopaedic THA and TKA performed as NOS when compared to OS. Operating schedules for OS in elective lower limb arthroplasty appear to be safe, given appropriate patient selection processes and may be a useful method to improve hospital efficiency. Informed consent and preoperative patient education should remain paramount.

LEVEL OF EVIDENCE

IV.

Surgeon Perspectives on Benefits and Downsides of Overlapping Surgery: In-depth, Qualitative Interviews

OBJECTIVE

The aim of the study was to characterize surgeon perspectives regarding the benefits and downsides of conducting overlapping surgery.

BACKGROUND

Although surgeons are key stakeholders in current discussions surrounding overlapping surgery, little has been published regarding their opinions on the practice. Further characterization of surgeon perspectives is needed to guide future studies and policy development regarding overlapping surgery.

METHODS

Study information was sent to all members of 3 professional surgical societies. Interested individuals were eligible to participate if they identified as attending surgeons in an academic setting who work with trainees. Purposive selection was used to diversify surgeons interviewed across multiple dimensions, including subspecialty and opinion regarding appropriateness of overlapping surgery. In-depth, qualitative interviews were conducted with participants regarding their opinions on overlapping surgery.

RESULTS

The 51 surgeons interviewed identified a wide array of potential benefits and disadvantages of overlapping surgery, some of which have not previously been measured, including downsides to surgeon wellness and patient experience, less surgeon control over procedures, and difficulty in scheduling cases. Interviewees often disagreed as to whether overlapping surgery negatively or positively affects each dimension discussed, particularly regarding the impact on resident training.

CONCLUSIONS

The utilization of the novel perspectives presented here will allow for targeted assessment of physician perspectives in future quantitative studies and increase the likelihood that variables measured encompass the range of factors that surgeons find meaningful and relevant. Priority areas of future research should include examining effects of overlapping surgery on surgical training and surgeon wellness.