1
|
Venkatraman V, Suarez AD, Kirsch EP, Heo H, Wu KA, McDaniel KE, Yang LZ, Jung SH, Dharmapurikar R, Lad SP, Haglund MM. Quantifying the Opportunity Cost of Neurosurgical Resident Education. World Neurosurg 2023; 175:e669-e677. [PMID: 37030478 DOI: 10.1016/j.wneu.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/31/2023] [Accepted: 04/01/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND/OBJECTIVE Education is at the core of neurosurgical residency, but little research in to the cost of neurosurgical education exists. This study aimed to quantify costs of resident education in an academic neurosurgery program using traditional teaching methods and the Surgical Autonomy Program (SAP), a structured training program. METHODS SAP assesses autonomy by categorizing cases into zones of proximal development (opening, exposure, key section, and closing). All first-time, 1-level to 4-level anterior cervical discectomy and fusion (ACDF) cases between March 2014 and March 2022 from 1 attending surgeon were divided into 3 groups: independent cases, cases with traditional resident teaching, and cases with SAP teaching. Surgical times for all cases were collected and compared within levels of surgery between groups. RESULTS The study found 2140 ACDF cases, with 1758 independent, 223 with traditional teaching, and 159 with SAP. For 1-level to 4-level ACDFs, teaching took longer than it did with independent cases, with SAP teaching adding additional time. A 1-level ACDF performed with a resident (100.1 ± 24.3 minutes) took about as long as a 3-level ACDF performed independently (97.1 ± 8.9 minutes). The average time for 2-level cases was 72.0 ± 18.2 minutes independently, 121.7 ± 33.7 minutes traditional, and 143.4 ± 34.9 minutes SAP, with significant differences among all groups. CONCLUSIONS Teaching takes significant time compared with operating independently. There is also a financial cost to educating residents, because operating room time is expensive. Because attending neurosurgeons lose time to perform more surgeries when teaching residents, there is a need to acknowledge surgeons who devote time to training the next generation of neurosurgeons.
Collapse
Affiliation(s)
- Vishal Venkatraman
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alexander D Suarez
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Elayna P Kirsch
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Helen Heo
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin A Wu
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Katherine E McDaniel
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lexie Z Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sin-Ho Jung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Shivanand P Lad
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael M Haglund
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA.
| |
Collapse
|
2
|
Gordon AM, Sheth BK, Horn AR, Magruder ML, Conway CA, Erez O. The Careful Return of Sports Medicine Procedures in the United States During COVID-19: Comparison of Utilization, Patient Demographics, and Complications. J Patient Saf 2023; 19:193-201. [PMID: 36729609 PMCID: PMC10044586 DOI: 10.1097/pts.0000000000001100] [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] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Sports medicine procedures encompass some of the highest-volume elective surgeries performed annually. Elective surgery was suspended because of the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic; therefore, the purpose was to compare temporal trends in procedural volume, patient demographics, and postoperative complications of elective sports medicine procedures in 2019 and 2020. METHODS Using a multicenter, nationwide sample, a retrospective query of the 2019 to 2020 American College of Surgeon's National Surgery Quality Improvement Program database was conducted for all patients undergoing common elective sports medicine procedures. Temporal trends in utilization, demographics, and 30-day complications were compared pre-COVID (2019 and 2020Q1) with post-COVID (2020Q2-Q4). Linear regression was used to evaluate changes in procedural volume over time. A significance threshold of P < 0.05 was used. RESULTS A total of 48,803 patients underwent elective surgery in 2019 (n = 27,883) and 2020 (n = 20,920), a 25.0% decline. Procedural utilization declined by 42.5% in 2020Q2 and never returned to prepandemic baseline in 2020Q3-Q4. The percentage decline in case volume from 2019 to 2020Q2 was greatest for meniscectomy (47.6%), rotator cuff repair (42.7%), labral repair (41.6%), biceps tenodesis (41.3%), and anterior cruciate ligament reconstruction (38.5%). Total complication rates were similar in 2019 (1.31%) versus 2020 (1.51%; P = 0.072). The 30-day readmission (0.74% versus 0.67%; P = 0.374), reoperation (0.35% versus 0.35%; P = 0.963), and mortality (0.01% versus 0.01%; P = 0.657) rates were similar between calendar years. CONCLUSIONS Sports medicine procedures declined during the second quarter of 2020. Despite pandemic restrictions, patients who did undergo surgery did not experience increased complications. The present study may be used by surgeons, hospitals, and subspecialty societies to support the careful utilization of elective surgery during COVID-19. LEVEL OF EVIDENCE III, prognostic study.
Collapse
|
3
|
Swindell HW, deMeireles AJ, Zhong JR, Bixby EC, Saltzman BM, Jobin CM, Levine WN, Trofa DP. Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopedic Shoulder Arthroplasty: A Matched - Pair Analysis. Shoulder Elbow 2023; 15:151-158. [PMID: 37035610 PMCID: PMC10078817 DOI: 10.1177/17585732211065444] [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: 09/19/2021] [Revised: 10/31/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022]
Abstract
Background There is minimal work defining the economic impact of resident participation in shoulder arthroplasty. Thus, this study quantified the opportunity cost of resident participation in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) by determining differences in operative time, relative value units (RVUs)/hour, and RVUs/case. Methods A retrospective analysis of shoulder arthroplasty procedures were identified from the ACS-NSQIP database from 2006 to 2014 using CPT codes. Demographic, comorbidity, preoperative laboratory data and surgical procedure were used to develop matched cohorts. Mean differences in operative time, RVUs/case and RVUs/hour between attending-only (AO) cases and cases with resident involvement (RI) were examined. Cost analysis was performed to identify differences in RVUs generated per hour in dollars/case. Results A total of 1786 AO and 1102 RI cases were identified. With the exception of PGY-3 and PGY-4 cases, RI cases had lower mean operative times compared to AO cases. The cost of RI was highest for PGY-3 ($199.87 per case) and PGY-4 ($9 .2 9) residents with all other postgraduate years providing a cost reduction. Discussion Involvement of residents was associated with shorter operative times leading to a savings of $29.64 per case. Involvement of intermediate-level (PGY-3) residents were associated with increased costs that ultimately decreased as residents became more senior.
Collapse
Affiliation(s)
- Hasani W Swindell
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Alirio J deMeireles
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, NY, USA
| | - Jack R Zhong
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, NY, USA
| | - Elise C Bixby
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, NY, USA
| | - Bryan M Saltzman
- Department of Orthopedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Charles M Jobin
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, NY, USA
| | - William N Levine
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, NY, USA
| | - David P Trofa
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, NY, USA
| |
Collapse
|
4
|
Gordon AM, Malik AT. Total elbow arthroplasty cases involving orthopaedic residents do not affect short-term postoperative complications. Shoulder Elbow 2023; 15:65-73. [PMID: 36895610 PMCID: PMC9990108 DOI: 10.1177/17585732211034455] [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: 02/08/2021] [Accepted: 06/29/2021] [Indexed: 11/17/2022]
Abstract
Background Impact of resident participation on short-term postoperative outcomes after total elbow arthroplasty has not been studied. The aim was to investigate whether resident participation affects postoperative complication rates, operative time, and length of stay. Methods The American College of Surgeons National Surgical Quality Improvement Program registry was queried from 2006 to 2012 for patients undergoing total elbow arthroplasty. A 1:1 propensity score match was performed to match resident cases to attending-only cases. Comorbidities, surgical time, and short-term (30-day) postoperative complications were compared between groups. Multivariate Poisson regression was used to compare the rates of postoperative adverse events between groups. Results After propensity score match, 124 cases (50% with resident participation) were included. Adverse event rate after surgery was 18.5%. On multivariate analysis, there were no significant differences between attending-only cases and resident involved cases, with regards to short-term major complications, minor complications, or any complications (all p > 0.071). Total operative time was similar between cohorts (149.16 vs. 165.66 min; p = 0.157). No difference was observed in the length of hospital stay (2.95 vs. 2.6 days), p = 0.399. Discussion Resident participation during total elbow arthroplasty is not associated with increased risk for short-term medical or surgical postoperative complications or operative efficiency.
Collapse
Affiliation(s)
- Adam M Gordon
- Department of Orthopaedics, The Ohio State University,
Columbus, OH, USA
| | - Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University,
Columbus, OH, USA
| |
Collapse
|
5
|
Kreulen RT, Raad M, Musharbash FN, Nayar SK, Best MJ, Puvanesarajah V, Marrache M, Srikumaran U, Wilckens JH. Factors associated with RVU generation in common sports medicine procedures. PHYSICIAN SPORTSMED 2022; 50:233-238. [PMID: 33751911 DOI: 10.1080/00913847.2021.1907258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Relative value units (RVUs) are integral to the U.S. physician compensation system used by the Centers for Medicare & Medicaid Services. The use of 'work RVUs' (herein, wRVUs) is intended to reimburse physicians according to the amount of expertise and effort needed to safely and effectively perform a procedure. Our purpose was to determine: 1) the number of wRVUs/hour generated by common sports medicine surgical procedures; and 2) how patient characteristics, surgical approach, and practice setting are associated with the number of wRVUs/hour. This analysis was performed to infer whether wRVUs are assigned appropriately according to the factors on which they are purported to be based. METHODS We queried the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database for common sports medicine surgical procedures performed in 2018. Data from 19,877 patients (8,258 women) with a mean age of 48 years (range, 18-90) who underwent a surgical sports medicine procedure were analyzed. Work RVUs and operative time were used to calculate work RVUs/hour for each surgical procedure. Univariate and multivariate analyses were used to assess correlations between patient characteristics and wRVUs/hour. RESULTS Knee chondroplasty generated the most mean (± standard deviation) wRVUs/hour at 22 ± 0.5, whereas 'open tenodesis of biceps tendon, long head' generated the least at 9.6 ± 0.25 wRVUs/hour. Factors associated with a greater mean number of wRVUs/hour were younger patient age, female sex, arthroscopic approach, and outpatient setting. Arthroscopic procedures also generated more wRVUs/hour than the same procedures performed through an open approach. wRVUs were not correlated with case complexity or surgical time. CONCLUSION wRVUs/hour in surgical sports medicine procedures vary widely depending on the procedure type, patient characteristics, surgical approach, and practice setting.
Collapse
Affiliation(s)
- R Timothy Kreulen
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Farah N Musharbash
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Suresh K Nayar
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John H Wilckens
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
6
|
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: 0] [Impact Index Per Article: 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.
Collapse
|
7
|
The Opportunity Cost of Resident Involvement in Adult Craniofacial Surgery: An Analysis of Relative Value Units. J Craniofac Surg 2021; 33:125-128. [PMID: 34456286 DOI: 10.1097/scs.0000000000008104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Within the academic surgical setting resident involvement may confer longer operative times. The increasing pressures to maximize clinical productivity and decreasing reimbursement rates, however, may conflict with these principles. This study calculates the opportunity cost of resident involvement in craniofacial surgery. METHODS Retrospective analysis was conducted with patients who underwent craniofacial procedures from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Patients were selected based on relevant Current Procedural Terminology codes for craniofacial pathologies (ie, trauma, head and neck reconstruction, orthognathic surgery, and facial reanimation). Variables included patient demographics, operative time, and presence or absence of resident trainee. Average relative value units were calculated to determine the opportunity cost of resident involvement for each craniofacial procedure. RESULTS In total, 2096 patients were identified through the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Resident involvement was associated with a statistically significant higher operative time (P < 0.001) for facial reanimation, facial trauma, orthognathic surgery, and head and neck reconstruction. The opportunity costs per case associated with resident involvement were the highest for head and neck reconstruction ($1468.04), followed by orthognathic surgery ($1247.03), facial trauma ($533.03), and facial reanimation ($358.32). Resident involvement was associated with higher rate of complications for head and neck reconstruction (P < 0.043). CONCLUSIONS Resident involvement is associated with longer operative times, higher complications, and higher re-operations, compared to attending exclusive surgical care. Future studies may consider how reimbursements should align incentives to promote resident education and training.
Collapse
|
8
|
Verma NN. Editorial Commentary: Resident Involvement in Orthopaedic Surgical Procedures Does Not Negatively Impact Patients. Arthroscopy 2020; 36:2696-2697. [PMID: 33039041 DOI: 10.1016/j.arthro.2020.06.035] [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] [Received: 06/28/2020] [Accepted: 06/30/2020] [Indexed: 02/02/2023]
Abstract
Residency and fellowship training programs have evolved significantly over the past 20 years. As the practice of medicine has become more sophisticated, and as increased economic factors exert pressures on health care delivery, postgraduate physician education is naturally affected. Residency programs have always been a formalized, graduate level apprenticeship, and there is really no way to adequately train new physicians other than direct experience in patient care. In surgery, this means providing young trainees the opportunity to be involved in surgical procedures with a gradual increase in autonomy. However, potential negative impacts, which may include financial or legal ramifications for the providers and adverse outcomes for the patient, are real. As a program director and clinician, I personally struggle with these challenges in balancing quality patient care, efficiency, and education.
Collapse
|
9
|
Wascher DC. Editorial Commentary: Resident Education: At What Cost? Arthroscopy 2020; 36:844. [PMID: 32139061 DOI: 10.1016/j.arthro.2019.11.102] [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] [Received: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 02/02/2023]
Abstract
Arthroscopic trainees may struggle to learn basic skills, resulting in slower and more expensive surgical procedures. However, the reward of resident involvement includes the satisfaction and benefit to society associated with medical mentorship, and the learning-clinical and otherwise-that is associated with teaching.
Collapse
|
10
|
Feldman MD. Editorial Commentary: Taking the Time to Teach the Next Generation of Orthopaedic Sports Medicine Physicians. Arthroscopy 2020; 36:842-843. [PMID: 32139060 DOI: 10.1016/j.arthro.2019.11.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/18/2019] [Indexed: 02/02/2023]
Abstract
Most everything in life has a cost, and for the academic orthopaedic sports medicine physician, it is time. But if it is to improve the skill set of the next generation of arthroscopic or sports medicine surgeons (who someday may perform surgery on me!), then I believe it is worth it.
Collapse
|