Association of overlapping cardiac surgery with short-term patient outcomes

Varying Degree of Overlap Following the Critical Steps of Lumbar Fusion and Short-term Outcomes

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The present study analyzes the impact of end-overlap on short-term outcomes after single-level, posterior lumbar fusions.

SUMMARY OF BACKGROUND DATA

Few studies have evaluated how "end-overlap" (i.e., surgical overlap after the critical elements of spinal procedures, such as during wound closure) influences surgical outcomes.

METHODS

Retrospective analysis was performed on 3563 consecutive adult patients undergoing single-level, posterior-only lumbar fusion over a 6-year period at a multi-hospital university health system. Exclusion criteria included revision surgery, missing key health information, significantly elevated body mass index (>70), non-elective operations, non-general anesthesia, and unclean wounds. Outcomes included 30-day emergency department visit, readmission, reoperation, morbidity, and mortality. Univariate analysis was carried out on the sample population, then limited to patients with end-overlap. Subsequently, patients with the least end-overlap were exact-matched to patients with the most. Matching was performed based on key demographic variables-including sex and comorbid status-and attending surgeon, and then outcomes were compared between exact-matched cohorts.

RESULTS

Among the entire sample population, no significant associations were found between the degree of end-overlap and short-term adverse events. Limited to cases with any end-overlap, increasing overlap was associated with increased 30-day emergency department visits ( P =0.049) but no other adverse outcomes. After controlling for confounding variables in the demographic-matched and demographic/surgeon-matched analyses, no differences in outcomes were observed between exact-matched cohorts.

CONCLUSIONS

The degree of overlap after the critical steps of single-level lumbar fusion did not predict adverse short-term outcomes. This suggests that end-overlap is a safe practice within this surgical population.

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.