Operative Autonomy among Senior Surgical Trainees during Infrainguinal Bypass Operations Is Not Associated with Worse Long-term Patient Outcomes

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Abstract

Background In an era of rapidly evolving surgical training, intraoperative teaching remains paramount to the education of surgical trainees. The impact of surgical trainees' level of expertise on outcomes after infrainguinal bypass surgery, a technically demanding operation, remains unknown. The purpose of this study was to explore the effects of surgical residents' experience on outcomes after infrainguinal bypass surgery. Methods Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified patients who underwent infrainguinal bypass from 2005 to 2012. Patients were stratified according to the training level of the most senior operating trainee. Univariate and multivariate analyses, as well as propensity score matched analysis, were performed to compare patient cohorts on operative time, length of hospital stay (LOS), bleeding, early graft failure, unplanned readmission, and 30-day mortality. Results A total of 19,579 patients were identified, of which 35.6% were female and 64.4% were male; mean age was 67.6 years. A PGY1 (postgraduate year) was the highest level trainee operating on 2.5%, a PGY2–4 for 26.2%, and a PGY5+ (postgraduate year 5 or greater) for 37.1%. Attending surgeons operated without trainees on 34.2%. PGY5+s were more likely to operate on patients who were younger, non-White, male, and on dialysis. In multivariable analysis, involvement of any surgical trainee was associated with procedures that took a greater length of time, had a greater odds of blood transfusion, and necessitated a longer hospital LOS relative to procedures performed by an attending surgeon alone. Only bypasses wherein PGY5+s were involved were associated with greater odds of early graft failure, unplanned readmission, and 30-day mortality when compared with procedures done without trainee involvement. After excluding lower extremity bypasses in which an attending surgeon operated without a trainee, propensity score matching analysis showed that patients operated on by PGY5+s had longer operative time (4.11 vs. 3.96 hr, P < 0.0001) and greater rates of postoperative bleeding (9.77% vs. 8.15%, P = 0.004) relative to patients operated on by attendings assisted by PGY1–4s, but no statistically significant difference in LOS, early graft failure, unplanned readmission, and perioperative mortality. Conclusions Operative involvement of senior trainees was associated with worse outcomes during infrainguinal bypass, potentially reflecting a lesser extent of attending surgeon involvement, but no difference in patient outcomes after bypass procedure.

Original languageEnglish (US)
Pages (from-to)42-53
Number of pages12
JournalAnnals of Vascular Surgery
Volume38
DOIs
StatePublished - Jan 1 2017

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Length of Stay
Propensity Score
Operative Time
Transplants
Mortality
Hemorrhage
Quality Improvement
Blood Transfusion
Dialysis
Lower Extremity
Teaching
Multivariate Analysis
Databases
Education
Surgeons

All Science Journal Classification (ASJC) codes

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

@article{86babc7c15db467ba396a5d651258bb9,
title = "Operative Autonomy among Senior Surgical Trainees during Infrainguinal Bypass Operations Is Not Associated with Worse Long-term Patient Outcomes",
abstract = "Background In an era of rapidly evolving surgical training, intraoperative teaching remains paramount to the education of surgical trainees. The impact of surgical trainees' level of expertise on outcomes after infrainguinal bypass surgery, a technically demanding operation, remains unknown. The purpose of this study was to explore the effects of surgical residents' experience on outcomes after infrainguinal bypass surgery. Methods Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified patients who underwent infrainguinal bypass from 2005 to 2012. Patients were stratified according to the training level of the most senior operating trainee. Univariate and multivariate analyses, as well as propensity score matched analysis, were performed to compare patient cohorts on operative time, length of hospital stay (LOS), bleeding, early graft failure, unplanned readmission, and 30-day mortality. Results A total of 19,579 patients were identified, of which 35.6{\%} were female and 64.4{\%} were male; mean age was 67.6 years. A PGY1 (postgraduate year) was the highest level trainee operating on 2.5{\%}, a PGY2–4 for 26.2{\%}, and a PGY5+ (postgraduate year 5 or greater) for 37.1{\%}. Attending surgeons operated without trainees on 34.2{\%}. PGY5+s were more likely to operate on patients who were younger, non-White, male, and on dialysis. In multivariable analysis, involvement of any surgical trainee was associated with procedures that took a greater length of time, had a greater odds of blood transfusion, and necessitated a longer hospital LOS relative to procedures performed by an attending surgeon alone. Only bypasses wherein PGY5+s were involved were associated with greater odds of early graft failure, unplanned readmission, and 30-day mortality when compared with procedures done without trainee involvement. After excluding lower extremity bypasses in which an attending surgeon operated without a trainee, propensity score matching analysis showed that patients operated on by PGY5+s had longer operative time (4.11 vs. 3.96 hr, P < 0.0001) and greater rates of postoperative bleeding (9.77{\%} vs. 8.15{\%}, P = 0.004) relative to patients operated on by attendings assisted by PGY1–4s, but no statistically significant difference in LOS, early graft failure, unplanned readmission, and perioperative mortality. Conclusions Operative involvement of senior trainees was associated with worse outcomes during infrainguinal bypass, potentially reflecting a lesser extent of attending surgeon involvement, but no difference in patient outcomes after bypass procedure.",
author = "Greenleaf, {Erin K.} and Faisal Aziz and Hollenbeak, {Christopher S.}",
year = "2017",
month = "1",
day = "1",
doi = "10.1016/j.avsg.2016.09.005",
language = "English (US)",
volume = "38",
pages = "42--53",
journal = "Annals of Vascular Surgery",
issn = "0890-5096",
publisher = "Elsevier Inc.",

}

TY - JOUR

T1 - Operative Autonomy among Senior Surgical Trainees during Infrainguinal Bypass Operations Is Not Associated with Worse Long-term Patient Outcomes

AU - Greenleaf, Erin K.

AU - Aziz, Faisal

AU - Hollenbeak, Christopher S.

PY - 2017/1/1

Y1 - 2017/1/1

N2 - Background In an era of rapidly evolving surgical training, intraoperative teaching remains paramount to the education of surgical trainees. The impact of surgical trainees' level of expertise on outcomes after infrainguinal bypass surgery, a technically demanding operation, remains unknown. The purpose of this study was to explore the effects of surgical residents' experience on outcomes after infrainguinal bypass surgery. Methods Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified patients who underwent infrainguinal bypass from 2005 to 2012. Patients were stratified according to the training level of the most senior operating trainee. Univariate and multivariate analyses, as well as propensity score matched analysis, were performed to compare patient cohorts on operative time, length of hospital stay (LOS), bleeding, early graft failure, unplanned readmission, and 30-day mortality. Results A total of 19,579 patients were identified, of which 35.6% were female and 64.4% were male; mean age was 67.6 years. A PGY1 (postgraduate year) was the highest level trainee operating on 2.5%, a PGY2–4 for 26.2%, and a PGY5+ (postgraduate year 5 or greater) for 37.1%. Attending surgeons operated without trainees on 34.2%. PGY5+s were more likely to operate on patients who were younger, non-White, male, and on dialysis. In multivariable analysis, involvement of any surgical trainee was associated with procedures that took a greater length of time, had a greater odds of blood transfusion, and necessitated a longer hospital LOS relative to procedures performed by an attending surgeon alone. Only bypasses wherein PGY5+s were involved were associated with greater odds of early graft failure, unplanned readmission, and 30-day mortality when compared with procedures done without trainee involvement. After excluding lower extremity bypasses in which an attending surgeon operated without a trainee, propensity score matching analysis showed that patients operated on by PGY5+s had longer operative time (4.11 vs. 3.96 hr, P < 0.0001) and greater rates of postoperative bleeding (9.77% vs. 8.15%, P = 0.004) relative to patients operated on by attendings assisted by PGY1–4s, but no statistically significant difference in LOS, early graft failure, unplanned readmission, and perioperative mortality. Conclusions Operative involvement of senior trainees was associated with worse outcomes during infrainguinal bypass, potentially reflecting a lesser extent of attending surgeon involvement, but no difference in patient outcomes after bypass procedure.

AB - Background In an era of rapidly evolving surgical training, intraoperative teaching remains paramount to the education of surgical trainees. The impact of surgical trainees' level of expertise on outcomes after infrainguinal bypass surgery, a technically demanding operation, remains unknown. The purpose of this study was to explore the effects of surgical residents' experience on outcomes after infrainguinal bypass surgery. Methods Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified patients who underwent infrainguinal bypass from 2005 to 2012. Patients were stratified according to the training level of the most senior operating trainee. Univariate and multivariate analyses, as well as propensity score matched analysis, were performed to compare patient cohorts on operative time, length of hospital stay (LOS), bleeding, early graft failure, unplanned readmission, and 30-day mortality. Results A total of 19,579 patients were identified, of which 35.6% were female and 64.4% were male; mean age was 67.6 years. A PGY1 (postgraduate year) was the highest level trainee operating on 2.5%, a PGY2–4 for 26.2%, and a PGY5+ (postgraduate year 5 or greater) for 37.1%. Attending surgeons operated without trainees on 34.2%. PGY5+s were more likely to operate on patients who were younger, non-White, male, and on dialysis. In multivariable analysis, involvement of any surgical trainee was associated with procedures that took a greater length of time, had a greater odds of blood transfusion, and necessitated a longer hospital LOS relative to procedures performed by an attending surgeon alone. Only bypasses wherein PGY5+s were involved were associated with greater odds of early graft failure, unplanned readmission, and 30-day mortality when compared with procedures done without trainee involvement. After excluding lower extremity bypasses in which an attending surgeon operated without a trainee, propensity score matching analysis showed that patients operated on by PGY5+s had longer operative time (4.11 vs. 3.96 hr, P < 0.0001) and greater rates of postoperative bleeding (9.77% vs. 8.15%, P = 0.004) relative to patients operated on by attendings assisted by PGY1–4s, but no statistically significant difference in LOS, early graft failure, unplanned readmission, and perioperative mortality. Conclusions Operative involvement of senior trainees was associated with worse outcomes during infrainguinal bypass, potentially reflecting a lesser extent of attending surgeon involvement, but no difference in patient outcomes after bypass procedure.

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U2 - 10.1016/j.avsg.2016.09.005

DO - 10.1016/j.avsg.2016.09.005

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JO - Annals of Vascular Surgery

JF - Annals of Vascular Surgery

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