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Warn MJ, Torabi SJ, Bitner BF, Chan D, Nguyen TV, Kuan EC. Clinical Productivity and Patient Complexity of Academic Rhinologists: An Analysis of Medicare Metrics. Laryngoscope 2024; 134:3960-3964. [PMID: 38597779 DOI: 10.1002/lary.31437] [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] [Received: 02/02/2024] [Revised: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/11/2024]
Abstract
INTRODUCTION Current data regarding reimbursement trends in Medicare services and the complexity of patients treated as physicians' progress in their academic career are conflicting. In otolaryngology, there are no data examining these metrics. METHODS Medicare services, reimbursement, and patient complexity risk scores (based on hierarchical condition category coding) of US rhinology fellowship-trained faculty were stratified and compared by rank and years in practice. RESULTS A cohort of 209 rhinologists were included. Full professors were reimbursed more per service than assistant professors ($791.53 [$491.69-1052.46] vs. $590.34 [$429.91-853.07] p = 0.045) and had lower risk scores (1.37 [1.26-1.52] vs. 1.49 [1.29-1.68], p = 0.013). Full professors had similar risk scores to associate professors (1.47 [1.25-1.64], p = 0.14). Full professors ($791.53 [$491.69-1,052.46], p < 0.001), associate professors ($706.85 [$473.48-941.15], p < 0.001), and assistant professors ($590.34 [$429.91-853.07], p < 0.001) were all reimbursed more per service than non-ranked faculty ($326.08 [$223.37-482.36]). As a cohort, significant declines in risk scores occurred within the 10th-14th year of practice (p = 0.032) and after the 20th year (p = 0.038). Years in practice were inversely correlated with risk score (R = -0.358, p < 0.001). CONCLUSION Full professors were reimbursed more per service and treated less comorbid Medicare patients than junior academic colleagues. Patient comorbidity was correlated negatively with years in practice, with significant drops in mid and late career. Rhinologists employed at academic institutions had greater total reimbursement and reimbursement per service than non-ranked faculty. LEVEL OF EVIDENCE N/A Laryngoscope, 134:3960-3964, 2024.
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Affiliation(s)
- Michael J Warn
- School of Medicine, University of California, Riverside, California, U.S.A
| | - Sina J Torabi
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, U.S.A
| | - Benjamin F Bitner
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, U.S.A
| | - Daniella Chan
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, U.S.A
| | - Theodore V Nguyen
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, U.S.A
| | - Edward C Kuan
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, U.S.A
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Rosengart TK, Chen JH, Gantt NL, Angelos P, Warshaw AL, Rosen JE, Perrier ND, Kaups KL, Doherty GM, Zoumpou T, Ashley SW, Doscher W, Welsh D, Savarise M, Sutherland MJ, Sidawy AN, Kopelan AM. Sustaining Lifelong Competency of Surgeons: Multimodality Empowerment Personal and Institutional Strategy. J Am Coll Surg 2024; 239:187-189. [PMID: 38591782 DOI: 10.1097/xcs.0000000000001066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Affiliation(s)
- Todd K Rosengart
- From the Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (Rosengart, Chen)
| | - Jennifer H Chen
- From the Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (Rosengart, Chen)
| | - Nancy L Gantt
- Department of Surgery, Northeast Ohio Medical University, Youngstown, OH (Gantt)
| | - Peter Angelos
- Section of General Surgery and Surgical Oncology, Department of Surgery, University of Chicago Medicine, Chicago, IL (Angelos)
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Warshaw)
| | - Jennifer E Rosen
- Division of Endocrine Surgery, MedStar-Washington Hospital Center, Washington, DC (Rosen)
| | - Nancy D Perrier
- Department of Surgical Oncology, Section of Surgical Endocrinology, The University of Texas MD Anderson Cancer Center, Houston, TX (Perrier)
| | - Krista L Kaups
- Department of Surgery, University of California San Francisco Fresno, Fresno, CA (Kaups)
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Doherty, Ashley)
| | - Theofano Zoumpou
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ (Zoumpou)
| | - Stanley W Ashley
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Doherty, Ashley)
| | - William Doscher
- Department of Surgery, Zucker School of Medicine at Hofstra, Northwell, NY (Doscher)
| | - David Welsh
- Margaret Mary Health, Batesville, IN (Welsh)
| | - Mark Savarise
- Section of Community General Surgery, University of Utah South Jordan Health Center, South Jordan, UT (Savarise)
| | | | - Anton N Sidawy
- Department of Surgery, George Washington University, Washington, DC (Sidawy)
| | - Adam M Kopelan
- Department of Surgery, Newark Beth Israel Medical Center, RWJ Barnabas Health, Newark, NJ (Kopelan)
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Cannas S, Casciani F, Vollmer CM. Extending Quality Improvement for Pancreatoduodenectomy Within the High-Volume Setting: The Experience Factor. Ann Surg 2024; 279:1036-1045. [PMID: 37522844 DOI: 10.1097/sla.0000000000006060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To analyze the association of a surgeon's experience with postoperative outcomes of pancreatoduodenectomies (PDs) when stratified by Fistula Risk Score (FRS). BACKGROUND Centralization is now well-established for pancreatic surgery. Nevertheless, the benefits of individual surgeon's experience in high-volume settings remain undefined. METHODS Pancreatoduodenectomies performed by 82 surgeons across 18 international specialty institutions (median: 140 PD/year) were analyzed. Surgeon cumulative PD volume was linked with postoperative outcomes through multivariable models, adjusted for patient/operative characteristics and the FRS. Then, surgeon experience was also stratified by the 10, previously defined, most clinically impactful scenarios for clinically relevant pancreatic fistula (CR-POPF) development. RESULTS Of 8189 PDs, 18.7% suffered severe complications (Accordion≥3), 4.8% were reoperated upon and 2.2% expired. Although the most experienced surgeons (top-quartile; >525 career PDs) more often operated on riskier cases, their experience was significantly associated with declines in CR-POPF ( P <0.001), severe complications ( P =0.008), reoperations ( P <0.001), and length of stay (LOS) ( P <0.001)-accentuated even more in the most impactful FRS scenarios (2830 patients). Risk-adjusted models indicate male sex, increasing age, ASA class, and FRS, but not surgeon experience, as being associated with severe complications, failure-to-rescue, and mortality. Instead, upper-echelon experience demonstrates significant reductions in CR-POPF (OR 0.66), reoperations (OR 0.64), and LOS (OR 0.65) in moderate-to-high fistula risk circumstances (FRS≥3, 68% of cases). CONCLUSIONS At specialty institutions, major morbidity, mortality, and failure-to-rescue are primarily associated with baseline patient characteristics, while cumulative surgical experience impacts pancreatic fistula occurrence and its attendant effects for most higher-risk pancreatoduodenectomies. These data also suggest an extended proficiency curve exists for this operation.
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Affiliation(s)
- Samuele Cannas
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Fabio Casciani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | - Charles M Vollmer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Bosco JA, Papalia A, Zuckerman JD. Surgery and the Aging Orthopaedic Surgeon. J Bone Joint Surg Am 2024; 106:241-246. [PMID: 38127852 DOI: 10.2106/jbjs.23.00653] [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] [Indexed: 12/23/2023]
Abstract
➤ Aging is associated with well-documented neurocognitive and psychomotor changes.➤ These changes can be expected to impact the skill with which orthopaedic surgeons continue to perform surgical procedures.➤ Currently, there is no standardized approach for assessing the changes in surgical skills and clinical judgment that may occur with aging.➤ Oversight by the U.S. Equal Employment Opportunity Commission, the impact of the Age Discrimination in Employment Act, and the current legal climate make it difficult to institute a mandatory assessment program.➤ The regularly scheduled credentialing process that occurs at each institution can be the most effective time to assess for these changes because it utilizes an established process that occurs at regularly scheduled intervals.➤ Each department of orthopaedic surgery and institution should determine an approach that can be utilized when there is concern that a surgeon's surgical skills have shown signs of deterioration.
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Affiliation(s)
- Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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Shilnikova N, Momoli F, Taher MK, Go J, McDowell I, Cashman N, Terrell R, Iscan Insel E, Beach J, Kain N, Krewski D. Should we screen aging physicians for cognitive decline? Aging Ment Health 2024; 28:207-226. [PMID: 37691440 DOI: 10.1080/13607863.2023.2252371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/18/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVES To synthesize evidence relevant for informed decisions concerning cognitive testing of older physicians. METHODS Relevant literature was systematically searched in Medline, EMBASE, PsycInfo, and ERIC, with key findings abstracted and synthesized. RESULTS Cognitive abilities of physicians may decline in an age range where they are still practicing. Physician competence and clinical performance may also decline with age. Cognitive scores are lower in physicians referred for assessment because of competency or performance concerns. Many physicians do not accurately self-assess and continue to practice despite declining quality of care; however, perceived cognitive decline, although not an accurate indicator of ability, may accelerate physicians' decision to retire. Physicians are reluctant to report colleagues' cognitive problems. Several issues should be considered in implementing cognitive screening. Most cognitive assessment tools lack normative data for physicians. Scientific evidence linking cognitive test results with physician performance is limited. There is no known level of cognitive decline at which a doctor is no longer fit to practice. Finally, relevant domains of cognitive ability vary across medical specialties. CONCLUSION Physician cognitive decline may impact clinical performance. If cognitive assessment of older physicians is to be implemented, it should consider challenges of cognitive test result interpretation.
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Affiliation(s)
- Natalia Shilnikova
- Risk Sciences International, Ottawa, Canada
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, Canada
| | - Franco Momoli
- Risk Sciences International, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Mohamed Kadry Taher
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- School of Mathematics and Statistics, Carleton University, Ottawa, Canada
| | - Jennifer Go
- Risk Sciences International, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Ian McDowell
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Neil Cashman
- Department of Medicine (Neurology), Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Rowan Terrell
- Risk Sciences International, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | | | - Jeremy Beach
- College of Physicians & Surgeons of Alberta, Edmonton, Alberta, Canada
| | - Nicole Kain
- College of Physicians & Surgeons of Alberta, Edmonton, Alberta, Canada
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Krewski
- Risk Sciences International, Ottawa, Canada
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- School of Mathematics and Statistics, Carleton University, Ottawa, Canada
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Henretig FM, Wood JN, Shea JA, Schapira MM, Ruddy RM. Pediatric Emergency Medicine Physicians' Perceptions of Colleagues' Clinical Performance Over Career Span. Pediatr Emerg Care 2023; 39:304-310. [PMID: 35766881 DOI: 10.1097/pec.0000000000002785] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The US physician workforce is aging, prompting concerns regarding clinical performance of senior physicians. Pediatric emergency medicine (PEM) is a high-acuity, multitasking, diagnostically complex and procedurally demanding specialty. Aging's impact on clinical performance in PEM has not been examined. We aimed to assess PEM physician's' perceptions of peers' clinical performance over career span. METHODS We surveyed 478 PEM physician members of the American Academy of Pediatrics' Section on Emergency Medicine survey study list-serve in 2020. The survey was designed by the investigators with iterative input from colleagues. Respondents rated, using a 5-point Likert scale, the average performance of 4 age categories of PEM physicians in 9 clinical competencies. Additional items included concerns about colleague's performance and preferences for age of physician managing a critically ill child family member. RESULTS We received 232 surveys with responses to core initial items (adjusted response rate, 49%). Most respondents were 36 to 49 (34.9%) or 50 to 64 (47.0%) years old. Fifty-three percent reported ever having concern about a colleague's performance. For critical care-related competencies, fewer respondents rated the ≥65-year age group as very good or excellent compared with midcareer physicians (36-49 or 50-64 years old). The ratings for difficult communications with families were better for those 65 years or older than those 35 years or younger. Among 129 of 224 respondents (58%) indicating a preferred age category for a colleague managing a critically ill child relative, most (69%) preferred a 36 to 49-year-old colleague. CONCLUSIONS Pediatric emergency medicine physicians' perceptions of peers' clinical performance demonstrated differences by peer age group. Physicians 65 years or older were perceived to perform less well than those 36 to 64 years old in procedural and multitasking skills. However, senior physicians were perceived as performing as well if not better than younger peers in communication skills. Further study of age-related PEM clinical performance with objective measures is warranted.
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Affiliation(s)
| | - Joanne N Wood
- General Pediatrics, Children's Hospital of Philadelphia, Departments of Pediatrics
| | | | - Marilyn M Schapira
- Division of General Internal Medicine, Veteran's Administration Medical Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Richard M Ruddy
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Jung Y, Kim K, Choi ST, Kang JM, Cho NR, Ko DS, Kim YH. Association between surgeon age and postoperative complications/mortality: a systematic review and meta-analysis of cohort studies. Sci Rep 2022; 12:11251. [PMID: 35788658 PMCID: PMC9252995 DOI: 10.1038/s41598-022-15275-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 06/21/2022] [Indexed: 11/09/2022] Open
Abstract
The surgical workforce, like the rest of the population, is ageing. This has raised concerns about the association between the age of the surgeon and their surgical outcomes. We performed a systematic review and meta-analysis of cohort studies on postoperative mortality and major morbidity according to the surgeons' age. The search was performed on February 2021 using the Embase, Medline and CENTRAL databases. Postoperative mortality and major morbidity were evaluated as clinical outcomes. We categorized the surgeons' age into young-, middle-, and old-aged surgeons. We compared the differences in clinical outcomes for younger and older surgeons compared to middle-aged surgeons. Subgroup analyses were performed for major and minor surgery. Ten retrospective cohort studies on 29 various surgeries with 1,666,108 patients were considered. The mortality in patients undergoing surgery by old-aged surgeons was 1.14 (1.02-1.28, p = 0.02) (I2 = 80%) compared to those by middle-aged surgeon. No significant differences were observed according to the surgeon's age in the major morbidity and subgroup analyses. This meta-analysis indicated that surgeries performed by old-aged surgeons had a higher risk of postoperative mortality than those by middle-aged surgeons. Thus, it necessitates the introduction of a multidisciplinary approach to evaluate the performance of senior surgeons.
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Affiliation(s)
- Yeongin Jung
- Department of Medicine, School of Medicine, Pusan National University, Busan, Republic of Korea
| | - Kihun Kim
- Department of Occupational and Environmental Medicine, Kosin University Gospel Hospital, Busan, Republic of Korea
| | - Sang Tae Choi
- Division of Vascular Surgery, Department of Surgery, Gachon University Gil Medical Center, Incheon, 21565, Republic of Korea
| | - Jin Mo Kang
- Division of Vascular Surgery, Department of Surgery, Gachon University Gil Medical Center, Incheon, 21565, Republic of Korea
| | - Noo Ree Cho
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, 21565, Republic of Korea.
| | - Dai Sik Ko
- Division of Vascular Surgery, Department of Surgery, Gachon University Gil Medical Center, Incheon, 21565, Republic of Korea.
| | - Yun Hak Kim
- Department of Biomedical Informatics, School of Medicine, Pusan National University, Yangsan, 50612, Republic of Korea. .,Department of Anatomy, School of Medicine, Pusan National University, Busan, Republic of Korea.
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Abstract
BACKGROUND With doctors in short supply and a strong demand for surgeon services in all areas of the United States, urban and rural, there are pressures to remain in active practice for longer. Even with an older workforce, there are currently no requirements for when a surgeon must retire in the United States. OBJECTIVES The aim of this article was to highlight the importance of the aging surgeon to the medical community and to provide an evidence-based overview of age-related cognitive and physical issues that develop during the later stages of a surgeon's career. METHODS A search of the PubMed/MEDLINE database was performed for the phrase "aging surgeon." Inclusion criteria were applied to include only those articles related to surgeon age or retirement. Additional reports were handpicked from citations to substantiate claims with statistical evidence. RESULTS The aging surgeon contributes extensive experience to patient care, but is also prone to age-related changes in cognition, vision, movement, and stress as it relates to new techniques, surgical performance, and safety measures. Studies show that although surgeons are capable of operating well into their senior years, there is the potential of decline. Nevertheless, there are proven recommendations on how to prepare an older surgeon for retirement. CONCLUSIONS Age-related trends in cognitive and physical decline must be counterbalanced with wisdom gained through decades of surgical experience.
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Affiliation(s)
| | - Jeffrey E Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Abstract
PURPOSE OF REVIEW This review addresses the importance of some of the human factors for intraoperative patient safety with particular focus on the active failures. These are the mishaps or sentinel events related to decisons taken and actions performed by the individual at the delivery end of a system. Such sentinel events may greatly affect intraoperative patient safety. RECENT FINDINGS Intimidating, aggressive and disruptive communication is a cause of adverse staff interaction, which may then represent an important patient safety threat. Also, anaesthesiologist's physical and mental state and limitations may interfere with patient safety. SUMMARY The concept of physician well being is multidimensional and includes factors related to each physician as an individual as well as to the working environment. Creating optimal safe conditions for patients, therefore, requires actions at both the personal level and the working conditions. Also, initiatives to ban rude and dismissive communication should be implemented in order to further improve intraoperative patient safety.
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Affiliation(s)
- Stefan De Hert
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
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Brancato SC, Wang M, Spinelli KJ, Gandhavadi M, Worrall NK, Lehr EJ, DeBoard ZM, Fitton TP, Leiataua A, Piccini JP, Gluckman TJ. Temporal trends and predictors of surgical ablation for atrial fibrillation across a multistate healthcare system. Heart Rhythm O2 2021; 3:32-39. [PMID: 35243433 PMCID: PMC8859806 DOI: 10.1016/j.hroo.2021.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Multiple class I and class IIa recommendations exist related to surgical ablation (SA) of atrial fibrillation (AF) in patients undergoing cardiac surgery. Objective Examine temporal trends and predictors of SA for AF in a large US healthcare system. Methods We retrospectively analyzed data from the Society for Thoracic Surgery (STS) Adult Cardiac Surgery Database for 21 hospitals in the Providence St. Joseph Health system. All patients with preoperative AF who underwent isolated coronary artery bypass graft (CABG) surgery, isolated aortic valve replacement (AVR), AVR with CABG surgery (AVR+CABG), isolated mitral valve repair or replacement (MVRr), and MVRr with CABG surgery (MVRr+CABG) from July 1, 2014, to March 31, 2020 were included. Temporal trends in SA were evaluated using the Cochran-Armitage trends test. A multilevel logistic regression model was used to examine patient-, hospital-, and surgeon-level predictors of SA. Results Among 3124 patients with preoperative AF, 910 (29.1%) underwent SA. This was performed most often in those undergoing isolated MVRr (n = 324, 44.8%) or MVRr+CABG (n = 75, 35.2%). Rates of SA increased over time and were highly variable between hospitals. Years since graduation from medical school for the primary operator was one of the few predictors of SA: odds ratio (95% confidence interval) = 0.71 (0.56–0.90) for every 10-year increase. Annual surgical (both hospital and operator) and AF catheter ablation volumes were not predictive of SA. Conclusion Wide variability in rates of SA for AF exist, underscoring the need for greater preoperative collaboration between cardiologists, electrophysiologists, and cardiac surgeons.
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Polster SP, Carrión-Penagos J, Lyne SB, Goldenberg FD, Mansour A, Ziai W, Carlson AP, Camarata PJ, Caron JL, Harrigan MR, Gregson B, Mendelow AD, Zuccarello M, Hanley DF, Dodd R, Awad IA. Thrombolysis for Evacuation of Intracerebral and Intraventricular Hemorrhage: A Guide to Surgical Protocols With Practical Lessons Learned From the MISTIE and CLEAR Trials. Oper Neurosurg (Hagerstown) 2021; 20:98-108. [PMID: 33313847 DOI: 10.1093/ons/opaa306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 07/11/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) procedure was recently tested in a large phase III randomized trial showing a significant probability of functional benefit in those cases that reached the goal hematoma evacuation of ≤15 mL residual (or ≥70% removal). Benefit of thrombolysis was also identified in cases with large intraventricular hemorrhage, and achieving at least 85% volume reduction in the Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. OBJECTIVE To protocolize steps in the MISTIE and CLEAR procedures in order to maximize hematoma evacuation and minimize complications. METHODS We articulate data-driven lessons and expert opinions surrounding the factors of patient selection, catheter placement, and dosing, which impacted safety and surgical performance in the MISTIE and CLEAR trials. RESULTS Modifiable factors to maximize evacuation efficiency include optimizing catheter placement and pursuing aggressive dosing to achieve treatment goals, while strictly adhering to the safety steps as articulated in the respective trials. Prognostic factors that are viewed as nonmodifiable include greater initial intracerebral hemorrhage volume with irregular shape, smaller intraventricular bleeds, and the uncommon but consequential development of new bleeding during the dosing period despite strict protocol adherence. CONCLUSIONS Surgeon education in this tutorial is aimed at maximizing the benefit of the MISTIE and CLEAR procedures by reviewing case selection, safety steps, treatment objectives, and technical nuances. Key lessons include stability imaging, etiology screening, and technical adherence to the protocol in order to achieve defined thresholds of evacuation.
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Affiliation(s)
- Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Julián Carrión-Penagos
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Seán B Lyne
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Fernando D Goldenberg
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Ali Mansour
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Paul J Camarata
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Jean-Louis Caron
- Department of Neurosurgery, University of Texas, San Antonio, Texas
| | - Mark R Harrigan
- Division of Neurosurgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Barbara Gregson
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - A David Mendelow
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Robert Dodd
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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13
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Giurgius M, Horn M, Thomas SD, Shishehbor MH, Barry Beiles C, Mwipatayi BP, Varcoe RL. The Relationship Between Carotid Revascularization Procedural Volume and Perioperative Outcomes in Australia and New Zealand. Angiology 2021; 72:715-723. [PMID: 33535812 DOI: 10.1177/0003319721991717] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) prevent stroke in selected patients. However, each intervention carries a risk of perioperative complications including stroke or death (S/D). We aimed to determine the relationship between operator volume, hospital volume, and the perioperative risk of S/D in carotid revascularization in Australia and New Zealand. Retrospective analysis was performed on prospectively collected data extracted from the Australasian Vascular Audit between 2010 and 2017. Annual caseload volume was analyzed in quintiles (Q) using multivariate regression to assess its impact on perioperative S/D. Carotid endarterectomy procedures (n = 16 765) demonstrated higher S/D rates for lower-volume operators (2.21% for Q1-Q3 [1-17 annual cases] vs 1.76% for Q4-Q5 [18-61 annual cases]; odds ratio [OR]: 1.28; 95% CI: 1.001-1.64; P = .049). Carotid artery stenting procedures (n = 1350) also demonstrated higher S/D rates for lower-volume operators (2.63% for Q1-Q3 [1-11 annual cases] vs 0.37% for Q4-Q5 [12-31 annual cases]; OR: 6.11; 95% CI: 1.27-29.33; P = .024). No significant hospital volume-outcome effect was observed for either procedure. An inverse relationship was demonstrated between operator volume and perioperative S/D rates following CEA and CAS. Consideration of minimum operator thresholds, restructuring of services and networked referral pathways of care in Australia and New Zealand, would likely result in improved patient outcomes.
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Affiliation(s)
- Mary Giurgius
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Marco Horn
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia
| | - Shannon D Thomas
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,The Vascular Institute, Prince of Wales Hospital, Sydney, Australia
| | - Mehdi H Shishehbor
- Harrington Heart & Vascular Institute and Case Western Reserve University School of Medicine, University Hospitals, Cleveland, OH, USA
| | - C Barry Beiles
- Australasian Vascular Audit, Australian and New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - B Patrice Mwipatayi
- Department of Vascular Surgery, University of Western Australia, School of Surgery and Royal Perth Hospital, Perth, Australia
| | - Ramon L Varcoe
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,The Vascular Institute, Prince of Wales Hospital, Sydney, Australia
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14
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Kelz RR, Sellers MM, Niknam BA, Sharpe JE, Rosenbaum PR, Hill AS, Zhou H, Hochman LL, Bilimoria KY, Itani K, Romano PS, Silber JH. A National Comparison of Operative Outcomes of New and Experienced Surgeons. Ann Surg 2021; 273:280-288. [PMID: 31188212 PMCID: PMC6898745 DOI: 10.1097/sla.0000000000003388] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine whether outcomes achieved by new surgeons are attributable to inexperience or to differences in the context in which care is delivered and patient complexity. BACKGROUND Although prior studies suggest that new surgeon outcomes are worse than those of experienced surgeons, factors that underlie these phenomena are poorly understood. METHODS A nationwide observational tapered matching study of outcomes of Medicare patients treated by new and experienced surgeons in 1221 US hospitals (2009-2013). The primary outcome studied is 30-day mortality. Secondary outcomes were examined. RESULTS In total, 694,165 patients treated by 8503 experienced surgeons were matched to 68,036 patients treated by 2119 new surgeons working in the same hospitals. New surgeons' patients were older (25.8% aged ≥85 vs 16.3%,P<0.0001) with more emergency admissions (53.9% vs 25.8%,P<0.0001) than experienced surgeons' patients. Patients of new surgeons had a significantly higher baseline 30-day mortality rate compared with patients of experienced surgeons (6.2% vs 4.5%,P<0.0001;OR 1.42 (1.33, 1.52)). The difference remained significant after matching the types of operations performed (6.2% vs 5.1%, P<0.0001; OR 1.24 (1.16, 1.32)) and after further matching on a combination of operation type and emergency admission status (6.2% vs 5.6%, P=0.0007; OR 1.12 (1.05, 1.19)). After matching on operation type, emergency admission status, and patient complexity, the difference between new and experienced surgeons' patients' 30-day mortality became indistinguishable (6.2% vs 5.9%,P=0.2391;OR 1.06 (0.97, 1.16)). CONCLUSIONS Among Medicare beneficiaries, the majority of the differences in outcomes between new and experienced surgeons are related to the context in which care is delivered and patient complexity rather than new surgeon inexperience.
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Affiliation(s)
- Rachel R. Kelz
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA
| | - Morgan M. Sellers
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Bijan A. Niknam
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - James E. Sharpe
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Paul R. Rosenbaum
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA
- Department of Statistics, The Wharton School, The University of Pennsylvania, Philadelphia, PA
| | - Alexander S. Hill
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Hong Zhou
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Lauren L. Hochman
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Karl Y. Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Northwestern Medicine, Chicago IL
| | - Kamal Itani
- VA Boston Health Care System, Boston, MA
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Patrick S. Romano
- Division of General Medicine and Center for Healthcare Policy and Research, University of California Davis School of Medicine, Sacramento, CA
| | - Jeffrey H. Silber
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
- The Departments of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia, PA
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15
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Sataloff RT, Hawkshaw M, Kutinsky J, Maitz EA. The Aging Physician and Surgeon. EAR, NOSE & THROAT JOURNAL 2020; 95:E35-48. [DOI: 10.1177/0145561318095004-507] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Robert T. Sataloff
- Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia
| | - Mary Hawkshaw
- Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia
| | - Joshua Kutinsky
- The Institute of Graduate Clinical Psychology at Widener University, Chester, Pa., and Aetna Life Insurance Company, Blue Bell, Pa
| | - Edward A. Maitz
- Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia
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16
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Satkunasivam R, Klaassen Z, Ravi B, Fok KH, Menser T, Kash B, Miles BJ, Bass B, Detsky AS, Wallis CJD. Relation between surgeon age and postoperative outcomes: a population-based cohort study. CMAJ 2020; 192:E385-E392. [PMID: 32392499 DOI: 10.1503/cmaj.190820] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Aging may detrimentally affect cognitive and motor function. However, age is also associated with experience, and how these factors interplay and affect outcomes following surgery is unclear. We sought to evaluate the effect of surgeon age on postoperative outcomes in patients undergoing common surgical procedures. METHODS We performed a retrospective cohort study of patients undergoing 1 of 25 common surgical procedures in Ontario, Canada, from 2007 to 2015. We evaluated the association between surgeon age and a composite outcome of death, readmission and complications. We used generalized estimating equations for analysis, accounting for relevant patient-, procedure-, surgeon- and hospital-level factors. RESULTS We found 1 159 676 eligible patients who were treated by 3314 surgeons and ranged in age from 27 to 81 years. Modelled as a continuous variable, a 10-year increase in surgeon age was associated with a 5% relative decreased odds of the composite outcome (adjusted odds ratio [OR] 0.95, 95% confidence interval [CI] 0.92 to 0.98, p = 0.002). Considered dichotomously, patients receiving treatment from surgeons who were older than 65 years of age had a 7% lower odds of adverse outcomes (adjusted OR 0.93, 95% CI 0.88-0.97, p = 0.03; crude absolute difference = 3.1%). INTERPRETATION We found that increasing surgeon age was associated with decreasing rates of postoperative death, readmission and complications in a nearly linear fashion after accounting for patient-, procedure-, surgeon- and hospital-level factors. Further evaluation of the mechanisms underlying these findings may help to improve patient safety and outcomes, and inform policy about maintenance of certification and retirement age for surgeons.
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Affiliation(s)
- Raj Satkunasivam
- Department of Urology (Satkunasivam, Miles) and Center for Outcomes Research (Satkunasivam, Menser, Kash, Bass), Houston Methodist Hospital, Houston, Tex.; Division of Urology (Klaassen), Medical College of Georgia - Augusta University, Augusta, Ga.; Division of Orthopedic Surgery (Ravi), Department of Surgery, and Sunnybrook Health Sciences, Centre, and Division of Urology (Fok, Wallis), Department of Surgery, University of Toronto, Toronto, Ont.; Department of Health Policy and Management (Kash), School of Public Health, Texas A&M University, College Station Tex.; Department of Surgery (Menser, Bass), Houston Methodist Hospital, Houston, Tex.; Institute for Health Policy, Management and Evaluation and Department of Medicine (Detsky), University of Toronto; Department of Medicine (Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Urology (Wallis), Vanderbilt University Medical Center, Nashville, Tenn.
| | - Zachary Klaassen
- Department of Urology (Satkunasivam, Miles) and Center for Outcomes Research (Satkunasivam, Menser, Kash, Bass), Houston Methodist Hospital, Houston, Tex.; Division of Urology (Klaassen), Medical College of Georgia - Augusta University, Augusta, Ga.; Division of Orthopedic Surgery (Ravi), Department of Surgery, and Sunnybrook Health Sciences, Centre, and Division of Urology (Fok, Wallis), Department of Surgery, University of Toronto, Toronto, Ont.; Department of Health Policy and Management (Kash), School of Public Health, Texas A&M University, College Station Tex.; Department of Surgery (Menser, Bass), Houston Methodist Hospital, Houston, Tex.; Institute for Health Policy, Management and Evaluation and Department of Medicine (Detsky), University of Toronto; Department of Medicine (Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Urology (Wallis), Vanderbilt University Medical Center, Nashville, Tenn
| | - Bheeshma Ravi
- Department of Urology (Satkunasivam, Miles) and Center for Outcomes Research (Satkunasivam, Menser, Kash, Bass), Houston Methodist Hospital, Houston, Tex.; Division of Urology (Klaassen), Medical College of Georgia - Augusta University, Augusta, Ga.; Division of Orthopedic Surgery (Ravi), Department of Surgery, and Sunnybrook Health Sciences, Centre, and Division of Urology (Fok, Wallis), Department of Surgery, University of Toronto, Toronto, Ont.; Department of Health Policy and Management (Kash), School of Public Health, Texas A&M University, College Station Tex.; Department of Surgery (Menser, Bass), Houston Methodist Hospital, Houston, Tex.; Institute for Health Policy, Management and Evaluation and Department of Medicine (Detsky), University of Toronto; Department of Medicine (Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Urology (Wallis), Vanderbilt University Medical Center, Nashville, Tenn
| | - Kai-Ho Fok
- Department of Urology (Satkunasivam, Miles) and Center for Outcomes Research (Satkunasivam, Menser, Kash, Bass), Houston Methodist Hospital, Houston, Tex.; Division of Urology (Klaassen), Medical College of Georgia - Augusta University, Augusta, Ga.; Division of Orthopedic Surgery (Ravi), Department of Surgery, and Sunnybrook Health Sciences, Centre, and Division of Urology (Fok, Wallis), Department of Surgery, University of Toronto, Toronto, Ont.; Department of Health Policy and Management (Kash), School of Public Health, Texas A&M University, College Station Tex.; Department of Surgery (Menser, Bass), Houston Methodist Hospital, Houston, Tex.; Institute for Health Policy, Management and Evaluation and Department of Medicine (Detsky), University of Toronto; Department of Medicine (Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Urology (Wallis), Vanderbilt University Medical Center, Nashville, Tenn
| | - Terri Menser
- Department of Urology (Satkunasivam, Miles) and Center for Outcomes Research (Satkunasivam, Menser, Kash, Bass), Houston Methodist Hospital, Houston, Tex.; Division of Urology (Klaassen), Medical College of Georgia - Augusta University, Augusta, Ga.; Division of Orthopedic Surgery (Ravi), Department of Surgery, and Sunnybrook Health Sciences, Centre, and Division of Urology (Fok, Wallis), Department of Surgery, University of Toronto, Toronto, Ont.; Department of Health Policy and Management (Kash), School of Public Health, Texas A&M University, College Station Tex.; Department of Surgery (Menser, Bass), Houston Methodist Hospital, Houston, Tex.; Institute for Health Policy, Management and Evaluation and Department of Medicine (Detsky), University of Toronto; Department of Medicine (Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Urology (Wallis), Vanderbilt University Medical Center, Nashville, Tenn
| | - Bita Kash
- Department of Urology (Satkunasivam, Miles) and Center for Outcomes Research (Satkunasivam, Menser, Kash, Bass), Houston Methodist Hospital, Houston, Tex.; Division of Urology (Klaassen), Medical College of Georgia - Augusta University, Augusta, Ga.; Division of Orthopedic Surgery (Ravi), Department of Surgery, and Sunnybrook Health Sciences, Centre, and Division of Urology (Fok, Wallis), Department of Surgery, University of Toronto, Toronto, Ont.; Department of Health Policy and Management (Kash), School of Public Health, Texas A&M University, College Station Tex.; Department of Surgery (Menser, Bass), Houston Methodist Hospital, Houston, Tex.; Institute for Health Policy, Management and Evaluation and Department of Medicine (Detsky), University of Toronto; Department of Medicine (Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Urology (Wallis), Vanderbilt University Medical Center, Nashville, Tenn
| | - Brian J Miles
- Department of Urology (Satkunasivam, Miles) and Center for Outcomes Research (Satkunasivam, Menser, Kash, Bass), Houston Methodist Hospital, Houston, Tex.; Division of Urology (Klaassen), Medical College of Georgia - Augusta University, Augusta, Ga.; Division of Orthopedic Surgery (Ravi), Department of Surgery, and Sunnybrook Health Sciences, Centre, and Division of Urology (Fok, Wallis), Department of Surgery, University of Toronto, Toronto, Ont.; Department of Health Policy and Management (Kash), School of Public Health, Texas A&M University, College Station Tex.; Department of Surgery (Menser, Bass), Houston Methodist Hospital, Houston, Tex.; Institute for Health Policy, Management and Evaluation and Department of Medicine (Detsky), University of Toronto; Department of Medicine (Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Urology (Wallis), Vanderbilt University Medical Center, Nashville, Tenn
| | - Barbara Bass
- Department of Urology (Satkunasivam, Miles) and Center for Outcomes Research (Satkunasivam, Menser, Kash, Bass), Houston Methodist Hospital, Houston, Tex.; Division of Urology (Klaassen), Medical College of Georgia - Augusta University, Augusta, Ga.; Division of Orthopedic Surgery (Ravi), Department of Surgery, and Sunnybrook Health Sciences, Centre, and Division of Urology (Fok, Wallis), Department of Surgery, University of Toronto, Toronto, Ont.; Department of Health Policy and Management (Kash), School of Public Health, Texas A&M University, College Station Tex.; Department of Surgery (Menser, Bass), Houston Methodist Hospital, Houston, Tex.; Institute for Health Policy, Management and Evaluation and Department of Medicine (Detsky), University of Toronto; Department of Medicine (Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Urology (Wallis), Vanderbilt University Medical Center, Nashville, Tenn
| | - Allan S Detsky
- Department of Urology (Satkunasivam, Miles) and Center for Outcomes Research (Satkunasivam, Menser, Kash, Bass), Houston Methodist Hospital, Houston, Tex.; Division of Urology (Klaassen), Medical College of Georgia - Augusta University, Augusta, Ga.; Division of Orthopedic Surgery (Ravi), Department of Surgery, and Sunnybrook Health Sciences, Centre, and Division of Urology (Fok, Wallis), Department of Surgery, University of Toronto, Toronto, Ont.; Department of Health Policy and Management (Kash), School of Public Health, Texas A&M University, College Station Tex.; Department of Surgery (Menser, Bass), Houston Methodist Hospital, Houston, Tex.; Institute for Health Policy, Management and Evaluation and Department of Medicine (Detsky), University of Toronto; Department of Medicine (Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Urology (Wallis), Vanderbilt University Medical Center, Nashville, Tenn
| | - Christopher J D Wallis
- Department of Urology (Satkunasivam, Miles) and Center for Outcomes Research (Satkunasivam, Menser, Kash, Bass), Houston Methodist Hospital, Houston, Tex.; Division of Urology (Klaassen), Medical College of Georgia - Augusta University, Augusta, Ga.; Division of Orthopedic Surgery (Ravi), Department of Surgery, and Sunnybrook Health Sciences, Centre, and Division of Urology (Fok, Wallis), Department of Surgery, University of Toronto, Toronto, Ont.; Department of Health Policy and Management (Kash), School of Public Health, Texas A&M University, College Station Tex.; Department of Surgery (Menser, Bass), Houston Methodist Hospital, Houston, Tex.; Institute for Health Policy, Management and Evaluation and Department of Medicine (Detsky), University of Toronto; Department of Medicine (Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Urology (Wallis), Vanderbilt University Medical Center, Nashville, Tenn
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17
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Weininger G, Mori M, Brooks C, Shang M, Faggion Vinholo T, Zhang Y, Assi R, Geirsson A, Vallabhajosyula P. Association Between Cardiac Surgeons' Number of Years in Practice and Surgical Outcomes in New York Cardiac Centers. JAMA Netw Open 2020; 3:e2023671. [PMID: 33141159 PMCID: PMC7610186 DOI: 10.1001/jamanetworkopen.2020.23671] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE More than half of US cardiothoracic surgeons are older than 55 years, and the association between surgeon number of years in practice and surgical outcomes remains unclear. OBJECTIVE To assess the association between cardiac surgeons' time in practice and operative outcomes for coronary artery bypass grafting (CABG) and valve surgery. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis performed of surgeon-level outcomes data from the 2014-2016 New York State Cardiac Data Reporting System across the 38 New York cardiac surgery centers. Years in practice were characterized as early career (<10 years) and late career (≥10 years). Participants were 120 cardiothoracic surgeons who performed CABG and 112 cardiothoracic surgeons who performed valve procedures between 2014 and 2016. Data were analyzed in April 2020. Surgeons who trained outside of the United States or had unclear training history were excluded. MAIN OUTCOMES AND MEASURES Risk-adjusted operative mortality rate (RAMR). Mortality was defined as all-cause death within 30 days of surgery or within the index hospitalization, whichever was longer. Risk adjustment was performed by a multivariable risk model developed by the New York State Department of Public Health. Restricted cubic spline curve identified the association between risk-adjusted mortality rate and surgeon number of years in practice. Linear regression models adjusted for surgeons' annual case volumes. RESULTS A total of 112 CABG surgeons and 120 valve surgeons performed 39 436 CABG and 18 596 valve procedures between 2014 and 2016. The median number of surgeon years in practice was 20.0 (interquartile range [IQR], 12.0-28.5) years. The median surgeon annual case volume was 160.0 (IQR, 92.5-245.0) for CABG procedures and 104.0 (IQR, 43.0-210.0) for valve procedures. The median RAMR was 1.3% (IQR, 0.2%-2.2%) for CABG procedures and 3.1% (IQR, 1.7%-5.1%) for valve procedures. Surgeons with less than 10 years of practice had higher RAMR for valve procedures compared with surgeons with more than 10 years of practice (4.0 [IQR, 1.5-7.7] vs 2.9 [IQR, 1.7-4.7]; P = .20), but the finding was not statistically signficant. The RAMR for surgeons with less than 10 years of practice was similar compared with surgeons with more than 10 years of practice for CABG procedures (1.3 [IQR, 0.3-2.1] vs 1.3 [IQR, 0.0-2.2]; P = .73). A lower number of years in practice was significantly associated with higher RAMR for valve procedures (RAMR estimates for linear term: -1.144; 95% CI, -1.955 to -0.332; P = .006; quadratic term: 0.059; 95% CI, 0.015 to 1.102; P = .008; and cubic term: -0.001; 95% CI, -0.002 to 0.000; P = .01). This association was not observed for CABG. CONCLUSIONS AND RELEVANCE In this cross-sectional study, compared with late-career cardiac surgeons, early-career cardiac surgeons were associated with worse risk-adjusted outcomes for valve operations but not for CABG. This finding suggests certain competence deficiency for valve surgery early after finishing training in cardiac surgery.
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Affiliation(s)
- Gabe Weininger
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Makoto Mori
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
| | - Cornell Brooks
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael Shang
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Thais Faggion Vinholo
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Yawei Zhang
- Section of Surgical Outcomes and Epidemiology, Yale School of Medicine, Yale School of Public Health, New Haven, Connecticut
| | - Roland Assi
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
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18
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Sataloff RT, Hawkshaw M, Kutinsky J, Maitz EA. The Aging Physician and Surgeon. EAR, NOSE & THROAT JOURNAL 2020:145561320944297. [PMID: 32993377 DOI: 10.1177/0145561320944297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND As the population of aging physicians increases, methods of assessing physicians' cognitive function and predicting clinically significant changes in clinical performance become increasingly important. Although several approaches have been suggested, no evaluation system is accepted or utilized widely. STUDY DESIGN Literature was reviewed using Medline, PubMed and other sources. Articles discussing the problems of geriatric physicians were summarized, stressing publications that proposed methods of evaluation. Selected literature on evaluating aging pilots also was reviewed, and potential applications for physician evaluation were proposed. Neuropsychological cognitive test protocols were reviewed, and a reduced evaluation protocol was proposed for interdisciplinary longitudinal research. RESULTS Although there are several articles evaluating cognitive function in aging physicians and aging pilots, and although a few institutions have instituted cognitive evaluation, there are no longitudinal data assessing cognitive function in physicians over time, and correlating them with performance. CONCLUSION Valid, reliable testing of cognitive function of physicians is needed. In order to understand its predictive value, physicians should be tested over time starting when they are young, and results should be correlated with physician performance. Early testing is needed to determine whether cognitive deficits are age-related or longstanding. A multi-institutional study over many years is proposed. Additional assessments of other factors, such as manual dexterity (perhaps using simulators) and physician frailty are recommended, but detailed discussion of these issues is beyond the scope of this article.
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Affiliation(s)
- Robert T Sataloff
- Professor and Chairman, Department of Otolaryngology - Head and Neck Surgery, Senior Associate Dean for Clinical Academic Specialties, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Mary Hawkshaw
- Research Associate Professor, Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Joshua Kutinsky
- Adjunct Professor of Clinical Psychology, The Institute of Graduate Clinical Psychology at Widener University, Chester, PA
- Counsel, Consumer Litigation Division, Legal and Regulatory Affairs, Aetna Life Insurance Company, Blue Bell, Pennsylvania
| | - Edward A Maitz
- Associate Professor, Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
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19
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Zibura AE, Robertson JB, Westermeyer HD. Gonioscopic iridocorneal angle morphology and incidence of postoperative ocular hypertension and glaucoma in dogs following cataract surgery. Vet Ophthalmol 2020; 24 Suppl 1:50-62. [PMID: 32649053 DOI: 10.1111/vop.12802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/04/2020] [Accepted: 06/10/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE To investigate the relationship between gonioscopic iridocorneal angle (ICA) morphology and the incidence of postoperative ocular hypertension (POH) and postoperative glaucoma in dogs undergoing cataract surgery. ANIMALS STUDIED Retrospective analysis of 138 eyes of 78 canine patients who underwent phacoemulsification at North Carolina State University from December 1, 2015 through April 30, 2017. METHODS Medical records of all phacoemulsification patients with preoperative RetCam gonioscopic images were reviewed for preoperative, intraoperative, and postoperative variables. Gonioscopic angle indices were calculated using a novel (ZibWest) angle grading system, and these indices were analyzed for outcome-related significance. RESULTS Increased surgeon experience was associated with increased probability of POH and vision loss. Higher average ZibWest Angle indices (ie, more open angles with less pectinate ligament dysplasia/ abnormality) were associated with a significantly decreased probability of medically unresponsive glaucoma. Increased patient age was significantly associated with an increased probability of both postoperative glaucoma and vision loss. Female dogs were significantly more likely to experience postoperative glaucoma compared to male dogs. Increased surgery time was significantly associated with increased probability of vision loss. CONCLUSIONS The ZibWest angle index may predict increased risk for developing medically unresponsive glaucoma with cataract surgery. Female sex, and increased patient age, surgical time, and surgeon experience were associated with increased postoperative morbidity.
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Affiliation(s)
- Ashley E Zibura
- Comparative Ophthalmology, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - James B Robertson
- Department of Veterinary Research, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - Hans D Westermeyer
- Comparative Ophthalmology, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
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20
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Awad IA, Polster SP, Carrión-Penagos J, Thompson RE, Cao Y, Stadnik A, Money PL, Fam MD, Koskimäki J, Girard R, Lane K, McBee N, Ziai W, Hao Y, Dodd R, Carlson AP, Camarata PJ, Caron JL, Harrigan MR, Gregson BA, Mendelow AD, Zuccarello M, Hanley DF. Surgical Performance Determines Functional Outcome Benefit in the Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) Procedure. Neurosurgery 2020; 84:1157-1168. [PMID: 30891610 DOI: 10.1093/neuros/nyz077] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/14/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr). OBJECTIVE To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes. METHODS Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n = 242) of the MISTIE trial. RESULTS Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of ≤15 mL end of treatment ICH volume or ≥70% volume reduction when controlling for disease severity factors. Mortality benefit was achieved at ≤30 mL end of treatment ICH volume, or >53% volume reduction. Initial hematoma volume, history of hypertension, irregular-shaped hematoma, number of alteplase doses given, surgical protocol deviations, and catheter manipulation problems were significant factors in failing to achieve ≤15 mL goal evacuation. Greater surgeon/site experiences were associated with avoiding poor hematoma evacuation. CONCLUSION This is the first surgical trial reporting thresholds for reduction of ICH volume correlating with improved mortality and functional outcomes. To realize the benefit of surgery, protocol objectives, surgeon education, technical enhancements, and case selection should be focused on this goal.
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Affiliation(s)
- Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Julián Carrión-Penagos
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Richard E Thompson
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Patricia Lynn Money
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Janne Koskimäki
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Yi Hao
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Robert Dodd
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Paul J Camarata
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Jean-Louis Caron
- Department of Neurosurgery, University of Texas, San Antonio, Texas
| | - Mark R Harrigan
- Division of Neurosurgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Barbara A Gregson
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - A David Mendelow
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
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21
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Boitano LT, DeCarlo C, Schwartz MR, Tanious A, LaMuraglia GM, Conrad MF, Eagleton MJ, Schwartz SI. Surgeon specialty significantly affects outcome of asymptomatic patients after carotid endarterectomy. J Vasc Surg 2020; 71:1242-1252. [DOI: 10.1016/j.jvs.2019.04.489] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/21/2019] [Indexed: 10/25/2022]
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Abstract
This article aims to provide an overview of the sources for error in interventional radiology (IR). Being both a procedure and an imaging-based specialty, IR has unique considerations as to how error can occur. However, compared to the surgical and medical literature, data on error in IR are lacking. The available IR literature is reviewed but supplemented with lessons from other specialties and the World Health Organization. Individual risks such as cognitive bias as well as system-level factors are also considered in order to generate a taxonomy for error in IR that includes the operator, patient, team, and environment.
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23
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Poorthuis MHF, Brand EC, Halliday A, Bulbulia R, Schermerhorn ML, Bots ML, de Borst GJ. A systematic review and meta-analysis of complication rates after carotid procedures performed by different specialties. J Vasc Surg 2020; 72:335-343.e17. [PMID: 32139311 DOI: 10.1016/j.jvs.2019.11.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/28/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Different competencies and skills are required and obtained during medical specialization. However, whether these have an impact on procedural outcomes of carotid endarterectomy (CEA) or carotid artery stenting (CAS) is unclear. We assessed the reported association between operator specialization and procedural outcomes after CEA or CAS to determine whether CEA and CAS should be performed by specific specialties. METHODS We systematically searched PubMed and Embase up to August 21, 2017, for randomized clinical trials and observational studies that compared two or more specialties performing CEA or CAS for symptomatic and asymptomatic carotid artery stenosis. The composite primary outcome was procedural stroke or death (ie, occurring within 30 days of the procedure or before discharge). Risk estimates were pooled with a generic inverse variance random effects model. RESULTS A total of 35 studies (26 providing data on CEA, 8 providing data on CAS, and 1 providing data on both CEA and CAS) were included, describing 256,033 CEA and 38,605 CAS procedures. For CEA, decreased risk of procedural stroke or death for operations performed by vascular surgeons was found with pooled unadjusted relative risk (RR) of 0.63 (95% confidence interval [CI], 0.46-0.86; seven studies) compared with neurosurgeons and RR of 0.81 (95% CI, 0.66-0.99; six studies) compared with general surgeons. An increased risk of procedural stroke or death for operations performed by neurosurgeons compared with cardiothoracic surgeons was found with a pooled unadjusted RR of 1.22 (95% CI, 1.02-1.46). No studies adjusted for potential confounding, and no significant unadjusted associations were found in other comparisons of operator specialty for the primary outcome. For CAS, no differences in procedural stroke or death were found by operator specialty. CONCLUSIONS Studies were at high risk of bias mainly because of potential confounding by patient selection for CEA and CAS. Current evidence is insufficient to restrict CEA or CAS to specific specialties.
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Affiliation(s)
- Michiel H F Poorthuis
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eelco C Brand
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, Level 6 John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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24
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Campbell RJ, El-Defrawy SR, Gill SS, Whitehead M, Campbell EDLP, Hooper PL, Bell CM, Ten Hove MW. Association of Cataract Surgical Outcomes With Late Surgeon Career Stages: A Population-Based Cohort Study. JAMA Ophthalmol 2019; 137:58-64. [PMID: 30326021 DOI: 10.1001/jamaophthalmol.2018.4886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Evidence suggests that the quality of some aspects of care provided by physicians may decrease during their late career stage. However, to our knowledge, data regarding the association of advancing surgeon career phase with cataract surgical outcomes have been lacking. Objective To investigate whether an increase in cataract surgical adverse events occurs during later surgeon career stages. Design, Setting, and Participants This population-based study of 499 650 cataract operations performed in Ontario, Canada, between January 1, 2009, and December 31, 2013, investigated the association between late surgeon career stage and the risk of surgical adverse events. Linked health care databases were used to study cataract surgical complications while controlling for patient-, surgeon-, and institution-level covariates. All ophthalmologists who performed cataract surgery in Ontario within the study period were included in the analysis. Exposures Isolated cataract surgery performed by surgeons at early, mid, and late career stages. Main Outcomes and Measures Four serious adverse events were evaluated: dropped lens fragments, posterior capsule rupture, suspected endophthalmitis, and retinal detachment. Results Of 416 502 participants, 244 670 (58.7%) were women, 90 429 (21.7%) were age 66 to 70 years, 111 530 (26.8%) were age 71 to 75 years, 90 809 (21.8%) were age 76 to 80 years, and 123 734 (29.7%) were 81 years or older. Late-career surgeons performed 143 108 of 499 650 cataract operations (28.6%) during the study period. Late surgeon career stage was not associated with an increased overall risk of surgical adverse events (odds ratio [OR] vs midcareer, 1.06; 95% CI, 0.85-1.32). In a sensitivity analysis with surgeon volume removed from the model, late career stage was still not associated with overall adverse surgical events (OR, 1.10; 95% CI, 0.88-1.38). Among individual complications, late surgeon career stage was associated with an increased risk of dropped lens fragment (OR, 2.30; 95% CI, 1.50-3.54) and suspected endophthalmitis (OR, 1.41; 95% CI, 1.01-1.98). These corresponded with small absolute risk differences of 0.11% (95% CI, 0.085%-0.130%) and 0.045% (95% CI, 0.028%-0.063%) for dropped lens fragment and suspected endophthalmitis, respectively. Conclusions and Relevance These findings suggest that later-career surgeons are performing a substantial proportion of cataract operations with overall low surgical adverse event rates. Future studies might extend evaluations to the frequency of secondary surgical interventions as additional measures of surgical care quality.
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Affiliation(s)
- Robert J Campbell
- Department of Ophthalmology, Queen's University, Kingston, Ontario, Canada.,Department of Ophthalmology, Kingston Health Sciences Centre, Hotel Dieu Hospital site, Kingston, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Queen's University and University of Toronto sites, Kingston and Toronto, Ontario, Canada
| | - Sherif R El-Defrawy
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada.,Department of Ophthalmology, Kensington Eye Institute, Toronto, Ontario, Canada
| | - Sudeep S Gill
- Institute for Clinical Evaluative Sciences, Queen's University and University of Toronto sites, Kingston and Toronto, Ontario, Canada.,Division of Geriatric Medicine, Queen's University, Kingston, Ontario, Canada.,Division of Geriatric Medicine, Providence Care Hospital, Kingston, Ontario, Canada
| | - Marlo Whitehead
- Institute for Clinical Evaluative Sciences, Queen's University and University of Toronto sites, Kingston and Toronto, Ontario, Canada.,Queen's University, Kingston, Ontario, Canada
| | - Erica de L P Campbell
- Department of Ophthalmology, Queen's University, Kingston, Ontario, Canada.,Department of Ophthalmology, Kingston Health Sciences Centre, Hotel Dieu Hospital site, Kingston, Ontario, Canada
| | - Philip L Hooper
- Department of Ophthalmology, University of Western Ontario, London, Ontario, Canada.,Department of Ophthalmology, St Joseph's Hospital, London, Ontario, Canada
| | - Chaim M Bell
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Martin W Ten Hove
- Department of Ophthalmology, Queen's University, Kingston, Ontario, Canada.,Department of Ophthalmology, Kingston Health Sciences Centre, Hotel Dieu Hospital site, Kingston, Ontario, Canada
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25
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Affiliation(s)
- Victor A. Del Bene
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason Brandt
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Seicean A, Kumar P, Seicean S, Neuhauser D, Weil RJ. Surgeon specialty and patient outcomes in carotid endarterectomy. J Neurosurg 2019; 131:387-396. [PMID: 30095343 DOI: 10.3171/2018.2.jns173014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/22/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to compare outcomes of carotid endarterectomy performed by neurological, general, and vascular surgeons. METHODS The authors identified 80,475 patients who underwent carotid endarterectomy between 2006 and 2015 in the National Surgical Quality Improvement Program, a prospectively collected, national clinical database with established reproducibility and validity. Nine hundred forty-three patients were operated on by a neurosurgeon; 75,649 by a vascular surgeon; and 3734 by a general surgeon. Preoperative and intraoperative characteristics and 30-day outcomes were stratified by the surgeon's primary specialty. Using propensity scores, comprising pre- and intraoperative characteristics as well as procedure and diagnostic codes, the authors matched 203 neurosurgery (NS) patients to 203 vascular surgery (VS) patients and 203 NS patients to 203 general surgery (GS) patients. No pre- or intraoperative factors were significantly different between specialties in the matched sample. Regular logistic regression and conditional logistic regression were used to predict postoperative complications in the full sample and in the matched sample. RESULTS In the complete population sample, NS patients, when compared to patients of general and vascular surgeons, were less likely to be admitted from home and more likely to have carotid artery occlusion or stenosis with cerebral infarction, to be a current smoker, to have had recent chemo- or radiotherapy, to have surgery under general anesthesia, to undergo multiple procedures, and to have longer surgery times. In unadjusted analyses, NS patients were more likely to experience major complications (NS vs VS: odds ratio 1.3, 95% CI 1.1-1.6; NS vs GS: odds ratio 1.3, 95% CI 1.0-1.7); minor complications (NS vs VS: odds ratio 2.9, 95% CI 2.0-4.1; NS vs GS: odds ratio 2.7, 95% CI 1.7-4.2); intra- or postoperative transfusions (NS vs VS: odds ratio 1.6, 95% CI 1.4-1.9; NS vs GS: odds ratio 1.9, 95% CI 1.6-2.3); prolonged hospitalization (NS vs VS: odds ratio 3.0, 95% CI 2.6-3.5; NS vs GS: odds ratio 2.6, 95% CI 2.2-3.0); and discharge to skilled care facilities (NS vs VS: odds ratio 2.8, 95% CI 2.3-3.4; NS vs GS: odds ratio 3.1, 95% CI 2.4-4.1). In adjusted, propensity-matched analyses, however, patients' outcome with carotid endarterectomy performed by NS was comparable with those completed by GS and VS. CONCLUSIONS Patients who undergo carotid endarterectomy performed by a neurosurgeon tend to have a greater preoperative disease burden than do those treated by a general or vascular surgeon, which contributes significantly to more morbid postoperative courses. In patients matched carefully on the basis of health status at the time of surgery and intraoperative variables that affect results, patients' outcomes after carotid endarterectomy do not appear to depend on the attending surgeon's primary specialty.
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Affiliation(s)
| | - Prateek Kumar
- 2Neurosurgery, University of Illinois at Chicago, Illinois; Departments of
| | | | - Duncan Neuhauser
- 4Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio; and
| | - Robert J Weil
- 5National Clinical Enterprise, Catholic Health Initiatives, Englewood, Colorado
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Rosengart TK, Doherty G, Higgins R, Kibbe MR, Mosenthal AC. Transition Planning for the Senior Surgeon. JAMA Surg 2019; 154:647-653. [DOI: 10.1001/jamasurg.2019.1159] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Todd K. Rosengart
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Gerard Doherty
- Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert Higgins
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melina R. Kibbe
- Departments of Surgery and Biomedical Engineering, University of North Carolina, Chapel Hill
- Editor, JAMA Surgery
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28
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Staub BN, Sadrameli SS. The use of robotics in minimally invasive spine surgery. JOURNAL OF SPINE SURGERY 2019; 5:S31-S40. [PMID: 31380491 DOI: 10.21037/jss.2019.04.16] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The field of spine surgery has changed significantly over the past few decades as once technological fantasy has become reality. The advent of stereotaxis, intra-operative navigation, endoscopy, and percutaneous instrumentation have altered the landscape of spine surgery. The concept of minimally invasive spine (MIS) surgery has blossomed over the past ten years and now robot-assisted spine surgery is being championed by some as another potential paradigm altering technological advancement. The application of robotics in other surgical specialties has been shown to be a safe and feasible alternative to the traditional, open approach. In 2004 the Mazor Spine Assist robot was approved by FDA to assist with placement of pedicle screws and since then, more advanced robots with promising clinical outcomes have been introduced. Currently, robotic platforms are limited to pedicle screw placement. However, there are centers investigating the role of robotics in decompression, dural closure, and pre-planned osteotomies. Robot-assisted spine surgery has been shown to increase the accuracy of pedicle screw placement and decrease radiation exposure to surgeons. However, modern robotic technology also has certain disadvantages including a high introductory cost, steep learning curve, and inherent technological glitches. Currently, robotic spine surgery is in its infancy and most of the objective evidence available regarding its benefits draws from the use of robots in a shared-control model to assist with the placement of pedicle screws. As artificial intelligence software and feedback sensor design become more sophisticated, robots could facilitate other, more complex surgical tasks such as bony decompression or dural closure. The accuracy and precision afforded by the current robots available for use in spinal surgery potentially allow for even less tissue destructive and more meticulous MIS surgery. This article aims to provide a contemporary review of the use of robotics in MIS surgery.
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Affiliation(s)
| | - Saeed S Sadrameli
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
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29
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Impact of Surgeon’s Experience on Surgical Outcomes in Colorectal Surgery. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1784-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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30
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Kallmayer MA, Salvermoser M, Knappich C, Trenner M, Karlas A, Wein F, Eckstein HH, Kuehnl A. Quality appraisal of systematic reviews, and meta-analysis of the hospital/surgeon-linked volume-outcome relationship of carotid revascularization procedures. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:354-363. [DOI: 10.23736/s0021-9509.19.10943-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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31
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Tsujimoto Y, Aoki T, Shinohara K, So R, Suganuma AM, Kimachi M, Yamamoto Y, Furukawa TA. Physician characteristics associated with proper assessment of overstated conclusions in research abstracts: A secondary analysis of a randomized controlled trial. PLoS One 2019; 14:e0211206. [PMID: 30682128 PMCID: PMC6347200 DOI: 10.1371/journal.pone.0211206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 01/09/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Little is known about the physician characteristics associated with appraisal skills of research evidence, especially the assessment of the validity of study methodology. This study aims to explore physician characteristics associated with proper assessment of overstated conclusions in research abstracts. DESIGN A secondary analysis of a randomized controlled trial. SETTING AND PARTICIPANTS We recruited 567 volunteers from the Japan Primary Care Association. METHODS Participants were randomly assigned to read the abstract of a research paper, with or without an overstatement, and to rate its validity. Our primary outcome was proper assessment of the validity of its conclusions. We investigated the association of physician characteristics and proper assessment using logistic regression models and evaluated the interaction between the associated characteristics and overstatement. RESULTS We found significant associations between proper assessment and post-graduate year (odds ratio [OR] = 0.67, 95% confidence interval [CI] 0.49 to 0.91, for every 10-year increase) and research experience as a primary investigator (PI; OR = 2.97, 95% CI 1.65 to 5.34). Post-graduate year and PI had significant interaction with overstatement (P = 0.015 and < 0.001, respectively). Among participants who read abstracts without an overstatement, post-graduate year was not associated with proper assessment (OR = 1.04, 95% CI 0.82 to 1.33), and PI experience was associated with lower scores of the validity (OR = 0.58, 95% CI 0.35 to 0.96). CONCLUSION Physicians who have been in practice longer should be trained in distinguishing overstatements in abstract conclusions. Physicians with research experience might be informed that they tend to rate the validity of research lower regardless of the presence or absence of overstatements. TRIAL REGISTRATION UMIN000026269.
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Affiliation(s)
- Yasushi Tsujimoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Nephrology and Dialysis, Kyoritsu Hospital, Kawanishi, Hyogo, Japan
| | - Takuya Aoki
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kiyomi Shinohara
- Department of Health Promotion and Human Behavior Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
| | - Ryuhei So
- Department of Health Promotion and Human Behavior Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
| | - Aya M. Suganuma
- Department of Health Promotion and Human Behavior Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
| | - Miho Kimachi
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
- * E-mail:
| | - Toshi A. Furukawa
- Department of Health Promotion and Human Behavior Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
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Xu T, Mehta A, Park A, Makary MA, Price DW. Association Between Board Certification, Maintenance of Certification, and Surgical Complications in the United States. Am J Med Qual 2019; 34:545-552. [PMID: 30654617 DOI: 10.1177/1062860618822752] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Physician credentialing processes aim to improve patient safety and quality, but little research has examined their direct relationship with surgical outcomes. Using national Medicare claims for 2009 to 2013, the authors studied the association between board certification and completion of Maintenance of Certification (MOC) requirements and surgeon rates of complications for 8 elective procedures. Exemplar surgeons were defined as those in the lowest decile of complication rates, and outlier surgeons were those in the highest decile. The analysis included 1.9 million procedures performed by 14 598 surgeons (64% orthopedics, 17% general surgery, 11% urology, 7% neurosurgery). Board-certified surgeons were less likely to be outliers (odds ratio 0.79 [0.66-0.94]). However, completion of MOC was not associated with differences in complication rates in orthopedic surgery or urology. Incorporating additional assessment methods into MOC, such as video evaluation of technical skills, retraining on state-of-the-art care, and peer review, may facilitate further improvements in surgical quality.
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Affiliation(s)
- Tim Xu
- Johns Hopkins University, Baltimore, MD
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33
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White AA, Sage WM, Osinska PH, Salgaonkar MJ, Gallagher TH. Patient safety and the ageing physician: a qualitative study of key stakeholder attitudes and experiences. BMJ Qual Saf 2018; 28:468-475. [PMID: 30237318 DOI: 10.1136/bmjqs-2018-008276] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/20/2018] [Accepted: 08/12/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Unprecedented numbers of physicians are practicing past age 65. Unlike other safety-conscious industries, such as aviation, medicine lacks robust systems to ensure late-career physician (LCP) competence while promoting career longevity. OBJECTIVE To describe the attitudes of key stakeholders about the oversight of LCPs and principles that might shape policy development. DESIGN Thematic content analysis of interviews and focus groups. PARTICIPANTS 40 representatives of stakeholder groups including state medical board leaders, institutional chief medical officers, senior physicians (>65 years old), patient advocates (patients or family members in advocacy roles), nurses and junior physicians. Participants represented a balanced sample from all US regions, surgical and non-surgical specialties, and both academic and non-academic institutions. RESULTS Stakeholders describe lax professional self-regulation of LCPs and believe this represents an important unsolved challenge. Patient safety and attention to physician well-being emerged as key organising principles for policy development. Stakeholders believe that healthcare institutions rather than state or certifying boards should lead implementation of policies related to LCPs, yet expressed concerns about resistance by physicians and the ability of institutions to address politically complex medical staff challenges. Respondents recommended a coaching and professional development framework, with environmental changes, to maximise safety and career longevity of physicians as they age. CONCLUSIONS Key stakeholders express a desire for wider adoption of LCP standards, but foresee significant culture change and practical challenges ahead. Participants recommended that institutions lead this work, with support from regulatory stakeholders that endorse standards and create frameworks for policy adoption.
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Affiliation(s)
- Andrew A White
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - William M Sage
- Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA.,School of Law at the University of Texas at Austin, Austin, Texas, USA
| | - Paulina H Osinska
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Monica J Salgaonkar
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Thomas H Gallagher
- Departments of Medicine and Bioethics, University of Washington School of Medicine, Seattle, Washington, USA
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Abstract
Our older physicians, an increasing number of those in practice, constitute a valuable human resource in the medical profession. Professional satisfaction, increasing life expectancy, concerns regarding financial security, and reluctance to retire are among the many reasons a physician might choose to extend practice into later adulthood. Despite the benefits of experience and expertise acquired by older physicians, cognitive changes associated with normal or pathological aging have been shown to have a significant negative effect on physician performance. Age-based cognitive assessment of physicians has been adopted in some countries and by some U.S. healthcare institutions for patient protection and improvement of physician quality of life, but there is no general guideline for the assessment and assistance of cognitively impaired late career physicians in the United States. Self-reports and reports from peers are an inadequate safeguard, leaving impaired physicians and their patients at risk. In this discussion, we will describe cognitive aging, the effects of cognitive aging on physician performance, some current monitoring systems, and recommendations for identifying and assisting physicians found to be impaired.
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35
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Tsugawa Y, Jena AB, Orav EJ, Blumenthal DM, Tsai TC, Mehtsun WT, Jha AK. Age and sex of surgeons and mortality of older surgical patients: observational study. BMJ 2018; 361:k1343. [PMID: 29695473 PMCID: PMC5915700 DOI: 10.1136/bmj.k1343] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To investigate whether patients' mortality differs according to the age and sex of surgeons. DESIGN Observational study. SETTING US acute care hospitals. PARTICIPANTS 100% of Medicare fee-for-service beneficiaries aged 65-99 years who underwent one of 20 major non-elective surgeries between 2011 and 2014. MAIN OUTCOME MEASURE Operative mortality rate of patients, defined as death during hospital admission or within 30 days of the operative procedure, after adjustment for patients' and surgeons' characteristics and indicator variables for hospitals. RESULTS 892 187 patients who were treated by 45 826 surgeons were included. Patients' mortality was lower for older surgeons than for younger surgeons: the adjusted operative mortality rates were 6.6% (95% confidence interval 6.5% to 6.7%), 6.5% (6.4% to 6.6%), 6.4% (6.3% to 6.5%), and 6.3% (6.2% to 6.5%) for surgeons aged under 40 years, 40-49 years, 50-59 years, and 60 years or over, respectively (P for trend=0.001). There was no evidence that adjusted operative mortality differed between patients treated by female versus male surgeons (adjusted mortality 6.3% for female surgeons versus 6.5% for male surgeons; adjusted odds ratio 0.97, 95% confidence interval 0.93 to 1.01). After stratification by sex of surgeon, patients' mortality declined with age of surgeon for both male and female surgeons (except for female surgeons aged 60 or older); female surgeons in their 50s had the lowest operative mortality. CONCLUSION Using national data on Medicare beneficiaries in the US, this study found that patients treated by older surgeons had lower mortality than patients treated by younger surgeons. There was no evidence that operative mortality differed between male and female surgeons.
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Affiliation(s)
- Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Thomas C Tsai
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Winta T Mehtsun
- Division of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ashish K Jha
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- The VA Healthcare System, Boston, MA 02138, USA
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Babu MA, Liau LM, Spinner RJ, Meyer FB. The Aging Neurosurgeon: When Is Enough, Enough? Attitudes Toward Ceasing Practice and Testing in Late Career. Mayo Clin Proc 2017; 92:1746-1752. [PMID: 29153596 DOI: 10.1016/j.mayocp.2017.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/30/2017] [Accepted: 09/13/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To present the first wide-scale survey to assess perceptions of testing the aging neurosurgeon. PATIENTS AND METHODS This study included 4899 neurosurgeons, 2435 American Board of Neurological Surgery Diplomates participating in Maintenance of Certification (MOC), 1440 Diplomates certified before 1999 (grandfathered), and 1024 retired Diplomates. We developed an online confidential survey conducted from March 1, 2016, to May 31, 2016. We received 1449 responses overall (30% response rate). RESULTS Most respondents (938; 65%) were aged 50 years and older. Overall, most respondents (718; 50%) believe that the aging neurosurgeon (65 years and older) should undergo additional testing, including cognitive assessment or a review of cases, in addition to a standard (MOC) examination. Nine hundred fifty-six (67%) respondents believed that there should be no absolute age cutoff at which neurosurgical practice is forced to end. Six hundred six (42%) respondents believed that MOC should be tailored to accommodate the aging neurosurgeon. Most respondents (766; 59%) believed that MOC should consist of a review individual case logs and patient outcomes for the aging neurosurgeon. CONCLUSION Appropriately assessing the aging neurosurgeon is important to protect patient safety and also maximize the capacity of an aging neurosurgical workforce. This first of its kind survey of neurosurgeon diplomates of the American Board of Neurological Surgery provides important information as to what mechanisms can be created to fairly evaluate aging neurosurgeons. Although this is a study of neurosurgeons, the implications of these findings are widely applicable across specialties, and additional research on testing for aging and competency is needed across specialties.
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Affiliation(s)
- Maya A Babu
- Department of Neurological Surgery, University of Miami, Miami, FL.
| | - Linda M Liau
- Department of Neurosurgery, UCLA Medical Center, Los Angeles, CA
| | | | - Fredric B Meyer
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
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Richards R, McLeod R, Latter D, Keshavjee S, Rotstein O, Fehlings MG, Ahmed N, Nathens A, Rutka J. Toward late career transitioning: a proposal for academic surgeons. Can J Surg 2017; 60:355-358. [PMID: 28742011 DOI: 10.1503/cjs.007617] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
SUMMARY In the absence of a defined retirement age, academic surgeons need to develop plans for transition as they approach the end of their academic surgical careers. The development of a plan for late career transition represents an opportunity for departments of surgery across Canada to initiate a constructive process in cooperation with the key stakeholders in the hospital or institution. The goal of the process is to develop an individual plan for each faculty member that is agreeable to the academic surgeon; informs the surgical leadership; and allows the late career surgeon, the hospital, the division and the department to make plans for the future. In this commentary, the literature on the science of aging is reviewed as it pertains to surgeons, and guidelines for late career transition planning are shared. It is hoped that these guidelines will be of some value to academic programs and surgeons across the country as late career transition models are developed and adopted.
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Affiliation(s)
- Robin Richards
- From the Department of Surgery, University of Toronto, Toronto, Ont
| | - Robin McLeod
- From the Department of Surgery, University of Toronto, Toronto, Ont
| | - David Latter
- From the Department of Surgery, University of Toronto, Toronto, Ont
| | - Shaf Keshavjee
- From the Department of Surgery, University of Toronto, Toronto, Ont
| | - Ori Rotstein
- From the Department of Surgery, University of Toronto, Toronto, Ont
| | | | - Najma Ahmed
- From the Department of Surgery, University of Toronto, Toronto, Ont
| | - Avery Nathens
- From the Department of Surgery, University of Toronto, Toronto, Ont
| | - James Rutka
- From the Department of Surgery, University of Toronto, Toronto, Ont
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Kennedy GT, McMillan MT, Maggino L, Sprys MH, Vollmer CM. Surgical experience and the practice of pancreatoduodenectomy. Surgery 2017; 162:812-822. [DOI: 10.1016/j.surg.2017.06.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/13/2017] [Accepted: 06/25/2017] [Indexed: 01/10/2023]
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Anderson BR, Wallace AS, Hill KD, Gulack BC, Matsouaka R, Jacobs JP, Bacha EA, Glied SA, Jacobs ML. Association of Surgeon Age and Experience With Congenital Heart Surgery Outcomes. Circ Cardiovasc Qual Outcomes 2017; 10:e003533. [PMID: 28710297 PMCID: PMC5656266 DOI: 10.1161/circoutcomes.117.003533] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 06/09/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surgeon experience concerns both families of children with congenital heart disease and medical providers. Relationships between surgeon seniority and patient outcomes are often assumed, yet there are little data. METHODS AND RESULTS This national study used linked data from the American Medical Association Physician Masterfile and the Society of Thoracic Surgeons-Congenital Heart Surgery Database to examine associations between surgeon years since medical school and major morbidity/mortality for children undergoing cardiac surgery. Sensitivity analyses explored the effects of patient characteristics, institutional/surgeon volumes, and various measures of institutional surgeon team experience. In secondary analyses, major morbidity and mortality were examined as separate end points. We identified 206 congenital heart surgeons from 91 centers performing 62 851 index operations (2010-2014). Median time from school was 25 years (range 9-55 years). A major morbidity/mortality occurred in 11.5% of cases. In multivariable analyses, the odds of major morbidity/mortality were similar for early-career (<15 years from medical school, ≈<40 years old), midcareer (15-24 years, ≈40-50 years old), and senior surgeons (25-35 years, ≈50-60 years old). The odds of major morbidity/mortality were ≈25% higher for operations performed by very senior surgeons (35-55 years from school, ≈60-80 years old; n=9044 cases). Results were driven by differences in morbidity. In extensive sensitivity analyses, these effects remained constant. CONCLUSIONS In this study of >200 congenital heart surgeons, we found patient outcomes for surgeons with the fewest years of experience to be comparable to those of their midcareer and senior colleagues, within the context of existing referral and support practices. Very senior surgeons had higher risk-adjusted odds of major morbidity/mortality. Contemporary approaches to training, referral, mentoring, surgical planning, and other support practices might contribute to the observed outcomes of junior congenital heart surgeons being comparable to those of more experienced colleagues. Understanding and disseminating these practices might benefit the medical community at large.
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Affiliation(s)
- Brett R Anderson
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.).
| | - Amelia S Wallace
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Kevin D Hill
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Brian C Gulack
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Roland Matsouaka
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Jeffrey P Jacobs
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Emile A Bacha
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Sherry A Glied
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
| | - Marshall L Jacobs
- From the Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Duke Clinical Research Institute, Durham, NC (A.S.W.); Department of Pediatrics, Duke Clinical Research Institute (K.D.H.) and Department of Surgery (B.C.G.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL (J.P.J., M.L.J.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (J.P.J., M.L.J.); Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY (E.A.B.); and The Robert F. Wagner Graduate School of Public Service, New York University (S.A.G.)
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Tsugawa Y, Newhouse JP, Zaslavsky AM, Blumenthal DM, Jena AB. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ 2017; 357:j1797. [PMID: 28512089 PMCID: PMC5431772 DOI: 10.1136/bmj.j1797] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Objectives To investigate whether outcomes of patients who were admitted to hospital differ between those treated by younger and older physicians.Design Observational study.Setting US acute care hospitals.Participants 20% random sample of Medicare fee-for-service beneficiaries aged ≥65 admitted to hospital with a medical condition in 2011-14 and treated by hospitalist physicians to whom they were assigned based on scheduled work shifts. To assess the generalizability of findings, analyses also included patients treated by general internists including both hospitalists and non-hospitalists.Main outcome measures 30 day mortality and readmissions and costs of care. Results 736 537 admissions managed by 18 854 hospitalist physicians (median age 41) were included. Patients' characteristics were similar across physician ages. After adjustment for characteristics of patients and physicians and hospital fixed effects (effectively comparing physicians within the same hospital), patients' adjusted 30 day mortality rates were 10.8% for physicians aged <40 (95% confidence interval 10.7% to 10.9%), 11.1% for physicians aged 40-49 (11.0% to 11.3%), 11.3% for physicians aged 50-59 (11.1% to 11.5%), and 12.1% for physicians aged ≥60 (11.6% to 12.5%). Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality. Readmissions did not vary with physician age, while costs of care were slightly higher among older physicians. Similar patterns were observed among general internists and in several sensitivity analyses.Conclusions Within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients.
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Affiliation(s)
- Yusuke Tsugawa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Joseph P Newhouse
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Harvard Kennedy School, Cambridge, MA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | | | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Campbell RJ, El-Defrawy SR, Gill SS, Whitehead M, Campbell EDL, Hooper PL, Bell CM, ten Hove M. New Surgeon Outcomes and the Effectiveness of Surgical Training. Ophthalmology 2017; 124:532-538. [DOI: 10.1016/j.ophtha.2016.12.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/07/2016] [Accepted: 12/08/2016] [Indexed: 10/20/2022] Open
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Abstract
PURPOSE OF REVIEW Impairment and/or disability resulting from any of a number of etiologies will afflict a significant number of anesthesiologists at some point during their career. The impaired anesthesiologist can be difficult to identify and challenging to manage. Questions will arise as to if, how, and when colleagues, family members, or friends should intercede if significant impairment is suspected.This review will examine the common sources of impairment among anesthesiologists and the professional implications of these conditions. We will discuss the obligations of an anesthesiologist and his/her colleagues when there is sufficient suspicion that he/she might be impaired. RECENT FINDINGS Substance use disorder remains one of the commonest sources of impairment among both resident and attending anesthesiologists. Other common etiologies of impairment include various physical ailments, major psychiatric disorders, especially depression and burnout, and age related dementia. Many regulatory organizations, healthcare systems, and state licensing agencies have developed programmes and protocols with which to identify and direct into treatment those suspected of significant impairment. SUMMARY Some degree of impairment will occur to one-third of anesthesiologists during the course of their career. It is important to understand how such impairments might impact the safe practice of anesthesiology.
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Lieber BA, Henry JK, Agarwal N, Day JD, Morris TW, Stephens ML, Abla AA. Impact of Surgical Specialty on Outcomes Following Carotid Endarterectomy. Neurosurgery 2016; 80:217-225. [DOI: 10.1093/neuros/nyw027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 10/22/2016] [Indexed: 11/13/2022] Open
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Affiliation(s)
- Mark R Katlic
- Department of Surgery, Sinai Center for Geriatric Surgery, Sinai Hospital, Northwest Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA.
| | - JoAnn Coleman
- Department of Surgery, Sinai Center for Geriatric Surgery, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA
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Yeh CC, Liao CC, Shih CC, Jeng LB, Chen TL. Postoperative adverse outcomes among physicians receiving major surgeries: A nationwide retrospective cohort study. Medicine (Baltimore) 2016; 95:e4946. [PMID: 27684836 PMCID: PMC5265929 DOI: 10.1097/md.0000000000004946] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Outcomes after surgeries involving physicians as patients have not been researched. This study compares postoperative adverse events between physicians as surgical patients and nonhealth professional controls.Using reimbursement claims data from Taiwan's National Health Insurance Program, we conducted a matched retrospective cohort study of 7973 physicians as surgical patients and 7973 propensity score-matched nonphysician controls receiving in-hospital major surgeries between 2004 and 2010. We compared postoperative major complications, length of hospital stay, intensive care unit (ICU), medical expenditure, and 30-day mortality.Compared with nonphysician controls, physicians as surgical patients had lower adjusted odds ratios (ORs) with 95% confidence intervals (CIs) of postoperative deep wound infection (OR 0.63, 95% CI 0.40-0.99; P < 0.05), prolonged length of stay (OR 0.68, 95% CI 0.62-0.75; P < 0.0001), ICU admission (OR 0.74, 95% CI 0.66-0.83; P < 0.0001), and increased medical expenditure (OR 0.80, 95% CI 0.73-0.88; P < 0.0001). Physicians as surgical patients were not associated with 30-day in-hospital mortality after surgery. Physicians working at medical centers (P < 0.05 for all), dentists (P < 0.05 for all), and those with fewer coexisting medical conditions (P < 0.05 for all) had lower risks for postoperative prolonged length of stay, ICU admission, and increased medical expenditure.Although our study's findings suggest that physicians as surgical patients have better outcomes after surgery, future clinical prospective studies are needed for validation.
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Affiliation(s)
- Chun-Chieh Yeh
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
| | - Chien-Chang Liao
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
- Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Chun-Chuan Shih
- School of Chinese Medicine for Post-Baccalaureate, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Long-Bin Jeng
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Ta-Liang Chen
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
- Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Correspondence: Ta-Liang Chen, Professor and Director, Department of Anesthesiology, Taipei Medical University Hospital, 252 Wuxing St., Taipei 11031, Taiwan (e-mail: )
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Hawkins RE, Welcher CM, Stagg Elliott V, Pieters RS, Puscas L, Wick PH. Ensuring Competent Care by Senior Physicians. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2016; 36:226-231. [PMID: 27584000 DOI: 10.1097/ceh.0000000000000080] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The increasing number of senior physicians and calls for increased accountability of the medical profession by the public have led regulators and policymakers to consider implementing age-based competency screening. Some hospitals and health systems have initiated age-based screening, but there is no agreed upon assessment process. Licensing and certifying organizations generally do not require that senior physicians pass additional assessments of health, competency, or quality performance. Studies suggest that physician performance, on average, declines with increasing years in medical practice, but the effect of age on an individual physician's competence is highly variable. Many senior physicians practice effectively and should be allowed to remain in practice as long as quality and safety are not endangered. Stakeholders in the medical profession should consider the need to develop guidelines and methods for monitoring and/or screening to ensure that senior physicians provide safe and effective care for patients. Any screening process needs to achieve a balance between protecting patients from harm due to substandard practice, while at the same time ensuring fairness to physicians and avoiding unnecessary reductions in workforce.
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Affiliation(s)
- Richard E Hawkins
- Dr. Hawkins: Vice President, Medical Education Outcomes, American Medical Association, Chicago, IL. Ms. Welcher: Senior Policy Analyst, Medical Education Outcomes, American Medical Association, Chicago, IL. Ms. Stagg Elliott: Technical Writer, Medical Education Outcomes, American Medical Association, Chicago, IL. Dr. Pieters: Professor of Radiation Oncology and Pediatrics, University of Massachusetts Medical School, Worcester, MA. Dr. Puscas: Associate Professor of Surgery, Duke University School of Medicine, Durham, NC. Dr. Wick: Assistant Professor, Psychiatry Department, Senior Behavioral Health Outpatient Services, University of Texas Health Northeast, Tyler, TX
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Bhatt NR, Morris M, O'Neil A, Gillis A, Ridgway PF. When should surgeons retire? Br J Surg 2015; 103:35-42. [PMID: 26577951 DOI: 10.1002/bjs.9925] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 05/30/2015] [Accepted: 07/31/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Retirement policies for surgeons differ worldwide. A range of normal human functional abilities decline as part of the ageing process. As life expectancy and their population increases, the performance ability of ageing surgeons is now a growing concern in relation to patient care. The aim was to explore the effects of ageing on surgeons' performance, and to identify current practical methods for transitioning surgeons out of practice at the appropriate time and age. METHODS A narrative review was performed in MEDLINE using the terms 'ageing' and 'surgeon'. Additional articles were hand-picked. Modified PRISMA guidelines informed the selection of articles for inclusion. Articles were included only if they explored age-related changes in brain biology and the effect of ageing on surgeons' performance. RESULTS The literature search yielded 1811 articles; of these, 36 articles were included in the final review. Wide variation in ability was observed across ageing individuals (both surgical and lay). Considerable variation in the effects of the surgeon's age on patient mortality and postoperative complications was noted. A lack of neuroimaging research exploring the ageing of surgeons' brains specifically, and lack of real markers available for measuring surgical performance, both hinder further investigation. Standard retirement policies in accordance with age-related surgical ability are lacking in most countries around the world. CONCLUSION Competence should be assessed at an individual level, focusing on functional ability over chronological age; this should inform retirement policies for surgeons.
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Affiliation(s)
- N R Bhatt
- Department of Surgery, University of Dublin, Trinity College, at the Adelaide and Meath Hospital, Tallaght, Ireland
| | - M Morris
- Department of Surgery, University of Dublin, Trinity College, at the Adelaide and Meath Hospital, Tallaght, Ireland.,Education Division, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - A O'Neil
- Education Division, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - A Gillis
- Department of Surgery, University of Dublin, Trinity College, at the Adelaide and Meath Hospital, Tallaght, Ireland
| | - P F Ridgway
- Department of Surgery, University of Dublin, Trinity College, at the Adelaide and Meath Hospital, Tallaght, Ireland.,Education Division, School of Medicine, Trinity College Dublin, Dublin, Ireland
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Luebke T, Brunkwall J. Meta- analysis and meta-regression analysis of the associations between sex and the operative outcomes of carotid endarterectomy. BMC Cardiovasc Disord 2015; 15:32. [PMID: 25956903 PMCID: PMC4432947 DOI: 10.1186/s12872-015-0029-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/21/2015] [Indexed: 12/26/2022] Open
Abstract
Background Subgroup analyses from randomized controlled trials (RCT) of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis suggest less benefit in women compared to men, due partly to higher age-independent peri-operative risk. However, a meta-analysis of case series and databases focussing on CEA-related gender differences has never been investigated. Methods A systematic review of all available publications (including case series, databases and RCTs) reporting data on the association between sex and procedural risk of stroke and/or death following CEA from 1980 to 2015 was investigated. Pooled Peto odds ratios of the procedural risk of stroke and/or death were obtained by Mantel-Haenszel random-effects meta-analysis. The I2 statistic was used as a measure of heterogeneity. Potential publication bias was assessed with the Egger test and represented graphically with Begg funnel plots of the natural log of the OR versus its standard error. Additional sensitivity analyses were undertaken to evaluate the potential effect of key assumptions and study-level factors on the overall results. Meta-regression models were formed to explore potential heterogeneity as a result of potential risk factors or confounders on outcomes. A tria sequential analysis (TSA) was performed with the aim to maintain an over- all 5 % risk of type I error, being the standard in most meta- analyses and systematic reviews. Results 58 articles reported combined stroke and mortality rates within 30 days of treatment. In the unselected overall meta-analysis, the incidence of stroke and death in the male and female groups differed significantly (Peto OR, 1,162; 95 % CI, 1.067-1.266; P = .001), revealing a worse outcome for female patients. Moderate heterogeneity among the studies was identified (I2 = 36 %), and the possibility of publication bias was low (P = .03). In sensitivity analyses the meta-analysis of case series with gender aspects as a secondary outcome showed a significantly increased risk for 30-day stroke and death in women compared to men (Peto OR, 1.390; 95 % CI, 1.148-1.684; P = .001), In contrast, meta-analysis of databases (Peto OR, 1.025; 95 % CI, 0.958-1.097; P = .474) and case series with gender related outcomes as a primary aim (Peto OR, 1.202; 95 % CI, 0.925-1.561; P = .168) demonstrated no increase in operative risk of stroke and death in women compared to men. Conclusions Metanalyses of case series and databases dealing with CEA reveal inconsistent results regarding gender differences related to CEA-procedure and should not be transferred into clinical practice.
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Affiliation(s)
- Thomas Luebke
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germay.
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germay.
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