The Opportunity Cost of Resident Involvement in Craniofacial Surgery: An Analysis of Relative Value Units

Abstract

PURPOSE: Within the academic surgical setting, it has been well-established that resident involvement confers longer operative times. While academic faculty have historically prioritized the education and training of residents, the increasing pressures to maximize clinical productivity and decreasing reimbursement rates may conflict with these principles. Using relative value unit (RVU)-based analysis, the purpose of this study is to calculate the opportunity cost of resident involvement in a myriad of common craniofacial surgical procedures. METHODS: Retrospective analysis was conducted with patients who underwent craniofacial procedures from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2012. Patients were selected based on relevant Current Procedural Terminology (CPT) codes for five common craniofacial pathologies (ie, trauma, head and neck reconstruction, orthognathic surgery, and facial reanimation). Variables collected included patient demographics, operative time, presence or absence of resident trainee, and postgraduate year (PGY) level. Average RVUs were calculated to determine the opportunity cost of resident involvement for each craniofacial procedure. Independent student t-test were used for statistical analysis. P < 0.05 was considered significant. RESULTS: In total, 2189 patients were identified after reviewing the ACS-NSQIP database from 2005 to 2012. Resident involvement was associated with a statistically significant higher operative time (P < 0.001) for facial reanimation, facial trauma, orthognathic surgery, and head and neck reconstruction. The opportunity costs associated with resident involvement were the highest for head and neck reconstruction ($1,468.04), followed by orthognathic surgery ($1247.03), facial trauma ($533.03), and facial reanimation ($358.32). Resident involvement was associated with a higher rate of complications for head and neck reconstruction (P < 0.043). CONCLUSIONS: Resident involvement is largely associated with longer operative times, higher complications, and higher re-operations, compared with attending-exclusive surgical care. With increasing pressures to maximize clinical productivity and shifts toward value-based care, one may consider how reimbursements should reflect resident involvement and ultimately, align incentives for academic surgeons to promote resident education and training. REFERENCES: 1. Zhu W, Beletsky A, Kordahi A, et al. The cost to attending surgeons of resident involvement in academic hand surgery. Ann Plast Surg. 2019;82:S285–S288. 2. Aibel K, Truong T, Shammas RL, et al. Assessing the effort associated with teaching residents. J Plast Reconstr Aesthet Surg. 2017;70:1725–1731. 3. Sasor S, Flores RL, Wooden WA, et al. The cost of intraoperative plastic surgery education. J Surg Educ 2013;70(5):655–659. 4. Nguyen K, Gart MS, Smetona, JT, et al. The relationship between relative value units and outcomes: a multivariate analysis of plastic surgery procedures. ePlasty 2012;12:500–510. 5. American College of Surgeons. American College of Surgeons national surgical quality improvement. Available at: https://www.facs.org/Quality-Programs/ACS-NSQIP. Published 2020. Retrieved February 28, 2021.