Resident Training in Hysterectomy and Patient Morbidity: Interrogating the Association

Abstract

BACKGROUND: Concern regarding resident inexperience as a contributing factor toward unfavorable surgical outcomes is often claimed but has been inadequately explored. METHODS: Data were abstracted from American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) on 33,278 benign hysterectomies performed from January 2005–December 2012. Associations between resident participation and morbidity were examined using multivariate-adjusted regression, adjusting for age, BMI, race, ethnicity, year of surgery, smoking, diabetes, hypertension, steroid use, ASA physical classification, uterine size, and postoperative diagnosis. Cases without resident involvement (63.4%) were used as the referent. RESULTS: Resident involvement was associated with significantly longer operative times regardless of surgical approach and year of training (all P<.0001). Odds of blood transfusion were increased with resident participation in abdominal (OR 1.74; 95% CI 1.40–2.17) and laparoscopic hysterectomy (OR 1.87; 95% CI 1.33–2.64), while odds of sepsis were increased in abdominal (OR 2.29; 95% CI 1.37–3.83) and vaginal hysterectomy (OR 2.49; 95% CI 1.24–5.00). Odds of urinary tract infections were uniformly higher with resident participation (all P<.001). When stratified by level of training, these associations only remained significant in hysterectomies involving senior residents. All associations were significantly attenuated or absent when operative time was included in the model. DISCUSSION: Resident involvement is associated with modest increases in the odds of blood transfusion and infectious morbidity after hysterectomy. These associations are likely driven by prolonged operative times with resident participation.