Relation between surgeon age and postoperative outcomes: a population-based cohort study

Impact of structured multicentre enhanced recovery after surgery (ERAS) protocol implementation on length of stay after colorectal surgery

BACKGROUND

Increased length of stay after surgery is associated with increased healthcare utilization and adverse patient outcomes. While enhanced recovery after surgery (ERAS) protocols have been shown to reduce length of stay after colorectal surgery in trial settings, their effectiveness in real-world settings is more uncertain. The aim of this study was to assess the impact of ERAS protocol implementation on length of stay after colorectal surgery, using real-world data.

METHODS

In 2012, ERAS protocols were introduced at 15 Ontario hospitals as part of the iERAS study. A cohort of patients undergoing colorectal surgery treated at these hospitals between 2008 and 2019 was created using health administrative data. Mean length of stay was computed for the intervals before and after ERAS implementation. Interrupted time series analyses were performed for predefined subgroups, namely all colorectal surgery, colorectal surgery without complications, right-sided colorectal surgery, and left-sided colorectal surgery. Sensitivity analyses were then conducted using adjusted length of stay, accounting for length of stay predictors, including: patient age, sex, marginalization, co-morbidities, and diagnosis; surgeon volume of cases, years in practice, and colorectal surgery expertise; hospital volume; and other contextual factors, including procedure type and timing, surgical approach, and in-hospital complications.

RESULTS

A total of 32 612 patients underwent colorectal surgery during the study interval. ERAS implementation led to a decrease in length of stay of 1.05 days (13.7%). Larger decreases in length of stay were seen with more complex surgeries, with a level change of 1.17 days (15.6%) noted for the subgroup of patients undergoing left-sided colorectal surgery. The observed decreases in length of stay were durable for the length of the study interval in all analyses. When adjusting for predictors of length of stay, the effect of ERAS implementation on length of stay was larger (reduction of 1.46 days).

CONCLUSION

Introducing formal ERAS protocols reduces length of stay after colorectal surgery significantly, independent of temporal trends toward decreasing length of stay. These effects are durable, demonstrating that ERAS protocol implementation is an effective hospital-level intervention to reduce length of stay after colorectal surgery.

Association of Surgeon Self-Reported Gender and Surgical Outcomes in Current US Practice

OBJECTIVE

This study aimed to evaluate the association of surgeon self-reported gender on clinical outcomes in contemporary US surgical practice.

BACKGROUND

Previous research has suggested that there are potentially improved surgical outcomes for female surgeons, yet the underlying causal path for this association remains unclear.

METHODS

Using the Vizient Clinical Database(2016-2021), 39 operations categorized by the CDC's National Healthcare Safety Network were analyzed. The surgeon self-reported gender as the primary exposure. The primary outcome was a composite of in-hospital death, complications, and/or 30-day readmission. Multivariable logistic regression and propensity score matching were used for risk adjustment.

RESULTS

The analysis included 4,882,784 patients operated on by 11,955 female surgeons (33% of surgeons performing 21% of procedures) and 23,799 male surgeons (67% of surgeons performing 79% of procedures). Female surgeons were younger (45±9 vs males-53±11 y; P <0.0001) and had lower operative volumes. Unadjusted incidence of the primary outcome was 13.6%(10.7%-female surgeons, 14.3%-male surgeons; P <0.0001). After propensity matching, the primary outcome occurred in 13.0% of patients [12.9%-female, 13.0%-male; OR (M vs. F)=1.02, 95% CI: 1.01-1.03; P =0.001), with female surgeons having small statistical associations with lower mortality and complication rates but not readmissions. Procedure-specific analyses revealed inconsistent or no surgeon-gender associations.

CONCLUSIONS

In the largest analysis to date, surgeon self-reported gender had a small statistical, clinically marginal correlation with postoperative outcomes. The variation across surgical specialties and procedures suggests that the association with surgeon gender is unlikely causal for the observed differences in outcomes. Patients should be reassured that surgeon gender alone does not have a clinically meaningful impact on their outcome.

Fibrosis Management Algorithm in Secondary Liposculpture

BACKGROUND

Liposuction is considered one of the most common procedures in plastic surgery. However, major postoperative complications such as visceral injury, fluid overload, and necrotizing fasciitis still occur. Likewise, minor complications such as ecchymosis, seromas, infections, and contour irregularities that do not threaten the life of the patient do generate significant dissatisfaction. Current evidence regarding the management of fibrosis after previous liposuction remains limited.

OBJECTIVES

The objective of this article is to standardize a management algorithm based on the extensive experience and successful results of the primary author (G.M.).

METHODS

Patients who underwent secondary liposculpture between August 2022 and May 2023 were evaluated prospectively. Inclusion criteria comprised females between 18 and 60 years old, nonsmokers, with a BMI < 35 kg/m2 and a history of previous body contouring surgeries. Identification of the patient's skin condition and subcutaneous lesions in the adipose tissue were obtained in detail. Statistical analysis of preoperative and postoperative medical photographs was also performed with the Fiji Biological image analyzer.

RESULTS

Photographic analysis of preoperative and postoperative photographs showed a statistically significant difference between the areas affected by fibrosis (P < .001). The most frequent clinical findings were depressions in 99% of the females (74), followed by soft nodules in 95% (70), hard nodules in 81% (61), adhesions in 47% (35), and finally cutaneous bursas in 4%.

CONCLUSIONS

Our classification system and management algorithm for fibrosis and contour irregularities is a safe and reliable tool. Results were objectively verified, yielding statistically significant outcomes.

LEVEL OF EVIDENCE: 3

Gender distribution of Top Doctors in otolaryngology-head and neck surgery

INTRODUCTION

Our study seeks to understand the profiles of otolaryngologists selected by Castle Connolly's Top Doctor list and how this compares to the entire field of otolaryngology.

METHODS

Top Doctor lists published in Castle Connolly affiliated magazines were analyzed for Otolaryngology, Otolaryngology/Facial Plastic Surgery, or Pediatric Otolaryngology physicians. Only lists published in 2021 or representing the 2021 Top Doctor lists were analyzed. Of the total 39 partnered magazines, 27 met our criteria. Information on the physician was analyzed from the Castle Connolly website and included: gender, education, faculty position, years as a Top Doctor, and certifications of each physician.

RESULTS

879 doctors, 742 (84%) men and 137 women (16%), were included in our analysis. 509 physicians completed a fellowship, 85 (62%) women and 424 (57%) men. The fellowship type varied significantly between gender (p = .002). 122 (14%) Top Doctors completed facial and plastic reconstructive surgery and 111 (91%) were men. Of the women Top Doctors completing a fellowship, 29 (34%) completed a fellowship in pediatric otolaryngology. A logistic regression found that men have an increased odds of being on the Top Doctors list for more years than females (OR: 1.36, p < .001).

CONCLUSION

The percentage of women named as Top Doctors was less than the proportion of women in otolaryngology. This may be attributed to gender differences we found in fellowship type and certification. Further research into the role of otolaryngology subspecialties in selection of Top Doctors is needed to better understand gender differences.

Association Between Anesthesiologist Sex and Patients' Postoperative Outcomes: A Population-based Cohort Study

OBJECTIVE

To examine the association of anesthesiologist sex on postoperative outcomes.

BACKGROUND

Differences in patient postoperative outcomes exist, depending on whether the primary surgeon is male or female, with better outcomes seen among patients treated by female surgeons. Whether the intraoperative anesthesiologist's sex is associated with differential postoperative patient outcomes is unknown.

METHODS

We performed a population-based, retrospective cohort study among adult patients undergoing one of 25 common elective or emergent surgical procedures from 2007 to 2019 in Ontario, Canada. We assessed the association between the sex of the intraoperative anesthesiologist and the primary end point of the adverse postoperative outcome, defined as death, readmission, or complication within 30 days after surgery, using generalized estimating equations.

RESULTS

Among 1,165,711 patients treated by 3006 surgeons and 1477 anesthesiologists, 311,822 (26.7%) received care from a female anesthesiologist and 853,889 (73.3%) from a male anesthesiologist. Overall, 10.8% of patients experienced one or more adverse postoperative outcomes, of whom 1.1% died. Multivariable adjusted rates of the composite primary end point were higher among patients treated by male anesthesiologists (10.6%) compared with female anesthesiologists (10.4%; adjusted odds ratio 1.02, 95% CI: 1.00-1.05, P =0.048).

CONCLUSIONS

We demonstrated a significant association between sex of the intraoperative anesthesiologist and patient short-term outcomes after surgery in a large cohort study. This study supports the growing literature of improved patient outcomes among female practitioners. The underlying mechanisms of why outcomes differ between male and female physicians remain elusive and require further in-depth study.

Effect of gender discordance on surgical outcomes in predominantly female patient surgeries in NYS

BACKGROUND

Preliminary evidence demonstrates female surgeons have improved post-operative outcomes compared to male colleagues despite underrepresentation in surgery. This study explores the effect of patient-surgeon gender discordance on outcomes in three specialties with high female patient populations: bariatric, foregut, colorectal.

METHODS

This is a retrospective study using the New York State (NYS) SPARCS database and first study evaluating outcomes based on surgeon/patient concordance in NYS. Bariatric, foregut, and colorectal surgery cases from 2013 to 2017 were identified.

RESULTS

Bariatric: female patients (FP) with CC had lower 30-day readmissions but higher complications compared with DC. Male patients (MP) with CC trended towards higher 30-day readmissions but lower complications compared with DC. FP received significantly better influence from CC in 30-day readmission, but disadvantages in complications. There was no significant difference in LOS or ED visits between CC and DC groups for either FP or MP. Foregut: FP with CC had lower LOS, 30-day readmissions, and 30-day ED visits compared with DC. MP showed opposite trends between CC and DC, although non-significant. The benefit from concordance was pronounced in FP compared to MP in LOS, 30-day readmissions, and 30-day ED visit. Concordance vs discordance did not significantly affect complications within either FP or MP group. Colorectal: the difference between CC and DC was not significant within FP or MP groups in any outcomes. When comparing the difference of 30-day readmissions in CC vs DC between FP and MP, there is a significant difference.

CONCLUSION(S)

Overall, our results show DC between patient and surgeon has significant effect on patient outcomes. A negative effect is seen for female patients in certain specialties, most pronounced in foregut surgery. This emphasizes need for surgeons to be conscious of care provided to opposite gender patients and underscores increasing female surgeons in high FP fields.

Superstition in Surgery: A Population-Based Cohort Study to Assess the Association Between Surgery on Friday the 13th and Postoperative Outcomes

Objective

We sought to examine whether the outcomes of patients who receive a surgical procedure on Friday the 13th differ from patients who receive surgery on flanking Fridays.

Background

Numerous studies have demonstrated that increased anxiety from the provider or patient around the time of surgery can lead to worse outcomes. Superstitious patients often express significant concern and anxiety when undergoing a surgical procedure on Friday the 13th.

Methods

A retrospective, population-based cohort study of 19,747 adults undergoing 1 of 25 common surgical procedures on Friday the 13th or flanking control Fridays (Friday the 6th and Friday the 20th) between January 1, 2007, and December 31, 2019, with 1 year of follow-up. The main outcomes included death, readmission, and complications at 30 days (short-term), 90 days (intermediate-term), and 1 year (long-term).

Results

A total of 7,349 (37.2%) underwent surgery on Friday the 13th, and 12,398 (62.8%) underwent surgery on a flanking Friday during the study period. Patient characteristics were similar between the 2 groups. We found no evidence that patients receiving surgery on Friday the 13th group were more likely to experience the composite primary outcome at 30 days [adjusted odds ratio (aOR) = 1.02 (95% CI = 0.94-1.09)], 90 days [aOR = 0.97 (95% CI = 0.90-1.04)], and 1 year [aOR = 0.99 (95% CI = 0.94-1.04)] after surgery.

Conclusion

Patients receiving surgery on Friday the 13th do not appear to fare worse than those treated on ordinary Fridays with respect to the composite outcome.

Surgery and the Aging Orthopaedic Surgeon

➤ 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.

Surgeon Sex and Health Care Costs for Patients Undergoing Common Surgical Procedures

Importance

Prior research has shown differences in postoperative outcomes for patients treated by female and male surgeons. It is important to understand, from a health system and payer perspective, whether surgical health care costs differ according to the surgeon's sex.

Objective

To examine the association between surgeon sex and health care costs among patients undergoing surgery.

Design, Setting, and Participants

This population-based, retrospective cohort study included adult patients undergoing 1 of 25 common elective or emergent surgical procedures between January 1, 2007, and December 31, 2019, in Ontario, Canada. Analysis was performed from October 2022 to March 2023.

Exposure

Surgeon sex.

Main Outcome and Measure

The primary outcome was total health care costs assessed 1 year following surgery. Secondarily, total health care costs at 30 and 90 days, as well as specific cost categories, were assessed. Generalized estimating equations were used with procedure-level clustering to compare costs between patients undergoing equivalent surgeries performed by female and male surgeons, with further adjustment for patient-, surgeon-, anesthesiologist-, hospital-, and procedure-level covariates.

Results

Among 1 165 711 included patients, 151 054 were treated by a female surgeon and 1 014 657 were treated by a male surgeon. Analyzed at the procedure-specific level and accounting for patient-, surgeon-, anesthesiologist-, and hospital-level covariates, 1-year total health care costs were higher for patients treated by male surgeons ($24 882; 95% CI, $20 780-$29 794) than female surgeons ($18 517; 95% CI, $16 080-$21 324) (adjusted absolute difference, $6365; 95% CI, $3491-9238; adjusted relative risk, 1.10; 95% CI, 1.05-1.14). Similar patterns were observed at 30 days (adjusted absolute difference, $3115; 95% CI, $1682-$4548) and 90 days (adjusted absolute difference, $4228; 95% CI, $2255-$6202).

Conclusions and Relevance

This analysis found lower 30-day, 90-day, and 1-year health care costs for patients treated by female surgeons compared with those treated by male surgeons. These data further underscore the importance of creating inclusive policies and environments supportive of women surgeons to improve recruitment and retention of a more diverse and representative workforce.

Should we screen aging physicians for cognitive decline?

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.

Surgeon factors but not hospital factors associated with length of stay after colorectal surgery - A population based study

AIM

Length of stay (LOS) after colorectal surgery (CRS) is a significant driver of healthcare utilization and adverse patient outcomes. To date, there is little high-quality evidence in the literature examining how individual surgeon and hospital factors independently impact LOS. We aimed to identify and quantify the independent impact of surgeon and hospital factors on LOS after CRS.

METHODS

A retrospective population-based cohort study was conducted using validated health administrative databases, encompassing all patients from the province of Ontario, Canada. All patients from 121 hospitals in Ontario who underwent elective CRS between 2008 and 2019 in Ontario were included, and factors pertaining to these patients and their treating surgeon and hospital were assessed. A negative binomial regression model was used to assess the independent effect of surgeon and hospital factors on LOS, accounting for a comprehensive collection of determinants of LOS. To minimize unmeasured confounding, the analysis was repeated in a subgroup comprising patients undergoing lower-complexity CRS without postoperative complications.

RESULTS

A total of 90,517 CRS patients were analysed. Independent of patient and procedural factors, low surgeon volume (lowest volume quartile) was associated with a 20% increase in LOS (95% CI: 12-29, p < 0.0001) compared to high surgeon volume (highest volume quartile). In the 22,639 patients undergoing uncomplicated lower-complexity surgeries, a 43% longer LOS was seen in the lowest volume surgeon quartile (95% CI: 26-61, p < 0.0001). In both models, more years-in-practice was associated with a small increase in LOS (RR 1.02, 95% CI: 1.02-1.03, p < 0.0001). Hospital factors were not significantly associated with increased LOS.

CONCLUSIONS

Surgeon factors, including low surgeon volume and increasing years-in-practice, were strongly and independently associated with longer LOS, whereas hospital factors did not have an independent impact. This suggests that LOS is driven primarily by surgeon-mediated care processes and may provide actionable targets for provider-level interventions to reduce LOS after CRS.

Association between patient-surgeon gender concordance and mortality after surgery in the United States: retrospective observational study

OBJECTIVE

To determine whether patient-surgeon gender concordance is associated with mortality of patients after surgery in the United States.

DESIGN

Retrospective observational study.

SETTING

Acute care hospitals in the US.

PARTICIPANTS

100% of Medicare fee-for-service beneficiaries aged 65-99 years who had one of 14 major elective or non-elective (emergent or urgent) surgeries in 2016-19.

MAIN OUTCOME MEASURES

Mortality after surgery, defined as death within 30 days of the operation. Adjustments were made for patient and surgeon characteristics and hospital fixed effects (effectively comparing patients within the same hospital).

RESULTS

Among 2 902 756 patients who had surgery, 1 287 845 (44.4%) had operations done by surgeons of the same gender (1 201 712 (41.4%) male patient and male surgeon, 86 133 (3.0%) female patient and female surgeon) and 1 614 911 (55.6%) were by surgeons of different gender (52 944 (1.8%) male patient and female surgeon, 1 561 967 (53.8%) female patient and male surgeon). Adjusted 30 day mortality after surgery was 2.0% for male patient-male surgeon dyads, 1.7% for male patient-female surgeon dyads, 1.5% for female patient-male surgeon dyads, and 1.3% for female patient-female surgeon dyads. Patient-surgeon gender concordance was associated with a slightly lower mortality for female patients (adjusted risk difference -0.2 percentage point (95% confidence interval -0.3 to -0.1); P<0.001), but a higher mortality for male patients (0.3 (0.2 to 0.5); P<0.001) for elective procedures, although the difference was small and not clinically meaningful. No evidence suggests that operative mortality differed by patient-surgeon gender concordance for non-elective procedures.

CONCLUSIONS

Post-operative mortality rates were similar (ie, the difference was small and not clinically meaningful) among the four types of patient-surgeon gender dyads.

Surgeon Sex and Long-Term Postoperative Outcomes Among Patients Undergoing Common Surgeries

Importance

Sex- and gender-based differences in a surgeon's medical practice and communication may be factors in patients' perioperative outcomes. Patients treated by female surgeons have improved 30-day outcomes. However, whether these outcomes persist over longer follow-up has not been assessed.

Objective

To examine whether surgeon sex is associated with 90-day and 1-year outcomes among patients undergoing common surgeries.

Design, Setting, and Participants

A population-based retrospective cohort study was conducted in adults in Ontario, Canada, undergoing 1 of 25 common elective or emergent surgeries between January 1, 2007, and December 31, 2019. Analysis was performed between July 15 and October 20, 2022.

Exposure

Surgeon sex.

Main Outcomes and Measures

An adverse postoperative event, defined as the composite of death, readmission, or complication, was assessed at 90 days and 1 year following surgery. Secondarily, each of these outcomes was assessed individually. Outcomes were compared between patients treated by female and male surgeons using generalized estimating equations with clustering at the level of the surgical procedure, accounting for patient-, procedure-, surgeon-, anesthesiologist-, and facility-level covariates.

Results

Among 1 165 711 included patients, 151 054 were treated by a female and 1 014 657 by a male surgeon. Overall, 14.3% of the patients had 1 or more adverse postoperative outcomes at 90 days and 25.0% had 1 or more adverse postoperative outcomes 1 year following surgery. Among these, 2.0% of patients died within 90 days and 4.3% died within 1 year. Multivariable-adjusted rates of the composite end point were higher among patients treated by male than female surgeons at both 90 days (13.9% vs 12.5%; adjusted odds ratio [AOR], 1.08; 95% CI, 1.03-1.13) and 1 year (25.0% vs 20.7%; AOR, 1.06; 95% CI, 1.01-1.12). Similar patterns were observed for mortality at 90 days (0.8% vs 0.5%; AOR 1.25; 95% CI, 1.12-1.39) and 1 year (2.4% vs 1.6%; AOR, 1.24; 95% CI, 1.13-1.36).

Conclusions and Relevance

After accounting for patient, procedure, surgeon, anesthesiologist, and hospital characteristics, the findings of this cohort study suggest that patients treated by female surgeons have lower rates of adverse postoperative outcomes including death at 90 days and 1 year after surgery compared with those treated by male surgeons. These findings further support differences in patient outcomes based on physician sex that warrant deeper study regarding underlying causes and potential solutions.

Complications following diagnostic and therapeutic sacroiliac joint region injections in horses: A study describing clinicians' experiences

BACKGROUND

There are no detailed data on complications of sacroiliac (SI) joint region injections or on the variability of the methods and circumstances of injections among clinicians.

OBJECTIVES

To describe complications following diagnostic, therapeutic and combined SI joint region injections and the details of how these are routinely performed by a large number of clinicians.

STUDY DESIGN

Cross-sectional questionnaire survey.

METHODS

Clinicians (members of American and European specialist colleges and veterinarians known to the authors), invited by email, who had performed ≥1 SI joint region injection, completed an online questionnaire. Data collected included the clinicians' experience in diagnostic, therapeutic and combined SI joint region injections, details of the injection technique, volume and substance used, and the type of complications seen following SI joint region anaesthesia, medications and combined injections, respectively. Descriptive data analysis was performed and the association between any complications seen and the clinicians' experience, technique, volume and substance used were assessed using binary logistic regression.

RESULTS

Of the 212 respondents, 110 had performed diagnostic, 187 therapeutic and 49 combined injections. More clinicians experienced complications after diagnostic (53/110) than after therapeutic (33/187) or combined (6/49) injections (p < 0.01). The most common complications were hindlimb weakness/ataxia after all types of injections (diagnostic: 44/110, 40%, 95% confidence interval [CI]: 30.8-49.8; therapeutic: 15/187, 8.0%, CI: 4.6-12.9; combined: 2/49, 4.1%, CI: 0.5-14.0). Death or horses requiring euthanasia were reported (after therapeutic injections: 5/187; diagnostic injections: 1/110).

MAIN LIMITATIONS

No prevalence of complications was established; no detailed descriptions of complications were available. Results may be influenced by selection and recall biases.

CONCLUSIONS

Complications were experienced by more clinicians following diagnostic injections than after therapeutic or combined SI joint region injections, but the types and distribution of complications were similar. Results should be interpreted considering the previous reports of low prevalence of complications.

Duration of consultant experience and patient outcome following acute medical unit admission: an observational cohort study

BACKGROUND

The effect of the duration of consultant experience on clinical outcomes in the acute medical unit (AMU) model remains unknown.

METHODS

Unscheduled AMU admissions (n=66,929) admitted by 56 consultant physicians between 2017 and 2020 to two large teaching hospital AMUs in Lothian, Scotland were examined. The associations of consultant experience on AMU with patient discharge, mortality, readmission and postdischarge death were calculated adjusting for clinical acuity, pathology and comorbidity.

RESULTS

Increasing consultant experience was associated with a continuous increase in likelihood of early AMU discharge (odds ratio (OR) 1.08; 95% confidence interval (CI) 1.07-1.10; p<0.001 per 5 years' experience), which persisted after adjustment for confounders (OR 1.06; 95% CI: 1.01-1.11; p=0.01). There was no association with early readmission, death after discharge or 30-day inpatient mortality. The marginal effect estimate translates into 31 (95% CI: 25-36), 41 (95% CI: 30-53) and 52 (95% CI: 35-71) additional safe discharges per 1,000 admissions for clinicians of 15, 20 and 25 years' experience, respectively compared with those recently completing training.

CONCLUSIONS

Increasing consultant physician experience associates with early safe discharge after AMU admission. These data suggest that the support and retention of experienced clinicians is vital if escalating pressures on unscheduled medical care are to be addressed.

Evidence-Based Antibiotic Prophylaxis in Clean Hand Surgeries: An Educational Intervention to Decrease Use

PURPOSE

Evidence for the use of prophylactic antibiotics in clean hand surgery is limited, yet surgeons continue to administer antibiotics to prevent postoperative infections. We sought to assess the effect of a program directed at reducing the use of antibiotic prophylaxis in carpal tunnel release surgery and elicit reasons for continued use.

METHODS

A surgeon leader implemented a program between September 1, 2018 and September 30, 2019 to reduce antibiotic prophylaxis in clean hand surgeries in a hospital system of 10 medical centers. It consisted of (1) an evidence-based educational session for all participating orthopedic and hand surgeons during which the elimination of the use of antibiotics in clean hand surgeries was requested and (2) a year-long, monthly antibiotic use audit and feedback cycle using carpal tunnel release (CTR) as a proxy for clean hand surgery. The rate of antibiotic use in the year of the intervention was compared to the rate prior to the intervention. Multivariable regression was used to determine patient-related risk factors for receiving antibiotics. Participating surgeons completed a survey to elucidate factors that contributed to continued use.

RESULTS

Antibiotic prophylaxis decreased from 1223/2379 (51%) in 2017-2018 to 531/2550 (21%) in 2018-2019. During the last month of evaluation, the rate decreased to 28/208 (14%). Logistic regression revealed a higher rate of antibiotic use during the period after the intervention among patients who had diabetes mellitus or who were operated upon by an older surgeon. The follow-up surgeon survey revealed a strong positive correlation between surgeon willingness to administer antibiotics and patient hemoglobin A1c and body mass index.

CONCLUSIONS

The rate of antibiotic use in carpal tunnel release decreased from 51% the year prior to 14% the final month of implementing a surgeon-led program to reduce antibiotic prophylaxis. Multiple barriers to the implementation of evidence-based practice were identified.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Is It the Load That Breaks You or the Way You Carry It: How Demanding Is Endourology?

Objective: Surgical outcomes are dependent on multiple factors. Besides patient-related or procedure-related factors, several surgeon-related factors contribute to surgical outcomes. The Surgery Task Load Index (SURG-TLX) questionnaire helps to assess the impact of several stressors on the perceived demands of surgeons during surgery. In this study, we evaluate the applicability of the SURG-TLX questionnaire for endourologic procedures and set a first point of reference. Materials and Methods: Between March and August 2022, 15 urologists and urology residents at a tertiary referral center for endourology completed the SURG-TLX questionnaire after endourologic procedures. After data acquisition, all participants were asked to evaluate the applicability of the questionnaire for endourologic procedures. Results: A total of 130 procedures were included between March and August 2022. Situational stress had the lowest median score (3.0/20; interquartile range [IQR] 2.0-7.0) and task complexity the highest (5.0/20; IQR 3.0-8.0). After weighing, the dimensions showed different proportions when compared with the nonweighted scores. Distractions received the highest score (15.0/100; IQR 7.5-32.8), temporal demands (6.0/100; IQR 3.0-12.5), and situational stress the lowest (6.0/100; IQR 2.0-21.0). This was caused by the higher weight that was attributed to distractions (3.4/5), as opposed to task complexity (2.6/5). In the questionnaire regarding applicability of the SURG-TLX, the overall satisfaction (6.0/10; IQR 5.0-7.0) and clarity (6.5/10; IQR 5.0-7.5) were moderate. The user-friendliness and applicability of the questionnaire were rated high (7.0/10; IQR 5.5-8.0 and 7.0/10; IQR 6.0-8.0, respectively) and task load (3.0/10; IQR 2.0-5.0) and time load (2.0/10; IQR 2.0-3.5) low. Conclusion: The SURG-TLX questionnaire is appropriate to assess the different dimensions of workload during endourologic procedures. Furthermore, the perceived workload during endourologic procedures is relatively low.

Patient-reported Outcomes After Primary Total Hip Arthroplasty Are Not Affected by the Sex of the Surgeon: A Register-based Study of 8,383 Procedures in Western Sweden

INTRODUCTION

Female surgeons remain a minority within the field of orthopaedics, particularly in certain specialties such as arthroplasty. There is no scientific evidence on whether the surgeon's sex affects the patient-reported outcome after orthopaedic surgery such as total hip arthroplasty (THA). We therefore aimed to investigate the association between surgeon sex and health-related quality of life after THA.

METHODS

Data on primary THAs performed between 2008 and 2016 were collected from 10 hospitals in western Sweden. The data were linked with the Swedish Hip Arthroplasty Register, a regional patient register and the National Board of Health and Welfare, resulting in a data set that included surgeon-related and patient-related data. The outcome of the study was the change in health-related quality of life, measured with the 3-level version of EQ-5D (EQ-5D-3L) Index and EQ-visual analog scale (VAS), before and 1-year after THA. Mixed models, using hierarchical linear regression adjusted for patient sex, age, preoperative health-related quality of life and Charnley classification, were fitted to estimate the gain in EQ-5D-3L Index and EQ-VAS with 95% confidence intervals based on surgeon sex.

RESULTS

In total, 8,383 primary THAs were done for osteoarthritis by 193 surgeons. Of those, 37 were women and 156 were men. The regression model was showed that patients operated by female surgeons had a β-coefficient of gain in EQ-5D-3L Index of -0.001 (-0.022 to 0.021) and a β-coefficient of gain in EQ VAS of 0.004 (-0.023 to 0.030), compared with patients operated by male surgeons. Similar results were obtained in a sensitivity analysis including attendings only.

DISCUSSION

Patients undergoing primary THA reported similar gain in health-related quality of life regardless of surgeon sex. Based on our results, health-related quality of life after primary THA was not associated with the sex of the operating surgeon.

Surgeon confidence in planning total shoulder arthroplasty improves after consulting a clinical decision support tool

PURPOSE

Software algorithms are increasingly available as clinical decision support tools (CDSTs) to support shared decision-making. We sought to understand if patient-specific predictions from a CDST would impact orthopedic surgeons' preoperative planning decisions and corresponding confidence.

METHODS

We performed a survey study of orthopedic surgeons with at minimum of 2 years of independent shoulder arthroplasty experience. We generated patient profiles for 18 faux cases presenting with glenohumeral osteoarthritis and emailed 93 surgeons requesting their recommendation for anatomic or reverse total shoulder arthroplasty for each case and their certainty in their recommendation on a 4-point Likert scale. The thirty respondents were later sent a second survey with the same cases that now included predicted patient-specific outcomes and complication rates generated by a CDST.

RESULTS

Initial recommendations and changes in recommendation varied widely by surgeon and by case. After viewing the results of the CDST, surgeons switched from anatomic to reverse recommendations in 46 instances (12% of initial anatomic) and from reverse to anatomic in 22 instances (6% of initial reverse). Overall, surgeon change in confidence increased significantly across all responses (p = 0.0001), with certain cases and certain surgeons having significant changes. Change in confidence did not correlate with surgeon-specific factors, including years in practice.

CONCLUSION

The addition of CDST reports to preoperative planning for anatomic and reverse total shoulder arthroplasty informed decision-making but did not direct recommendations uniformly. However, the CDST information provided did increase surgeon confidence regardless of implant selection and irrespective of surgeon experience.

Fellowship Training in Oral and Maxillofacial Surgery: Opportunities and Outcomes

The pursuit of fellowship training stems from one's desire to master a focused area of surgery. Successful applicants tend to have published articles and participated in other scholarly activities. They commonly have a mentor within the subspecialty of their interest. Selection of the program is generally based on the breadth of experience available followed by faculty reputation and location. Advantages to the successful fellowship graduate include the experience and confidence to provide specialized and efficient care to patients. Enhancements to an academic department with a fellowship program include mentorship for residents and guidance toward fellowship, as well as an increased level of scholarly activity.

Cosmetic surgery—why training matters

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The Influence of Surgeon Sex on Adverse Events Following Primary Total Hip Arthroplasty: A Register-Based Study of 11,993 Procedures and 200 Surgeons in Swedish Public Hospitals

BACKGROUND

Stereotypes may prevail, but little is known about the influence that the sex of an orthopaedic surgeon may have on outcomes. In a recently published study, there were no differences in the rate of adverse events following total hip arthroplasties (THAs) performed by female or male orthopaedic surgeons. The objective of the present study was to investigate whether there was any difference in adverse events within 90 days following a primary THA performed by either a male or female surgeon in Sweden.

METHODS

A retrospective study was performed to evaluate primary THAs performed for osteoarthritis between 2008 and 2016 at 10 hospitals in western Sweden. Local hospital data were linked with the Swedish Hip Arthroplasty Register (SHAR) and with a regional patient register. Data collected from local hospitals and the SHAR included surgeon-related information (e.g., sex, annual volume, and level of training) and patient-related information (e.g., age, sex, and Elixhauser comorbidity index). Adverse events were retrieved from the regional patient register. The definition of adverse events followed the SHAR definition of adverse events. Mixed models were used to investigate the impact of surgeon sex on adverse events.

RESULTS

A total of 11,993 primary THAs were performed by 200 surgeons, of whom 17.5% were women. The proportions of adverse events within 90 days were similar for female (6%) and male (7%) surgeons. No association was found between surgeon sex and adverse events (adjusted odds ratio, 0.72; 95% confidence interval, 0.52 to 1.00) when all surgeons (both attendings and residents) were included in the analysis. A sensitivity analysis that included attendings only yielded similar results (adjusted odds ratio, 0.88; 95% confidence interval, 0.60 to 1.29).

CONCLUSIONS

Despite a small tendency toward lower rates of adverse events at 90 days after THAs performed by female surgeons, there was no significant association between surgeon sex and the risk of adverse events following THA.

LEVEL OF EVIDENCE

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

Factors Predicting Surgical Effort Using Explainable Artificial Intelligence in Advanced Stage Epithelial Ovarian Cancer

(1) Background: Surgical cytoreduction for epithelial ovarian cancer (EOC) is a complex procedure. Encompassed within the performance skills to achieve surgical precision, intra-operative surgical decision-making remains a core feature. The use of eXplainable Artificial Intelligence (XAI) could potentially interpret the influence of human factors on the surgical effort for the cytoreductive outcome in question; (2) Methods: The retrospective cohort study evaluated 560 consecutive EOC patients who underwent cytoreductive surgery between January 2014 and December 2019 in a single public institution. The eXtreme Gradient Boosting (XGBoost) and Deep Neural Network (DNN) algorithms were employed to develop the predictive model, including patient- and operation-specific features, and novel features reflecting human factors in surgical heuristics. The precision, recall, F1 score, and area under curve (AUC) were compared between both training algorithms. The SHapley Additive exPlanations (SHAP) framework was used to provide global and local explainability for the predictive model; (3) Results: A surgical complexity score (SCS) cut-off value of five was calculated using a Receiver Operator Characteristic (ROC) curve, above which the probability of incomplete cytoreduction was more likely (area under the curve [AUC] = 0.644; 95% confidence interval [CI] = 0.598−0.69; sensitivity and specificity 34.1%, 86.5%, respectively; p = 0.000). The XGBoost outperformed the DNN assessment for the prediction of the above threshold surgical effort outcome (AUC = 0.77; 95% [CI] 0.69−0.85; p < 0.05 vs. AUC 0.739; 95% [CI] 0.655−0.823; p < 0.95). We identified “turning points” that demonstrated a clear preference towards above the given cut-off level of surgical effort; in consultant surgeons with <12 years of experience, age <53 years old, who, when attempting primary cytoreductive surgery, recorded the presence of ascites, an Intraoperative Mapping of Ovarian Cancer score >4, and a Peritoneal Carcinomatosis Index >7, in a surgical environment with the optimization of infrastructural support. (4) Conclusions: Using XAI, we explain how intra-operative decisions may consider human factors during EOC cytoreduction alongside factual knowledge, to maximize the magnitude of the selected trade-off in effort. XAI techniques are critical for a better understanding of Artificial Intelligence frameworks, and to enhance their incorporation in medical applications.

Association Between Surgeon and Anesthesiologist Sex Discordance and Postoperative Outcomes: A Population-Based Cohort Study

OBJECTIVE

To examine the effect of surgeon-anesthesiologist sex discordance on postoperative outcomes.

SUMMARY BACKGROUND DATA

Optimal surgical outcomes depend on teamwork, with surgeons and anesthesiologists forming two key components. There are sex and gender-based differences in interpersonal communication and medical practice which may contribute to patients' perioperative outcomes.

METHODS

We performed a population-based, retrospective cohort study among adult patients undergoing one of 25 common elective or emergent surgical procedures from 2007-2019 in Ontario, Canada. We assessed the association between differences in sex between surgeon and anesthesiologists (sex discordance) on the primary endpoint of adverse postoperative outcome, defined as death, readmission, or complication within 30-days following surgery using generalized estimating equations.

RESULTS

Among 1,165,711 patients treated by 3,006 surgeons and 1,477 anesthesiologists, 791,819 patients were treated by sex concordant teams (male surgeon/male anesthesiologist: 747,327 and female surgeon/female anesthesiologist: 44,492) while 373,892 were sex discordant (male surgeon/female anesthesiologist: 267,330 and female surgeon/male anesthesiologist: 106,562). Overall, 12.3% of patients experienced one or more adverse postoperative outcomes of whom 1.3% died. Sex discordance between surgeon and anesthesiologist was not associated with a significant increased likelihood of composite adverse postoperative outcomes (adjusted odds ratio [aOR] 1.00, 95% confidence interval [CI] 0.97-1.03).

CONCLUSIONS

We did not demonstrate an association between intraoperative surgeon and anesthesiologist sex discordance on adverse postoperative outcomes in a large patient cohort. Patients, clinicians, and administrators may be reassured that physician sex discordance in operating room teams is unlikely to clinically meaningfully affect patient outcomes after surgery.

Variations in management of A3 and A4 cervical spine fractures as designated by the AO Spine Subaxial Injury Classification System

OBJECTIVE

Optimal management of A3 and A4 cervical spine fractures, as defined by the AO Spine Subaxial Injury Classification System, remains controversial. The objectives of this study were to determine whether significant management variations exist with respect to 1) fracture location across the upper, middle, and lower subaxial cervical spine and 2) geographic region, experience, or specialty.

METHODS

A survey was internationally distributed to 272 AO Spine members across six geographic regions (North America, South America, Europe, Africa, Asia, and the Middle East). Participants' management of A3 and A4 subaxial cervical fractures across cervical regions was assessed in four clinical scenarios. Key characteristics considered in the vignettes included degree of neurological deficit, pain severity, cervical spine stability, presence of comorbidities, and fitness for surgery. Respondents were also directly asked about their preferences for operative management and misalignment acceptance across the subaxial cervical spine.

RESULTS

In total, 155 (57.0%) participants completed the survey. Pooled analysis demonstrated that surgeons were more likely to offer operative intervention for both A3 (p < 0.001) and A4 (p < 0.001) fractures located at the cervicothoracic junction compared with fractures at the upper or middle subaxial cervical regions. There were no significant variations in management for junctional incomplete (p = 0.116) or complete (p = 0.342) burst fractures between geographic regions. Surgeons with more than 10 years of experience were more likely to operatively manage A3 (p < 0.001) and A4 (p < 0.001) fractures than their younger counterparts. Neurosurgeons were more likely to offer surgical stabilization of A3 (p < 0.001) and A4 (p < 0.001) fractures than their orthopedic colleagues. Clinicians from both specialties agreed regarding their preference for fixation of lower junctional A3 (p = 0.866) and A4 (p = 0.368) fractures. Overall, surgical fixation was recommended more often for A4 than A3 fractures in all four scenarios (p < 0.001).

CONCLUSIONS

The subaxial cervical spine should not be considered a single unified entity. Both A3 and A4 fracture subtypes were more likely to be surgically managed at the cervicothoracic junction than the upper or middle subaxial cervical regions. The authors also determined that treatment strategies for A3 and A4 subaxial cervical spine fractures varied significantly, with the latter demonstrating a greater likelihood of operative management. These findings should be reflected in future subaxial cervical spine trauma algorithms.

Association of Surgeon-Patient Sex Concordance With Postoperative Outcomes

Importance

Surgeon sex is associated with differential postoperative outcomes, though the mechanism remains unclear. Sex concordance of surgeons and patients may represent a potential mechanism, given prior associations with physician-patient relationships.

Objective

To examine the association between surgeon-patient sex discordance and postoperative outcomes.

Design, Setting, and Participants

In this population-based, retrospective cohort study, adult patients 18 years and older undergoing one of 21 common elective or emergent surgical procedures in Ontario, Canada, from 2007 to 2019 were analyzed. Data were analyzed from November 2020 to March 2021.

Exposures

Surgeon-patient sex concordance (male surgeon with male patient, female surgeon with female patient) or discordance (male surgeon with female patient, female surgeon with male patient), operationalized as a binary (discordant vs concordant) and 4-level categorical variable.

Main Outcomes and Measures

Adverse postoperative outcome, defined as death, readmission, or complication within 30-day following surgery. Secondary outcomes assessed each of these metrics individually. Generalized estimating equations with clustering at the level of the surgical procedure were used to account for differences between procedures, and subgroup analyses were performed according to procedure, patient, surgeon, and hospital characteristics.

Results

Among 1 320 108 patients treated by 2937 surgeons, 602 560 patients were sex concordant with their surgeon (male surgeon with male patient, 509 634; female surgeon with female patient, 92 926) while 717 548 were sex discordant (male surgeon with female patient, 667 279; female surgeon with male patient, 50 269). A total of 189 390 patients (14.9%) experienced 1 or more adverse postoperative outcomes. Sex discordance between surgeon and patient was associated with a significant increased likelihood of composite adverse postoperative outcomes (adjusted odds ratio [aOR], 1.07; 95% CI, 1.04-1.09), as well as death (aOR, 1.07; 95% CI, 1.02-1.13), and complications (aOR, 1.09; 95% CI, 1.07-1.11) but not readmission (aOR, 1.02; 95% CI, 0.98-1.07). While associations were consistent across most subgroups, patient sex significantly modified this association, with worse outcomes for female patients treated by male surgeons (compared with female patients treated by female surgeons: aOR, 1.15; 95% CI, 1.10-1.20) but not male patients treated by female surgeons (compared with male patients treated by male surgeons: aOR, 0.99; 95% CI, 0.95-1.03) (P for interaction = .004).

Conclusions and Relevance

In this study, sex discordance between surgeons and patients negatively affected outcomes following common procedures. Subgroup analyses demonstrate that this is driven by worse outcomes among female patients treated by male surgeons. Further work should seek to understand the underlying mechanism.

Physicians' clinical experience and its association with healthcare quality: a systematised review

BACKGROUND AND PURPOSE

There is conflicting evidence regarding whether physicians' clinical experience affects healthcare quality. Knowing whether an association exists and which dimensions of quality might be affected can help healthcare services close quality gaps by tailoring improvement initiatives according to physicians' clinical experience. Here, we present a systematised review that aims to assess the potential association between physicians' clinical experience and different dimensions of healthcare quality.

METHODS

We conducted a systematised literature review, including the databases MEDLINE, Embase, PsycINFO and PubMed. The search strategy involved combining predefined terms that describe physicians' clinical experience with terms that describe different dimensions of healthcare quality (ie, safety, clinical effectiveness, patient-centredness, timeliness, efficiency and equity). We included relevant, original research published from June 2004 to November 2020.

RESULTS

Fifty-two studies reporting 63 evaluations of the association between physicians' clinical experience and healthcare quality were included in the final analysis. Overall, 27 (43%) evaluations found a positive or partially positive association between physicians' clinical experience and healthcare quality; 22 (35%) found no association; and 14 (22%) evaluations reported a negative or partially negative association. We found a proportional association between physicians' clinical experience and quality regarding outcome measures that reflect safety, particularly in the surgical fields. For other dimensions of quality, no firm evidence was found.

CONCLUSION

We found no clear evidence of an association between measures of physicians' clinical experience and overall healthcare quality. For outcome measures related to safety, we found that physicians' clinical experience was proportional with safer care, particularly in surgical fields. Our findings support efforts to secure adequate training and supervision for early-career physicians regarding safety outcomes. Further research is needed to reveal the potential subgroups in which gaps in quality due to physicians' clinical experience might exist.

A narrative review on the validity of electronic health record-based research in epidemiology

Electronic health records (EHRs) are widely used in epidemiological research, but the validity of the results is dependent upon the assumptions made about the healthcare system, the patient, and the provider. In this review, we identify four overarching challenges in using EHR-based data for epidemiological analysis, with a particular emphasis on threats to validity. These challenges include representativeness of the EHR to a target population, the availability and interpretability of clinical and non-clinical data, and missing data at both the variable and observation levels. Each challenge reveals layers of assumptions that the epidemiologist is required to make, from the point of patient entry into the healthcare system, to the provider documenting the results of the clinical exam and follow-up of the patient longitudinally; all with the potential to bias the results of analysis of these data. Understanding the extent of as well as remediating potential biases requires a variety of methodological approaches, from traditional sensitivity analyses and validation studies, to newer techniques such as natural language processing. Beyond methods to address these challenges, it will remain crucial for epidemiologists to engage with clinicians and informaticians at their institutions to ensure data quality and accessibility by forming multidisciplinary teams around specific research projects.

Predictors of same-day discharge after minimally invasive hysterectomy for benign indications

OBJECTIVE

To identify predictors of same-day discharge after benign minimally invasive hysterectomy.

METHODS

In this retrospective cohort study, we identified women (n = 1084) undergoing benign minimally invasive hysterectomy from 2009 to 2016. Multivariate logistic regression was used to examine demographic, operative, and surgeon factors associated with discharge on postoperative day 0.

RESULTS

In our study population, 238 women (22%) were discharged on the same day. Robotic hysterectomy (risk ratio [RR] 2.24; 95% confidence interval [CI] 1.13-4.44), shorter operative time (lowest quartile; RR 5.28; 95% CI 2.66-10.46), and minimal blood loss (lowest quartile; RR 3.01; 95% CI 1.68-6.23) were associated with higher same-day discharge likelihood whereas later procedure start time (2-5 pm; RR 0.38; 95% CI 0.17-0.85) and postoperative complications (RR 0.19; 95% CI 0.06-0.55) significantly decreased its likelihood. The strongest predictor was surgeon's number of years in practice, with recently graduated surgeons more likely to discharge their patients on the same day (RR 3.15; 95% CI 2.09-4.77).

CONCLUSION

Same-day discharge after minimally invasive hysterectomy is determined by several patient, operative, and surgeon factors that can be incorporated into an implementation plan to promote earlier discharge. Most especially, scheduling patients based on perceived case complexity and targeted surgeon education can qualify a larger cohort for same-day discharge.

A Consensus Study: Generational Differences in Neurosurgeons' Perception of Retirement and Practice Limits

BACKGROUND

Concerns about the changing demographics in the United States and the aging of the neurosurgical workforce exist. Both the importance and inherent risk of surgical responsibilities suggest that thought be given to whether workloads should change later in surgeons' careers. We sought to assess current neurosurgeons' expectations concerning their late-stage careers.

METHODS

A survey was sent to 3317 U.S. board-certified neurosurgeons. It was designed to assess surgeons' perceptions of call and operative responsibilities in the later stages of their careers. Statistical analyses were completed in R version 3.6.1, with an alpha set to 0.05.

RESULTS

Six-hundred and fifty-nine neurosurgeons completed the questionnaire. Seventy-seven percent believed that the call burden should decrease later in practice, and 66% planned to decrease their own call burden later in their career. The most common age range for planned retirement was 65 to 69 years (36%), followed by 70+ years (33%). Most (67%) believed that there should not be a mandatory age to stop operating. More recent year of residency completion was negatively associated with the belief that call burden should decrease at older age groups and positively associated with support for a mandatory age to stop operating as well as an earlier retirement age.

CONCLUSIONS

This study suggests that neurosurgeons have differing views on how workloads should change later in their careers. Younger neurosurgeons support an earlier decrease in workload or even a policy-mandated stop to operating after a certain age. These results may give insight into future trends and turnover in neurosurgery and provide a valuable tool to help practices anticipate workforce changes.

Optimal surgeon and hospital volume thresholds to reduce mortality and length of stay for CABG

Objective

We used nationwide population-based data to identify optimal hospital and surgeon volume thresholds and to discover the effects of these volume thresholds on operative mortality and length of stay (LOS) for coronary artery bypass surgery (CABG).

Design

Retrospective cohort study.

Setting

General acute care hospitals throughout Taiwan.

Participants

A total of 12,892 CABG patients admitted between 2011 and 2015 were extracted from Taiwan National Health Insurance claims data.

Main Outcome Measures

Operative mortality and LOS. Restricted cubic splines were applied to discover the optimal hospital and surgeon volume thresholds needed to reduce operative mortality. Generalized estimating equation regression modeling, Cox proportional-hazards modeling and instrumental variables analysis were employed to examine the effects of hospital and surgeon volume thresholds on the operative mortality and LOS.

Results

The volume thresholds for hospitals and surgeons were 55 cases and 5 cases per year, respectively. Patients who underwent CABG from hospitals that did not reach the volume threshold had higher operative mortality than those who received CABG from hospitals that did reach the volume threshold. Patients who underwent CABG with surgeons who did not reach the volume threshold had higher operative mortality and LOS than those who underwent CABG with surgeons who did reach the volume threshold.

Conclusions

This is the first study to identify the optimal hospital and surgeon volume thresholds for reducing operative mortality and LOS. This supports policies regionalizing CABG at high-volume hospitals. Identifying volume thresholds could help patients, providers, and policymakers provide optimal care.

Successful navigation of late career transitions

The purpose of this educational review was to describe the challenges that may face the anesthesiologist near the end of their career and to propose strategies that will enable the individual to continue to be a productive and valued member of their Department, both clinically and by other contributions.