Does a "July Effect" Exist for Fellowship Training in Total Hip and Knee Arthroplasty?

The impact of an anesthesia residency teaching service on anesthesia-controlled time and postsurgical patient outcomes: a retrospective observational study on 15,084 surgical cases

BACKGROUND

Limited data exists regarding the impact of anesthesia residents on operating room efficiency and patient safety outcomes. This investigation hypothesized that supervised anesthesiology residents do not increase anesthesia-controlled or prolonged extubation times compared to supervised certified registered nurse anesthetists (CRNA)/certified anesthesiologist assistants (CAA) or anesthesiologists working independently. Secondary objectives included differences in critical outcomes such as intraoperative hypotension, cardiac and pulmonary complications, acute kidney injury, and mortality.

METHODS

This retrospective single-center 24-month (January 1, 2020- December 31, 2021) cohort focused on primary outcomes of anesthesia-controlled times and prolonged extubation (>15 min) with additional assessment of secondary patient outcomes in adult patients having general anesthesia with an endotracheal tube or laryngeal mask airway for elective non-cardiac surgery. The study excluded sedation, obstetric, endoscopic, ophthalmology, and non-operating room procedures. Procedures were divided into three groups: anesthesiologists working solo, anesthesiologists supervising residents, or anesthesiologists supervising CRNA/CAAs. After univariate analysis, multivariable models were constructed to control for the univariate cofactor differences in the primary and secondary outcomes.

RESULTS

A total of 15,084 surgical cases met the inclusion criteria for this study for the three different care models: solo anesthesiologists (1,204 cases), anesthesiologist/resident pairing (3,146 cases), and anesthesiologist/CRNA/CAA (14,040 cases). Before multivariate analysis, the resident group exhibited longer anesthesia-controlled times (median, [interquartile range], 26.1 [21.7-32.0], p < 0.001), compared to CRNA/CAA (23.9 [19.7-29.5]), and attending-only surgical cases (21.0 [17.9-25.4]). After adjusting for covariates in a general linear regression model (age, BMI, ASA classification, comorbidities, arterial line insertion, surgical service, and surgical location), there were no significant differences in the anesthesia-controlled times between the provider groups. Prolonged extubation times (>15 min) were significantly less common in the anesthesiologist-only group compared to the other groups (p < 0.001). Despite these time differences, there were no clinically significant differences among the groups in postoperative pulmonary or cardiac complications, renal impairment, or the 30-day mortality rate of patients.

CONCLUSION

Anesthesia residents do not increase anesthesia-controlled operating room times or adversely affect clinically relevant patient outcomes compared to anesthesiologists working independently or supervising certified registered nurse anesthetists or certified anesthesiologist assistants.

Evaluating Patient and Surgeon Characteristics Associated with Care Cost and Outcomes for Knee and Hip Replacement Procedures: A National Medicare Cohort Study

Background

The role of physician credentialing has been widely considered in quality and outcome improvement studies. However, the association between surgeon characteristics and health-care costs remains unclear.

Methods

Our objective was to determine the association of orthopaedic surgeon characteristics with health outcomes and costs, utilizing Medicare data. We used 100% Fee-for-Service Medicare data from 2015 to 2019 to identify all patients ≥65 years of age who underwent 2 common orthopaedic surgical procedures, total hip and knee replacement. After determining whether the patients had been readmitted after discharge from their initial admission for surgery, we computed 3 metrics of total medical expenditure: the costs of the initial surgery admission and 30-day and 180-day episode-based bundles of care. Hierarchical linear regression and logistic regression models were used to evaluate patient and surgeon characteristics associated with care costs and the likelihood of readmission.

Results

We identified 2,269 surgeons who performed total knee replacements on 298,934 patients and 1,426 surgeons who performed total hip replacements on 204,721 patients. Patient characteristics associated with higher initial surgery costs included increasing age, female sex, racial minority status, and a higher Charlson Comorbidity Index. Surgeon characteristics associated with lower readmission rates included practice in the Northeast region and a higher patient volume; having malpractice claims was associated with higher readmission rates.

Conclusions

A higher volume of patients treated by the orthopaedic surgeon was associated with lower overall costs and readmission rates. Information on surgeons' malpractice claims and annual volume should be made publicly available to assist patients, payer networks, and hospitals in surgeon selection and oversight. These results could also inform the guidelines of physician credentialing organizations.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of Trainee Level on Surgical Time and Postoperative Complications of Anterior Cruciate Ligament Reconstruction

PURPOSE

The objective of this study was to investigate the association between trainee level and surgical time and postoperative complications of anterior cruciate ligament reconstruction (ACLR).

METHODS

A retrospective chart review of patients who underwent ACLR at an academic orthopaedic ambulatory surgery center collected demographic and clinical information, including the number of trainees present and trainee level. Unadjusted and adjusted regression analyses assessed the association between trainee number and level with surgical time (time from skin incision to closure) and postoperative complications.

RESULTS

Of 799 patients in this study operated on by one of five academic sports surgeons, 87% had at least one trainee involved. The average surgical time overall was 93 ± 21 minutes and by trainee level was 99.7 (junior resident), 88.5 (senior residents), 96.6 (fellows), and 95.6 (no trainees). Trainee level was significantly associated with surgical time (P = 0.0008), with increased surgical time in cases involving fellows (0.0011). Fifteen complications (1.9%) were observed within 90 days of surgery. No notable risk factors of postoperative complications were identified.

CONCLUSION

Resident trainee level does not have a notable effect on surgical time or postoperative complications for ACLR at an ambulatory surgery center, although cases involving fellows had longer surgical times. Trainee level was not associated with risk of postoperative complications.

Effect of Time of Year on Surgical Outcomes in Patients Undergoing Minimally Invasive Sacral Colpopexy or Uterosacral Ligament Suspension

IMPORTANCE

Academic urogynecologists incorporating fellows/residents into operative cases must ensure safety and quality outcomes throughout the learning curve of the academic year.

OBJECTIVES

We evaluated if the month of year relative to fellow/resident promotions in July affects operating time, complications, and prolapse recurrence for minimally invasive sacral colpopexy (MISC) or uterosacral ligament suspension (USLS).

STUDY DESIGN

This was a retrospective study comprising MISC and USLS from January 2009 to August 2015. Patient demographics, clinical, and surgical data were compared between months with July as month 1. Linear regression assessed operating time. Logistic regression assessed prolapse recurrence (composite of any POP-Q point beyond the hymen, pessary use, or reoperation) and complications.

RESULTS

One thousand seven participants had a mean age of 59.9 ± 9.4, body mass index of 27.6 ± 4.2, gravity of 3.0 ± 1.5, and parity of 2.6 ± 1.1. Most had stage III (67.7%) or II prolapse (25.6%). Minimally invasive sacral colpopexy represented 81.0% (58.8% laparoscopic, 41.2% robotic). Uterosacral ligament suspensions were 68.1% vaginal versus laparoscopic/robotic. Median follow-up was 34 weeks (interquartile range, 11-82). Mean operating time was 199.8 ± 66.4 minutes with no impact by month ( P = 0.26). Minimally invasive sacral colpopexy (vs USLS, β = 36.4 minutes), conversion to laparotomy (β = 112.9 minutes), and concomitant hysterectomy (β = 33.4 minutes) increased operating time ( P < 0.001). Complications ranged 7.9% (January) to 23.8% (March) with mean of 17.1%. Complications were unaffected by month (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.95-1.04), but USLS had more complications than MISC (OR, 1.55; 95% CI, 1.05-2.28). Prolapse recurred in 9.4% with no impact by month (OR, 0.95; 95% CI, 0.88-1.02). Minimally invasive sacral colpopexy had less recurrence than USLS (OR, 0.33; 95% CI, 0.18-0.60).

CONCLUSIONS

Month of year relative to resident/fellow promotion did not affect operating time, complications, or recurrence, debunking the myth of worse outcomes earlier in the academic year.

The Impact of Month on Joint Arthroplasty In-Hospital Outcomes: The December Effect

Background

The purpose of this study was to assess the impact of month of the year on postsurgical outcomes after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) and to specifically analyze for a December effect.

Material and methods

The National Inpatient Sample was used to identify all patients older than 40 years undergoing primary TKA and THA between 2006 and 2015. Patients were stratified based on the month of the year of surgery. In-hospital complication, disposition, and economic outcomes were comparatively analyzed.

Results

There were statistically significant differences in outcomes based on month of the year. When comparing December to the other months, both TKA and THA patients had significantly lower rates of any complication, postoperative anemia, and genitourinary complications, while there were significantly higher rates of home than rehab discharge and shorter average length of stay in December. THA patients additionally had significantly lower rates of cardiac and respiratory complications during December.

Conclusion

Postoperative outcomes are significantly associated with the month in which arthroplasty is performed. This study provides evidence of a positive "December effect" of improved in-hospital complications and economic outcomes for surgeries performed in December. Future research should direct attention to the impact that social factors may have on outcomes after elective surgical procedures and how these factors may be translated to other months.