Impact of Resident Participation on Outcomes After Single-Level Anterior Cervical Diskectomy and Fusion: An Analysis of 3265 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database

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

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.

Development and External Validation of a Risk Calculator for Prediction of Major Complications and Readmission After Anterior Cervical Discectomy and Fusion

STUDY DESIGN

A retrospective, case-control study.

OBJECTIVE

We aim to build a risk calculator predicting major perioperative complications after anterior cervical fusion. In addition, we aim to externally validate this calculator with an institutional cohort of patients who underwent anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

The average age and proportion of patients with at least one comorbidity undergoing ACDF have increased in recent years. Given the increased morbidity and cost associated with perioperative complications and unplanned readmission, accurate risk stratification of patients undergoing ACDF is of great clinical utility.

METHODS

This is a retrospective cohort study of adults who underwent anterior cervical fusion at any nonfederal California hospital between 2015 and 2017. The primary outcome was major perioperative complication or 30-day readmission. We built standard and ensemble machine learning models for risk prediction, assessing discrimination, and calibration. The best-performing model was validated on an external cohort comprised of consecutive adult patients who underwent ACDF at our institution between 2013 and 2020.

RESULTS

A total of 23,184 patients were included in this study; there were 1886 cases of major complication or readmissions. The ensemble model was well calibrated and demonstrated an area under the receiver operating characteristic curve of 0.728. The variables most important for the ensemble model include male sex, medical comorbidities, history of complications, and teaching hospital status. The ensemble model was evaluated on the validation cohort (n=260) with an area under the receiver operating characteristic curve of 0.802. The ensemble algorithm was used to build a web-based risk calculator.

CONCLUSION

We report derivation and external validation of an ensemble algorithm for prediction of major perioperative complications and 30-day readmission after anterior cervical fusion. This model has excellent discrimination and is well calibrated when tested on a contemporaneous external cohort of ACDF cases.

Total elbow arthroplasty cases involving orthopaedic residents do not affect short-term postoperative complications

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.

Resident and Fellow Participation Does Not Affect Short-Term Postoperative Complications After Distal Radius Fracture Fixation

Background  Complications after open reduction internal fixation (ORIF) for distal radius fractures (DRF) are well documented, but the impact of trainee involvement on postoperative outcomes has not been studied. Questions  Does trainee involvement affect postoperative complication rates and length of hospital stay? Methods  The American College of Surgeons National Surgical Quality Improvement Program was queried from 2006 to 2012 for patients undergoing DRF ORIF. A 1:1 propensity score matched resident/fellow involved cases to attending-only cases. Demographics, length of stay, and postoperative complications were compared between the two groups. Logistic regression was used to evaluate independent predictors of adverse events and to evaluate cases with and without trainee involvement. Results  Overall, 3,003 patients underwent DRF ORIF from 2006 to 2012. After matching, 1,150 cases (50% with resident/fellow involvement) were included. The overall rate of adverse events was 4.4% (46/1,050). There were no significant differences in the short-term complication rate in trainee-involved (2.3%) versus attending-only cases (3.9%) ( p  = 0.461). For ORIF of DRF, there were no significant differences, between attending-only cases and resident/fellow-involved cases, with regard to short-term major complications ( p  = 0.720) or minor complications ( p  = 0.374). Length of hospital stay was similar between cohorts (1.22 vs. 0.98 days) ( p  = 0.723). On multivariate analysis, trainee involvement was not an independent predictor of minor, major, or any complication after DRF fixation after controlling for multiple independent factors (all p  > 0.364). Discussion  Trainee participation in DRF ORIF is not associated with increased risk of short-term (30 days) medical or surgical postoperative complications. Level of Evidence  This is a Level IV case-control study.

Effect of Fellow Involvement and Experience on Patient Outcomes in Spine Surgery

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.

Work relative value units and perioperative outcomes in patients undergoing brain tumor surgery

The work relative value unit (wRVU) is a commonly cited surrogate for surgical complexity; however, it is highly susceptible to subjective interpretation and external forces. Our objective was to evaluate whether wRVU is associated with perioperative outcomes, including complications, after brain tumor surgery. The 2006-2014 American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients ≥ 18 years who underwent brain tumor resection. Patients were categorized into approximate quintiles based on total wRVU. The relationship between wRVU and several perioperative outcomes was assessed with univariate and multivariate analyses. Subgroup analyses were performed using a Current Procedural Terminology code common to all wRVU groups. The 16,884 patients were categorized into wRVU ranges 0-30.83 (4664 patients), 30.84-34.58 (2548 patients), 34.59-38.04 (3147 patients), 38.05-45.38 (3173 patients), and ≥ 45.39 (3352 patients). In multivariate logistic regression analysis, increasing wRVU did not predict more 30-day postoperative complications, except respiratory complications and need for blood transfusion. Linear regression analysis showed that wRVU was poorly correlated with operative duration and length of stay. On multivariate analysis of the craniectomy subgroup, wRVU was not associated with overall or respiratory complications. The highest wRVU group was still associated with greater risk of requiring blood transfusion (OR 3.01, p < 0.001). Increasing wRVU generally did not correlate with 30 days postoperative complications in patients undergoing any surgery for brain tumor resection; however, the highest wRVU groups may be associated with greater risk of respiratory complications and need for transfusion. These finding suggests that wRVU may be a poor surrogate for case complexity.

Resident Involvement in Posterior Lumbar Interbody Fusion is Associated With Increased Readmissions and Operative Time, But No Increased Short-term Risks

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim was to compare rates of adverse events and additional posterior lumbar interbody fusion (PLIF) cases assisted by residents versus cases performed solely by an orthopedic attending.

SUMMARY OF BACKGROUND DATA

PLIF is a widely accepted surgical technique for the management of a variety of spinal conditions requiring spinal stabilization and fusion. However, no published studies have assessed the effects of resident involvement on intraoperative and postoperative outcomes in PLIF.

METHODS

This retrospective study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry from 2007 to 2012 to identify patients who underwent PLIF procedures. A propensity score matching model was utilized to reduce patient cohort variances. The perioperative data and outcomes in the matched population were analyzed using paired t test and the McNemar test in order to assess, based on resident presence, the rates of postoperative adverse events, readmission, reoperation within 30 days, and operative time.

RESULTS

In total, 1633 patients undergoing PLIF were included in the study, with 24.62% involving resident participation. The propensity score matching algorithm yielded 396 well-matched resident and nonresident pairs. Patients undergoing PLIF involving a resident were associated with a higher rate of readmission (1.77% vs. 0.00%; P=0.008), and longer operative time (245.7 vs. 197.7 min; P<0.001). However, these procedures were not associated with any significant difference in minor or severe adverse events.

CONCLUSIONS

Resident involvement in PLIF was associated with an increased rate of readmissions, and operative time; however, was not associated with an increase in minor or severe adverse events. Further investigation is needed to characterize the role of resident involvement based on level of training experience, as well as methods to improve the learning curve to independence while reducing postoperative hospital length of stay.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

"July Effect" Revisited: July Surgeries at Residency Training Programs are Associated with Equivalent Long-term Clinical Outcomes Following Lumbar Spondylolisthesis Surgery

STUDY DESIGN

Retrospective analysis of a prospective registry.

OBJECTIVE

We utilized the Quality Outcomes Database (QOD) registry to investigate the "July Effect" at QOD spondylolisthesis module sites with residency trainees.

SUMMARY OF BACKGROUND DATA

There is a paucity of investigation on the long-term outcomes following surgeries involving new trainees utilizing high-quality, prospectively collected data.

METHODS

This was an analysis of 608 patients who underwent single-segment surgery for grade 1 degenerative lumbar spondylolisthesis at 12 high-enrolling sites. Surgeries were classified as occurring in July or not in July (non-July). Outcomes collected included estimated blood loss, length of stay, operative time, discharge disposition, complications, reoperation and readmission rates, and patient-reported outcomes (Oswestry Disability Index [ODI], Numeric Rating Scale [NRS] Back Pain, NRS Leg Pain, EuroQol-5D [EQ-5D] and the North American Spine Society [NASS] Satisfaction Questionnaire). Propensity score-matched analyses were utilized to compare postoperative outcomes and complication rates between the July and non-July groups.

RESULTS

Three hundred seventy-one surgeries occurred at centers with a residency training program with 21 (5.7%) taking place in July. In propensity score-matched analyses, July surgeries were associated with longer operative times ( average treatment effect = 22.4 minutes longer, 95% confidence interval 0.9-449.0, P = 0.041). Otherwise, July surgeries were not associated with significantly different outcomes for the remaining perioperative parameters (estimated blood loss, length of stay, discharge disposition, postoperative complications), overall reoperation rates, 3-month readmission rates, and 24-month ODI, NRS back pain, NRS leg pain, EQ-5D, and NASS satisfaction score (P > 0.05, all comparisons).

CONCLUSION

Although July surgeries were associated with longer operative times, there were no associations with other clinical outcomes compared to non-July surgeries following lumbar spondylolisthesis surgery. These findings may be due to the increased attending supervision and intraoperative education during the beginning of the academic year. There is no evidence that the influx of new trainees in July significantly affects long-term patient-centered outcomes.Level of Evidence: 3.

How Does the Presence of a Surgical Trainee Impact Patient Outcomes in Lumbar Fusion Surgery?

BACKGROUND

While the impact of trainee involvement in other surgical fields is well established, there is a paucity of literature assessing this relationship in orthopaedic spine surgery. The goal of this study was to further elucidate this relationship.

METHODS

A retrospective cohort study was initiated on patients undergoing 1-3 level lumbar spine fusion at a single academic center. Operative reports from cases were examined, and patients were divided into 2 groups depending on whether a fellow or resident (F/R) or a physician's assistant (PA) was used as the primary assist. Patients with less than 1-year follow-up were excluded. Multiple linear regression was used to assess change in each patient-reported outcome, and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission.

RESULTS

One hundred and seventy-two patients were included in the F/R group compared with 178 patients in the PA group. No differences existed between groups for total surgery time, length of stay, 30- or 90-day readmissions, infection, or revision rates. No differences existed between groups in terms of patient-reported outcomes preoperatively or postoperatively. In addition, presence of a surgical trainee was not a significant predictor of patient outcomes or rates of infection, overall revision, or 30- and 90-day readmission rates.

CONCLUSIONS

The results of this study indicate the presence of an orthopaedic spine F/R does not increase complication rates and does not affect short-term patient-reported outcomes in lumbar decompression and fusion surgery.

LEVEL OF EVIDENCE

3.

Are Patient Outcomes Affected by the Presence of a Fellow or Resident in Lumbar Decompression Surgery?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to determine whether the presence of a fellow or resident (F/R) compared to a physician assistant (PA) affected surgical variables or short-term patient outcomes.

SUMMARY OF BACKGROUND DATA

Although orthopedic spine fellows and residents must participate in minimum number of decompression surgeries to gain competency, the impact of trainee presence on patient outcomes has not been assessed.

METHODS

One hundred and seventy-one patients that underwent a one- to three-level lumbar spine decompression procedure at a high-volume academic center were retrospectively identified. Operative reports from all cases were examined and patients were placed into one of two groups based on whether the first assist was a F/R or a PA. Univariate analysis was used to compare differences in total surgery duration, 30-day and 90-day readmissions, infection and revision rates, patient-reported outcome measures (Short Form-12 Physical Component Score and Mental Component Score, Oswestry Disability Index, Visual Analog Scale [VAS] Back, VAS Leg) between groups. Multiple linear regression was used to assess change in each patient reported outcome and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission.

RESULTS

Seventy-eight patients were included in the F/R group compared to 93 patients in the PA group. There were no differences between groups for total surgery time, 30-day or 90-day readmissions, infection, or revision rates. Using univariate analysis, there were no differences between the two groups pre- or postoperatively (P > 0.05). Using multivariate analysis, presence of a surgical trainee did not significantly influence any patient reported outcome and did not affect infection, revision, or 30- and 90-day readmission rates.

CONCLUSION

This is one of the first studies to show that the presence of an orthopedic spine fellow or resident does not affect patient short-term outcomes in lumbar decompression surgery.

LEVEL OF EVIDENCE

3.

Procedures performed during neurosurgery residency in Europe

Background

In a previous article (10.1007/s00701-019-03888-3), preliminary results of a survey, aiming to shed light on the number of surgical procedures performed and assisted during neurosurgery residency in Europe were reported. We here present the final results and extend the analyses.

Methods

Board-certified neurosurgeons of European Association of Neurosurgical Societies (EANS) member countries were asked to review their residency case logs and participate in a 31-question electronic survey (SurveyMonkey Inc., San Mateo, CA). The responses received between April 25, 2018, and April 25, 2020, were considered. We excluded responses that were incomplete, from non-EANS member countries, or from respondents that have not yet completed their residency.

Results

Of 430 responses, 168 were considered for analysis after checking in- and exclusion criteria. Survey responders had a mean age of 42.7 ± 8.8 years, and 88.8% were male. Responses mainly came from surgeons employed at university/teaching hospitals (85.1%) in Germany (22.0%), France (12.5%), the United Kingdom (UK; 8.3%), Switzerland (7.7%), and Greece (7.1%). Most responders graduated in the years between 2011 and 2019 (57.7%). Thirty-eight responders (22.6%) graduated before and 130 responders (77.4%) after the European WTD 2003/88/EC came into effect. The mean number of surgical procedures performed independently, supervised or assisted throughout residency was 540 (95% CI 424–657), 482 (95% CI 398–568), and 579 (95% CI 441–717), respectively. Detailed numbers for cranial, spinal, adult, and pediatric subgroups are presented in the article. There was an annual decrease of about 33 cases in total caseload between 1976 and 2019 (coeff. − 33, 95% CI − 62 to − 4, p = 0.025). Variables associated with lesser total caseload during residency were training abroad (1210 vs. 1747, p = 0.083) and female sex by trend (947 vs. 1671, p = 0.111), whereas case numbers were comparable across the EANS countries (p = 0.443).

Conclusion

The final results of this survey largely confirm the previously reported numbers. They provide an opportunity for current trainees to compare their own case logs with. Again, we confirm a significant decline in surgical exposure during training between 1976 and 2019. In addition, the current analysis reveals that female sex and training abroad may be variables associated with lesser case numbers during residency.

Electronic supplementary material

The online version of this article (10.1007/s00701-020-04513-4) contains supplementary material, which is available to authorized users.

Prolonged Length of Stay and Risk of Unplanned 30-Day Readmission After Elective Spine Surgery: Propensity Score-Matched Analysis of 33,840 Patients

STUDY DESIGN

Retrospective database study.

OBJECTIVE

To assess the association between prolonged length of hospital stay (pLOS) (≥4 d) and unplanned readmission in patients undergoing elective spine surgery by controlling the clinical and statistical confounders.

SUMMARY OF BACKGROUND DATA

pLOS has previously been cited as a risk factor for unplanned hospital readmission. This potentially modifiable risk factor has not been distinguished as an independent risk factor in a large-scale, multi-institutional, risk-adjusted study.

METHODS

Data were collected from the American College of Surgeons National Surgical Quality Improvement Program database. A retrospective propensity score-matched analysis was used to reduce baseline differences between the cohorts. Univariate and multivariate analyses were performed to assess the degree of association between pLOS and unplanned readmission.

RESULTS

From the 99,575 patients that fit the inclusion criteria, propensity score matching yielded 16,920 well-matched pairs (mean standard propensity score difference = 0.017). The overall 30-day unplanned readmission rate of these 33,840 patients was 5.5%. The mean length of stay was 2.0 ± 0.9 days and 6.0 ± 4.5 days (P ≤ 0.001) for the control and pLOS groups, respectively. In our univariate analysis, pLOS was associated with postoperative complications, especially medical complications (22.7% vs. 8.3%, P < 0.001). Multivariate analysis of the propensity score-matched population, which adjusted identified confounders (P < 0.02 and ≥10 occurrences), showed pLOS was associated with an increased risk of 30-day unplanned readmission (odds ratio [OR] 1.423, 95% confidence interval [CI] 1.290-1.570, P < 0.001).

CONCLUSION

Patients who undergo elective spine procedures who have any-cause pLOS (≥4 d) are at greater risk of having unplanned 30-day readmission compared with patients with shorter hospital stays.

LEVEL OF EVIDENCE

4.

The Impact of Resident Involvement on Postoperative Complications After Shoulder Arthroscopy: A Propensity-Matched Analysis

PURPOSE

Shoulder arthroscopy is the second most frequently performed procedure by orthopaedic surgeons taking the American Board of Orthopaedic Surgery part II examination. However, the impact of resident involvement on outcomes after shoulder arthroscopy is poorly understood. The aim of this study was to investigate whether resident involvement in shoulder arthroscopic procedures affects postoperative complication rates and surgical time using propensity score-matched cohorts.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program registry was queried to identify patients who underwent common shoulder arthroscopic procedures between 2006 and 2012. Cases without information on resident involvement, treatment of septic arthritis or osteomyelitis of the shoulder, or concomitant open or miniopen procedures were excluded from the study. A 1:1 propensity score match was used based on demographic and comorbidity factors to match cases with resident involvement to nonresident cases. Patient demographics, comorbidities, surgical time, length of hospital stay, and 30-day postoperative complications were compared between the two groups.

RESULTS

Overall, 15,857 patients who underwent shoulder arthroscopy were identified. After propensity score matching, 3474 cases (50% with resident involvement) were included. Appropriate matching was verified with no difference in demographic or health characteristics. No significant differences in the overall rate of 30-day complications was noted in resident-involved versus nonresident group (P = 0.576). No significant difference was observed in postoperative surgical or medical complications. Resident involvement was significantly longer surgical time (75.9 ± 35.9 versus 75.1 ± 40.5 minutes, P = 0.03) when compared with cases performed without a resident.

CONCLUSIONS

Resident involvement in shoulder arthroscopy is not associated with increased risk for medical or surgical 30-day postoperative complications. Resident participation in shoulder arthroscopy cases did increase surgical time; however, this finding is likely clinically insignificant.

Is selective nerve root block necessary for learning percutaneous endoscopic lumbar discectomy: a comparative study using a cumulative summation test for learning curve

PURPOSE

The aim of this study was to investigate the effect of lumbar spine selective nerve root block (SNRB) experience on the learning efficiency of percutaneous endoscopic lumbar discectomy (PELD) for junior trainees.

METHODS

A total of 480 patients undergoing single-level PELD performed by eight junior trainees were included. The trainees were divided into two groups based on whether they had previous SNRB experience (group A, yes; group B, no). Surgical proficiency was defined as total operation time less than 65 minutes and cumulative radiation exposure time no more than 40 seconds. The learning curve was analyzed by cumulative summation (CUSUM) test. Clinical evaluations included Macnab classification, visual analog scale (VAS)-low back score, VAS-leg score, and Oswestry Disability Index (ODI). Follow-up information at 12 months was also obtained.

RESULTS

Integral number of cases before achieving an acceptable surgical level in group A (47.75 ± 2.50 cases) was significantly smaller than that in group B (56.50 ± 1.29 cases, p < 0.05), along with less accumulated failure (18.75 ± 0.96 cases vs. 25.50 ± 1.75 cases, p < 0.05). The two groups were comparable in clinical outcomes. Forty-seven cases of complications were observed, with 17 in group A and 30 in group B (p < 0.05).

CONCLUSION

Previous experience of SNRB improved the performance of PELD with shorter operation time and less radiation exposure. SNRB practice may reduce the complication rate without a significant effect on the recurrence of symptoms and reoperation.

Supervision of Resident Physicians

Supervision of resident physicians is a high-risk area of emergency medicine, and what constitutes appropriate supervision is a complex question. In this article, policies and procedures for appropriate supervision of resident physicians and the implications for billing are reviewed. Recommendations on supervision of resident physicians in the emergency department are detailed, with attention paid to addressing challenges in balancing patient safety with resident autonomy and education during the course of patient care and graduate medical education.

Impact of resident involvement on cervical and lumbar spine surgery outcomes

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.

Effect of an additional neurosurgical resident on procedure length, operating room time, estimated blood loss, and post-operative length-of-stay

Introduction: Neurosurgical residency training is costly, with expenses largely borne by the academic institutions that train residents. One expense is increased operative duration, which leads to poorer patient outcomes. Although other studies have assessed the effect of one resident assisting, none have investigated two residents; thus, we sought to investigate if two residents versus one scrubbed-in impacted operative time, estimated blood loss (EBL), and length-of-stay (LOS).Methods: In this retrospective review of patients who underwent a neurosurgical procedure involving one or two residents between January 2013 and April 2016, we performed multivariable linear regression to determine if there was an association between resident participation and case length, operating room time, EBL, and LOS. We also included patient demographics, attending surgeon, day of the week, start time, pre-operative LOS, procedure performed, and other variables in our model. Only procedures performed at least 40 times during the study period were analyzed.Results: Of 860 procedures that met study criteria, 492 operations were one of six procedures performed at least 40 times, which were anterior cervical discectomy and fusion, cerebrospinal fluid (CSF) shunt insertion, CSF shunt revision, lumbar laminectomy, intracranial hematoma evacuation, and non-skull base, supratentorial parenchymal brain tumor resection. An additional resident was associated with a 35.1-min decrease (p = .01) in operative duration for lumbar laminectomies. However, for intracranial hematoma evacuations, an extra resident was associated with a 24.1 min increase (p = .03) in procedural length. There were no significant differences observed in the other four surgeries.Conclusion: An additional resident may lengthen duration of intracranial hematoma evacuations. However, two residents scrubbed-in were associated with decreased lumbar laminectomy duration. Overall, an extra resident does not increase procedural duration, total operating room utilization, EBL, or post-operative LOS. Allowing two residents to scrub in may be a safe and cost-effective method of educating neurosurgical residents.

Does Posterior Cervical Decompression Conducted by Junior Surgeons Affect Clinical Outcomes in the Treatment of Cervical Spondylotic Myelopathy? Results From a Multicenter Study

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVES

To evaluate the outcomes of posterior cervical decompression for cervical spondylotic myelopathy (CSM) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons.

METHODS

We reviewed outcomes for 675 patients who underwent surgery for CSM, were followed at least 1 year after surgery, and were assessed preoperatively and at final follow-up by Japanese Orthopaedic Association (JOA) scores and by the visual analog scale (VAS) for the neck. Cervical alignment was assessed on radiographs by C2-C7 angles, and range of motion (ROM) by extension minus flexion C2-C7 angles. We compared outcomes for BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and for NBCS surgeons.

RESULTS

BCS surgeons performed 432 of 675 laminoplasties. NBCS surgeons were primary in 243 surgeries, of which 187 were directly supervised by a BCS surgeon. BCS surgeons required significantly less time in surgery (98.0 ± 39.5 vs 108.1 ± 49.7 min; P < .01). BCS and NBCS surgeons had comparable perioperative complications rates, and preoperative-to-postoperative changes in JOA scores (2.9 ± 2.1 vs 3.1 ± 2.3; P = .40) and VAS (-1.5 ± 2.9 vs -1.4 ± 2.5; P = .96). Lordotic cervical alignment and ROM were maintained after operations by both groups.

CONCLUSIONS

Surgical outcomes such as functional recovery, complication rates, and cervical dynamics were comparable between the BCS and NBCS groups. Thus, posterior cervical decompression for CSM is safe and effective when performed by junior surgeons who have been trained and supervised by experienced spine surgeons.

Resident Involvement in Shoulder Arthroscopy Is Not Associated With Short-term Risk to Patients

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.

Effect of Resident Involvement on Morbidity and Mortality Following Thoracic Endovascular Aortic Repair

OBJECTIVE

To evaluate the effect of resident involvement in thoracic endovascular aortic repair (TEVAR).

SUMMARY OF BACKGROUND DATA

Although the influence of resident intraoperative involvement in several types of surgical procedures has been reported, the effect of resident participation in TEVAR is unknown. We evaluated patient outcomes in resident-involved TEVAR procedures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was analyzed for TEVAR performed from 2010 to 2012. Current procedural terminology codes were used to identify adult patients (≥18 y) who underwent TEVAR. Patients were grouped into those with and without resident involvement. Descriptive and binomial logistic statistics were used to determine the effect of resident involvement on post-TEVAR outcomes. p values < 0.05 were considered statistically significant.

RESULTS

A total of 676 patients met inclusion criteria for this study. Of these, 517 (76.5%) had residents involved. Overall mortality was 9.8%, with no significant difference between the 2 groups (p = 0.88). Resident involvement was not a significant predictor of any post-TEVAR complication. Postoperative pneumonia (3.5% vs 6.9%, p = 0.06), prolonged mechanical ventilation (11.8% vs 11.9%, p = 0.96), stroke (2.7% vs 5.7%, p = 0.07), urinary tract infection (3.3% vs 4.4%, p = 0.50), progressive renal insufficiency (1.2% vs 2.5%, p = 0.22), acute renal failure (4.1% vs 5.0%, p = 0.60), cardiac arrest (2.9% vs 5.0%, p = 0.20), myocardial infarction (1.7% vs 1.9%, p = 0.91), deep venous thrombosis (1.7% vs 1.3%, p = 0.67), red blood cells transfusions (29.2% vs 36.5%, p = 0.08), sepsis (2.9% vs 4.4%, p = 0.35), septic shock (1.9% vs 3.8%, p = 0.18), and unplanned reintubation (8.7% vs 9.4%, p = 0.78) were not significantly affected. Additionally, resident involvement did not significantly affect operative time (176.1 ± 122.8 min vs 180.3 ± 119.1 min, p = 0.71) and anesthesia time (282.1 ± 146.6 min vs 278.3 ± 140.5 min, p = 0.78).

CONCLUSIONS

The participation of residents in TEVAR did not significantly affect all 30-day patient outcomes. Resident involvement in TEVAR is safe and should be encouraged.

MINI ABSTRACT

This study evaluated the effect of resident participation on postoperative outcomes of thoracic endovascular aortic repair (TEVAR) using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. Results showed that resident involvement in TEVAR does not negatively affect patient outcomes.

Resident Participation is Not Associated With Worse Outcomes After TKA

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.

The utility of preoperative laboratories in predicting postoperative complications following posterolateral lumbar fusion

BACKGROUND CONTEXT

Several studies have suggested that laboratory results have minimal impact on clinical decision making in surgery. Despite the widespread use of preoperative testing in spine surgery and the large volume of posterolateral lumbar fusions (PLFs) being performed each year, no study has assessed the ability of preoperative laboratories to predict adverse events following PLF.

PURPOSE

The purpose of this study was to explore the relationship between commonly obtained preoperative laboratory results and postoperative complications following one- to two-level PLF.

STUDY DESIGN

This is a retrospective study of prospectively collected data.

PATIENT SAMPLE

The 2006-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was employed to identify all patients who underwent one- to two-level PLF.

OUTCOME MEASURES

The outcome variables of interest were 30-day postoperative complications, which were assessed as major complications, minor adverse events, and total complications.

MATERIALS AND METHODS

Demographics, comorbidities, and perioperative characteristics were collected for each patient. Preoperative laboratories included sodium, blood urea nitrogen, creatinine, albumin, bilirubin, serum glutamic oxaloacetic transaminase, alkaline phosphatase, white blood cell count, hematocrit, platelet count, prothrombin time, international normalized ratio, and partial thromboplastin time. Bivariate analysis and multivariate logistic regression modeling were used to explore the relationship between abnormal preoperative laboratories and the incidence of postoperative complications.

RESULTS

After controlling for age, ASA score, length of surgery, and all significant comorbidities, abnormal sodium (odds ratio [OR]=2.47, 95% confidence interval [CI]: 1.45-4.19, p=.001) and abnormal INR (OR=2.33, 95% CI: 1.09-4.98, p=.029) were significantly associated with the development of any complication. Sodium (OR=1.61, 95% CI: 1.01-2.54, p=.04) and platelets (OR=1.58, 95% CI: 1.02-2.44, p=.04) were associated with minor complications. Meanwhile, creatinine (OR=1.74, 95% CI: 1.02-2.99, p=.04) and platelets (OR=1.71, 95% CI: 1.02-2.89, p=.04) were significant predictors of major adverse events.

CONCLUSIONS

This study represents the first attempt to assess the utility of preoperative laboratories in predicting postoperative complications in PLF. Although the majority of laboratories were not significantly associated with adverse events, abnormal sodium values, INR, creatinine, and platelets were shown to be predictive of various complications.

Prevalence of Frailty in Patients with Osteoporotic Vertebral Compression Fracture and Its Association with Numbers of Fractures

PURPOSE

To assess the association between frailty and osteoporotic vertebral compression fracture (OVCF) and to evaluate the relationship between numbers of OVCFs and frailty.

MATERIALS AND METHODS

We enrolled 760 subjects, including 59 patients (with OVCF) and 701 controls (without OVCF). Successful matching provided 56 patient-control pairs. We analyzed principal clinical and demographic information, which included sex, age, height, weight, body mass index (BMI), variable frailty phenotypes, and Oswestry Disability Index (ODI) and EuroQol 5-dimension questionnaire (EQ-5D) scores. The association between frailty and OVCF was ascertained. In addition, the degrees of disability and quality of life attributable to frailty were determined.

RESULTS

The prevalence of frailty was significantly higher in the OVCF group than in the control group (p<0.001). Most of the frailty phenotypes, such as exhaustion, physical inactivity, slowness, and handgrip strength, were also significantly observed in the OVCF group. Within the OVCF group, the participants with frailty had significantly higher disability and lower quality of life than those in a robust state (p<0.001 for ODI and EQ-5D). In addition, the multivariate logistic regression analysis demonstrated that the patients with low BMI [odds ratio (OR)=0.704; 95% confidence interval (CI), 0.543-0.913] and ≥3 fractures (OR=9.213; 95% CI, 1.529-55.501) within the OVCF group were associated with higher odds of frailty.

CONCLUSION

The present study showed significant relationships between frailty and OVCF, severity of symptoms, and disability induced by OVCF. Furthermore, frailty could be a causal and/or resulting factor of OVCFs.

Discrepancies in the Definition of "Outpatient" Surgeries and Their Effect on Study Outcomes Related to ACDF and Lumbar Discectomy Procedures: A Retrospective Analysis of 45,204 Cases

STUDY DESIGN

This is a retrospective study.

OBJECTIVE

To study the differences in definition of "inpatient" and "outpatient" [stated status vs. actual length of stay (LOS)], and the effect of defining populations based on the different definitions, for anterior cervical discectomy and fusion (ACDF) and lumbar discectomy procedures in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

SUMMARY OF BACKGROUND DATA

There has been an overall trend toward performing ACDF and lumbar discectomy in the outpatient setting. However, with the possibility of patients who underwent outpatient surgery staying overnight or longer at the hospital under "observation" status, the distinction of "inpatient" and "outpatient" is not clear.

MATERIALS AND METHODS

Patients who underwent ACDF or lumbar discectomy in the 2005-2014 ACS-NSQIP database were identified. Outpatient procedures were defined in 1 of 2 ways: either as being termed "outpatient" or hospital LOS=0. Differences in definitions were studied. Further, to evaluate the effect of the different definitions, 30-day outcomes were compared between "inpatient" and "outpatient" and between LOS>0 and LOS=0 for ACDF patients.

RESULTS

Of the 4123 "outpatient" ACDF patients, 919 had LOS=0, whereas 3204 had LOS>0. Of the 13,210 "inpatient" ACDF patients, 337 had LOS=0, whereas 12,873 had LOS>0. Of the 15,166 "outpatient" lumbar discectomy patients, 8968 had LOS=0, whereas 6198 had LOS>0. Of the 12,705 "inpatient" lumbar discectomy patients, 814 had LOS=0, whereas 11,891 had LOS>0. On multivariate analysis of ACDF patients, when comparing "inpatient" with "outpatient" and "LOS>0" with "LOS=0" there were differences in risks for adverse outcomes based on the definition of outpatient status.

CONCLUSIONS

When evaluating the ACS-NSQIP population, ACDF and lumbar discectomy procedures recorded as "outpatient" can be misleading and often did not correlate with same day discharge. These findings have significant impact on the interpretation of existing studies and define an area that needs clarification for future studies.

LEVEL OF EVIDENCE

Level 3.

The Quality In-Training Initiative: Giving Residents Data to Learn Clinical Effectiveness

BACKGROUND

Training programs are expected to provide clinical outcomes data to residents. Few systems have the necessary infrastructure. We evaluated initial adoption and use of the Quality In-Training Initiative (QITI) platform linking National Surgical Quality Improvement Program (NSQIP) data to trainees.

STUDY DESIGN

Proportions of Accreditation Council for Graduate Medical Education general surgery residency programs with differing levels of NSQIP and QITI affiliation were calculated and program characteristics were compared. All NSQIP sites that captured QITI custom field data from July 2013 to June 2016 were included in case analysis. Differences in case collection were compared between participating (P) sites that actively participated in QITI and nonparticipating (NP) sites that did not. Resident participation by procedure type was examined.

RESULTS

Of 268 accredited general surgery residency programs, 92% (n = 248) is affiliated with a NSQIP hospital and 61% of all clinical months is spent at NSQIP sites. For 42% of all programs (n = 114), the primary teaching hospital is affiliated with the QITI. In all, 74 P sites and 89 NP sites captured a total of 417,816 cases. The median number of cases captured per site was statistically higher for P sites (3063) compared with NP sites (2307, p < 0.001). A total of 68.3% of all cases captured had resident participation indicated by postgraduate year (n = 285,469). The most common procedures with resident participation were laparoscopic appendectomy (n = 17,082, 6.0%) and laparoscopic cholecystectomy (n = 15,502, 5.4%). Percentage coverage rates ranged from 17.3% to 91.8%.

CONCLUSION

Most general surgery rotations are at NSQIP sites. Identifying resident participation in captured NSQIP cases is feasible on a large scale. Captured cases reflect national case-mix. The platform has the potential to collect data on institutional and program-level variation in resident operative experience that may be used to improve training.

Comparative study of perioperative complication rates of cervical laminoplasty performed by residents and teaching neurosurgeons

Early surgical education is required for neurosurgical residents to learn many surgical procedures. However, the participation of less experienced residents may increase perioperative complication rates. Perioperative complication studies in the field of neurosurgery are being increasingly published; however, studies have not yet focused on cervical laminoplasty. The study population included 193 consecutive patients who underwent cervical laminoplasty in Tokyo Metropolitan Neurological Hospital between 2008 and 2014. Patient and surgeon background factors, as well as perioperative complication rates were retrospectively compared between resident and board-certified spine neurosurgeon groups. Deteriorated or newly developed neurological deficits and surgical site complications within 30days of cervical laminoplasty were defined as perioperative complications. Out of 193 patients, 123 (64%) were operated on by residents as the first operator and 70 (36%) by board-certified spine neurosurgeons. No significant differences were observed in patient and surgeon factors between the two groups, except for hyperlipidemia (13 vs 17, p=0.02). Furthermore, no significant differences were noted in perioperative complication rates between the two groups (7 [5.7%] vs 4 [5.7%], p=1). Cervical laminoplasty performed in a standardized manner by residents who received their surgical training in our hospital did not increase perioperative complication rates, and ensured the safety of patients.

Comparing National Inpatient Sample and National Surgical Quality Improvement Program: An Independent Risk Factor Analysis for Risk Stratification in Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective study of prospectively collected data.

OBJECTIVE

To explore interdatabase reliability between National Inpatient Sample (NIS) and National Surgical Quality Improvement Program (NSQIP) for anterior cervical discectomy and fusion (ACDF) in data collection and its impact on subsequent statistical analyses.

SUMMARY OF BACKGROUND DATA

Clinical studies in orthopedics using national databases are ubiquitous, but analytical differences across databases are largely unexplored.

METHODS

A retrospective cohort study of patients undergoing ACDF surgery was performed in NIS and NSQIP. Key demographic variables, comorbidities, intraoperative characteristics, and postoperative complications were analyzed via bivariate and multivariate analyses.

RESULTS

A total of 112,162 patients were identified from NIS and 10,617 from NSQIP. Bivariate analysis revealed small, but significant, differences between patient demographics, whereas patient comorbidities and ACDF intraoperative variables were largely much more distinct across the two databases. Multivariate analysis identified independent risk factors between NIS and NSQIP for mortality, cardiac complications, and postoperative sepsis, some of which were identified in both but most of which were unique to one database. Identification of independent risk factors from both databases specifically highlights their greater validity and importance in stratifying patient risks. In addition, NSQIP was found to be a more accurate predictor for complications based on the average areas under the receiver-operating curve (CNSQIP = 0.83 vs. CNIS = 0.81) across the multivariate models. Complication rate analysis between inpatient and outpatient settings in NSQIP showed the importance of at least 30-day patient follow up, which was devoid in NIS data tabulation and further marked its weakness compared with NSQIP.

CONCLUSION

Despite having largely similar patient demographics, this study highlights critical risk factors for ACDF and demonstrates how different patient profiles can be across NIS and NSQIP, the impact of such differences on identification of independent risk factors, and how NSQIP is ultimately better suited for adverse-event studies.

LEVEL OF EVIDENCE

3.