Affairs Surgical Quality Improvement Program Research Articles

General Surgery Resident Complement and Operative Autonomy – Size Matters

Operative autonomy has progressively decreased for surgery residents. This study investigates the effect of general surgery resident complement size at Veterans Affairs (VA) hospitals on operative autonomy for the residents. We hypothesize that smaller complements of residents would result in fewer opportunities for operative autonomy. Retrospective analysis of the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Operative cases within the VASQIP database from July 1, 2004 to September 30, 2019 were analyzed. All general surgery procedures performed at teaching VA hospitals from January 2004 to September 2019 were included. The level of resident operative autonomy is defined as follows: attending primary surgeon with or without a resident (AP), resident primary surgeon with attending scrubbed (AR), and resident primary without attending scrubbed (RP). Resident complement is based on funded resident positions at each VA hospital during the academic year 2017-2018 and stratified into 3 groups: small (≤4), medium (>4-<7), and large (≥7). The primary outcome was the proportion of operative autonomy for each resident complement group. Secondary outcomes were level of autonomy over time, and mortality and morbidity for RP procedures. Categorical data were compared with Chi-squared test. Four hundred sixty-one thousand seven hundred thirty-four procedures across 92 VA hospitals with general surgery residents were included in the analysis. There were 126,062 cases performed at 29 small resident complement hospitals, 135,539 at 28 medium resident complement hospitals, and 200,133 at 35 large resident complement hospitals. The percentage of RP procedures was higher with increasing resident complement (2.1% vs 6.8% vs 9.9%, p < 0.001). RP procedures have decreased over time in all groups, but the relative decrease was less pronounced as resident complement increased (79.5% vs 73.3% vs 64.7%, p < 0.001). There was no significant difference in adjusted 30-day all-cause mortality between groups. Increased resident complement at VA hospitals is associated with increased resident autonomy in resident primary procedures. Resident autonomy has decreased over time regardless of complement size, but it is less dramatic at sites with more residents. Increasing resident complement at a site may improve operative autonomy, leading to an improved educational experience for surgical residents.

Declining Surgical Resident Operative Autonomy in Acute Care Surgical Cases

IntroductionSurgical resident operative autonomy has decreased markedly over time, reducing resident readiness for independent practice. We sought to examine operative resident autonomy for emergency acute care surgery (ACS) compared to elective cases and associated patient outcomes at veterans affairs hospitals. MethodsThe Veterans Affairs Surgical Quality Improvement Program database was queried for ACS cases (emergency general, vascular, and thoracic) at veterans affairs hospitals from 2004 to 2019. Cases are coded prospectively for the level of supervision: attending primary surgeon (AP); attending scrubbed with resident surgeon (AR); resident primary (RP), attending not scrubbed. Baseline demographics, operative variables, and outcomes were compared. ResultsA total of 61,275 ACS cases and 605,146 elective cases were performed during the study period. The ACS had a higher proportion of RP cases (7.2% versus 5.7%, P < 0.001). The proportion of ACS RP cases decreased from 9.9% to 4.1% (58.6%); elective RP cases decreased from 8.9% to 2.9% (67.4%). The most common ACS RP surgeries were appendectomy, amputations, and cholecystectomy. RP cases had lower American Society of Anesthesia class and lower median work relative value units than AP and AR. There was no difference between mortality rates of RP compared to AP (adjusted odds ratio [OR] 0.94 [0.80-1.09] or AR 0.94 [0.81-1.08]). While there was no difference in complications between the RP and AP (OR 1.01 [0.92-1.12]), there were significantly more complications in AR compared to RP (OR 1.20 [1.10-1.31]). ConclusionsMore autonomy is granted for ACS cases compared to elective cases. While both decreased over time, the decrease is less for ACS cases. Resident autonomy does not negatively impact outcomes, even in emergent cases.

Resident Involvement in Inguinal Hernia Repair Is Safe but Associated With Increased Operative Time

Understanding how resident participation in surgery affects outcomes is critical for academic surgeons. The purpose of this study was to evaluate if resident participation was associated with adverse outcomes for inguinal hernia repair. We used the Veterans Affairs Surgical Quality Improvement Program to look at 61,737 patients aged ≥18y who had open inguinal hernia repairs from 1998 to 2018. Propensity weighting was used to compare postoperative complications and operative time for patients having surgery performed by an attending alone versus attending with a postgraduate year (PGY) 1, 3, or 5 residents. There were 29,806 hernias (48%) repaired by an attending, 12,024 (19%) by an intern, 9008 (15%) by a PGY-3 resident, and 10,898 (18%) by a PGY-5 resident. After propensity weighting, there was a 0.13% (95% CI -0.11% to 0.38%, P=0.29) increase in complications with PGY-1 participation compared to cases performed by attendings alone, a 0.3% increase (95% CI 0.01% to 0.59%, P=0.04) for PGY-3 residents, and a 0.4% increase (95% CI 0.11% to 0.69%, P=0.007) for PGY-5 residents. There was also an increase in operative time of 26min (95% CI 25 to 27, P<0.001) with PGY-1 participation, 19min (95% CI 18 to 20, P<0.001) with PGY-3 participation, and 23min (95% CI 22 to 24, P<0.001) with PGY-5 participation. Resident involvement in inguinal hernia surgery was associated with a significant increase in operative time but had a minimal impact on postoperative complications. Although resident participation in hernia surgery is safe, surgical programs should focus on enhancing operative efficiency for residents.

Risk factors for cerebrovascular accident after isolated coronary artery bypass grafting in Veterans.

Cerebrovascular accident (CVA) after coronary artery bypass grafting (CABG) is a devastating complication. Patient comorbidities and intraoperative elements contribute to the risk of CVA. The aim of this study is to identify risk factors for CVA in Veterans undergoing CABG. Veterans undergoing isolated CABG from 2008 to 2019 were retrospectively identified using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Thirty-day postoperative outcomes were observed. Univariate analysis followed by multivariable logistic regression identified independent risk factors for postoperative CVA. Receiver operating characteristicdiagnostics identified optimal inflection points between continuous risk factors and odds of CVA. Twenty-eight thousand seven hundred fifty-sevenpatients met inclusion criteria. Incidence of CVA was 1.1% (310 cases). In multivariate analysis, preoperative cerebrovascular disease had the strongest association with postoperative CVA (adjusted odds ratio = 2.29; p < .001). There was an inverse relationship between CVA incidence and ejection fraction (EF), with EF of 35%-39% conferring a 2.11 times higher risk compared to EF>55% (p < .001). CVA incidence was not different in on-pump versus off-pump cases; however, after 104 min or more on bypass patients had a 55% greater adjusted odds of CVA (p < .001). Other risk factors included poor kidney function, prior myocardial infarction, and intra-aortic balloon pump use. The risk of CVA after CABG is multifactorial and involves multiple organ systems, including cardiac disease, poor renal function, and cerebrovascular disease, which was the strongest contributing risk factor. Optimization of these comorbidities and time on bypass may help improve clinical outcomes and lower the risk of this devastating complication.

Predictors of 30-Day Pulmonary Complications after Video-Assisted Thoracoscopic Surgery Lobectomy.

Pulmonary complications are the most common adverse event after lung resection, yet few large-scale studies have examined pertinent risk factors after video-assisted thoracoscopic surgery (VATS) lobectomy. Veterans, older and less healthy compared with nonveterans, represent a cohort that requires further investigation. Our objective is to determine predictors of pulmonary complications after VATS lobectomy in veterans. A retrospective review was conducted on patients who underwent VATS lobectomy from 2008 to 2018 using the Veterans Affairs Surgical Quality Improvement Program database. Patients were divided into two cohorts based on development of a pulmonary complication within 30 days. Patient characteristics were compared via multivariable analysis to determine clinical predictors associated with pulmonary complication and reported as adjusted odds ratios (aORs) with 95% confidence intervals. Patients with preoperative pneumonia, ventilator dependence, and emergent cases were excluded. In 4,216 VATS lobectomy cases, 480 (11.3%) cases had ≥1 pulmonary complication. Preoperative factors independently associated with pulmonary complication included chronic obstructive pulmonary disease (COPD) (aOR = 1.37 [1.12-1.69]; p = 0.003), hyponatremia (aOR = 1.50 [1.06-2.11]; p = 0.021), and dyspnea (aOR = 1.33 [1.06-1.66]; p = 0.013). Unhealthy alcohol consumption was associated with pulmonary complication via univariable analysis (17.1 vs. 13.0%; p = 0.016). Cases with pulmonary complication were associated with increased mortality (12.1 vs. 0.8%; p < 0.001) and longer length of stay (12.0 vs. 6.8 days; p < 0.001). This analysis revealed several preoperative factors associated with development of pulmonary complications. It is imperative to optimize pulmonary-specific comorbidities such as COPD or dyspnea prior to VATS lobectomy. However, unhealthy alcohol consumption and hyponatremia were linked with development of pulmonary complication in our analysis and should be addressed prior to VATS lobectomy. Future studies should explore long-term consequences of pulmonary complications.

Hospital Operative Volume and Esophagectomy Outcomes in the Veterans Affairs System.

Previous studies reported that increased hospital case volume improves outcomes after esophagectomy. Yet, the standard for high and low-volume hospitals varies in the literature. This study attempts to define the relationship between hospital operative volume and 30-day post-operative outcomes of esophagectomy in the Veterans Affairs (VA) system. This is a retrospective review of patients that underwent esophagectomy from 2008 to 2019 utilizing the Veterans Affairs Surgical Quality Improvement Program Database. Receiver operating characteristic (ROC) analysis quantified an inflection point of optimal association between 30-day morbidity and mortality by facility volume. This point was used to separate cohorts for comparison of outcomes using 1:1 propensity score matching (PSM) to account for confounding covariates. Two thousand two hundred and twelve esophagectomies were performed from 2008 to 2019 and ROC analysis identified an inflection point at 43 cases (4 cases/y) where bidirectional operative volume significantly affected outcomes. Subsequent PSM resulted in 1718 cases utilized for analysis (n=859 per cohort). Facility volume ≥4 cases/y was significantly associated with decreased odds of 30-day mortality (odds ratio(OR)=0.57; P=0.03), shorter length of stay (median 13 versus 14d; P=0.04) and longer operative times (6.5 versus 6.0h; P<0.001). VA hospitals that averaged ≥4 esophagectomies/y had significantly lower rates of mortality and length of stay. This volume threshold may serve as a benchmark to determine the optimal setting for esophageal resection. However, our findings also may reflect the benefits of cumulative operating room and multidisciplinary team experience at VA centers in conjunction with dedicated surgeons. Future studies should focus on long-term outcomes after esophagectomy in relation to hospital operative volume.

Prior Antibiotic Exposure Is Associated With Reoperation After Elective Non-colorectal Surgery.

Recent antibiotic exposure has previously been associated with poor outcomes following elective surgery. The purpose of this study is to evaluate the impact of prior recent antibiotic exposure in a multicenter cohort of Veterans Affairs patients undergoing elective non-colorectal surgery. This is a retrospective cohort study of the Veterans Affairs Surgical Quality Improvement Program, including elective, non-cardiovascular, non-colorectal surgery from 2013 to 2017. Outpatient antibiotic exposure within 90days prior to surgery was identified from the Veterans Affairs outpatient pharmacy database and matched with each case. Primary outcomes included serious complication, any complication, any infection, or surgical site infection. Secondary outcomes included 30-day mortality, length of stay, and Clostridioides difficile infection. Of 21,112 eligible patients, 2885 (13.7%) were exposed to antibiotics within 90days prior to surgery with a duration of 7 (IQR: 5-10) days and prescribed 42 (IQR: 21-64) days prior to surgical intervention. Compared to non-exposed patients, exposed patients had higher unadjusted complication rates, increased length of stay, and rates of return to the operating. Exposure was independently associated with return to the operating room (OR: 1.39; 99% CI: 1.05-1.84). Among Veterans, recent antibiotic exposure within 90days of elective surgery was associated with a 39% increase in the odds of return to the operating room. Further work is needed to evaluate the effects of antibiotic exposure and dysbiosis on surgical outcomes.

Patients undergoing colorectal surgery at a Veterans Affairs Hospital do not experience racial disparity in length of stay either before or after implementing an enhanced recovery pathway

BackgroundEnhanced Recovery Pathways (ERP) have been shown to reduce racial disparities following surgery. The objective of this study is to determine whether ERP implementation mitigates racial disparities at a Veterans Affairs Hospital.MethodsA retrospective cohort study was conducted using data obtained from the Veterans Affairs Surgical Quality Improvement Program. All patients undergoing elective colorectal surgery following ERP implementation were included. Current procedural terminology (CPT) codes were used to identify patients who underwent similar procedures prior to ERP implementation.ResultsOur study included 417 patients (314 pre-ERP vs. 103 ERP), 97.1% of which were male, with an average age of 62.32 (interquartile range (IQR): 25–90). ERP patients overall had a significantly shorter post-operative length of stay (pLOS) vs. pre-ERP patients (median 4 days (IQR: 3–6.5) vs. 6 days (IQR: 4–9) days (p < 0.001)). Within the pre-ERP group, median pLOS for both races was 6 days (IQR: 4–6; p < 0.976) and both groups experienced a decrease in median pLOS (4 vs. 6 days; p < 0.009 and p < 0.001) following ERP implementation.ConclusionsRacial disparities did not exist in patients undergoing elective surgery at a single VA Medical Center. Implementation of an ERP significantly reduced pLOS for black and white patients.

Age is associated with increased morbidity after laparoscopic appendectomy

BackgroundLaparoscopic appendectomy is one of the most common emergency general surgery procedures in the United States. Little is known about its postoperative outcomes for older adults because appendicitis typically occurs in younger patients. The purpose of this study was to examine the association between age and postoperative complications after appendectomy. We hypothesized that age would have a significant and nonlinear association with morbidity. MethodsWe conducted a retrospective cohort study of individuals whose laparoscopic appendectomies were recorded in the Veterans Affairs (VA) Surgical Quality Improvement Program (from 2000–2018; n = 14,619) and National Surgical Quality Improvement Program (2005–2019; n = 349,909) databases. The primary outcome was 30-day morbidity. We used logistic regression with fractional polynomials to model nonlinear relationships between age and outcomes. ResultsThe median age (interquartile range) of the nonveteran cohort was 36 years (26–51; 8.4% of patients were 65 or older) versus 51 years among veterans (35–63; 21% were 65 or older). For veterans and nonveterans, there was a significant and nonlinear relationship between age and risk of complications. In the nonveteran cohort, the predicted probability (with 95% confidence interval) of postoperative complications was 9.8% (9.7–10.1) at age 65, 11.9% (11.7–12.3) at age 75, and 14.5% (14.1–14.9) at age 85. Among veterans, the risk was 7.5% (6.9–8.1) at age 65, 8.3% (7.6–9.1) at age 75, and 9.1% (8.1–10.1) at age 85. ConclusionFor both veterans and nonveterans, older age was associated with a significantly increased risk of postoperative complications. Notably, morbidity within the VA was lower for older adults than in non-VA hospitals.

MP10-02 UROLOGY RESIDENT AUTONOMY COMPARED TO GENERAL SURGERY RESIDENT AUTONOMY

You have accessJournal of UrologyCME1 May 2022MP10-02 UROLOGY RESIDENT AUTONOMY COMPARED TO GENERAL SURGERY RESIDENT AUTONOMY Kunj Jain, Janmejay Hingu, Anh Nguyen, Devashish Anjaria, Joseph B. Oliver, and Hossein Sadeghi-Nejad Kunj JainKunj Jain More articles by this author , Janmejay HinguJanmejay Hingu More articles by this author , Anh NguyenAnh Nguyen More articles by this author , Devashish AnjariaDevashish Anjaria More articles by this author , Joseph B. OliverJoseph B. Oliver More articles by this author , and Hossein Sadeghi-NejadHossein Sadeghi-Nejad More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002532.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urology and general surgery resident autonomy in the operating room has been declining in recent years. This may be due to perceptions of poorer outcomes, complications, and operating time. Residents and faculty have expressed decreased preparedness as independent surgeons due to inadequate autonomy during residency. We sought to compare resident involvement for general surgery and urology residents and evaluated the associated outcomes. METHODS: This study is a retrospective study from the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. All operative cases from July 1, 2004 to September 30, 2019 in the VASQIP database were included in the study. Patients who underwent a urologic surgical procedure were identified based on the code of the surgeon’s specialty and stratified based on CPT codes. The cases were coded based on the level of supervision by an attending physician: AP- attending as primary surgeon, RP- resident as primary surgeon, AR- attending and resident as primary surgeons. Logistic regression and ANOVA analysis was performed. RESULTS: The VASQIP database included 127,757 patients who underwent urologic surgery over the 15 year time frame. There was decline in resident primary surgeon (RP) cases from 31.3% in 2004 to 18.6% in 2019 with an increase in total cases (p <0.01). The number of urology RP cases is higher compared to general surgery/vascular surgery RP cases which decreased from 15% to 5% in the same period. Urology and general surgery AR cases had increased operating times, but RP surgeries did not have significantly increased operating times when compared to AP surgeries. There was no increase in mortality with RP or AR urology cases. However, the 30-day return to OR was significantly increased compared to AP cases. There was no difference in mortality between RP or AP general surgery cases, but AP general surgery cases had an increased rate of complications. CONCLUSIONS: Residents in urology and general surgery have had a major decline in resident autonomy between 2004 and 2019. Although urology has had better autonomy maintenance compared to general surgery, both specialties have seen a decline that is not warranted based on operating time, complications, and patient outcomes. There is a need for increased efforts to expand resident autonomy to create prepared and independent future surgeons. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e146 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kunj Jain More articles by this author Janmejay Hingu More articles by this author Anh Nguyen More articles by this author Devashish Anjaria More articles by this author Joseph B. Oliver More articles by this author Hossein Sadeghi-Nejad More articles by this author Expand All Advertisement PDF DownloadLoading ...

Assessing Resident Impact on Surgical Outcomes in Below-the-Knee Amputations Based on Operative Autonomy

Gradual increases in resident autonomy with attending physician oversight is crucial to developing safe and competent surgeons1. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) follows surgical outcomes within the VA. We set forth to examine the VASQIP database to compare outcomes between resident independent cases and nonindependent cases during below-the-knee amputations (BKA). All VASQIP records for BKA from 2000 to 2020 were examined and categorized based on whether the attending was scrubbed during the case. Case matching was performed based on preoperative comorbidities; 30-day postoperative outcomes, including a return to the operating room, wound infection, and mortality, were assessed in addition to operative time, hospital length of stay, and transfusion requirements. Student's t-test and Fisher's Exact Test were utilized. A total of 13,208 BKA VASQIP records were obtained. After case control matching, 2,688 cases remained. Cases were identified with the attending surgeon noted as being scrubbed during the case (n=1,344), or not scrubbed (n=1,344). Patients were similar in comorbidities across both groups. No statistically significant difference in operative time (1.52hr±0.78 vs. 1.47hr±0.75, P=0.08), 30-day mortality (3.3% vs. 4.8%, P=0.05), or complication rate (19.5% vs. 21.3%, P=0.25). Resident independent cases were noted to have slightly longer postop length of stay (12.47days±12.69 vs. 15.33days±20.56, P<0.01) and operative bleeding requiring more than 4 units transfused (0.3% vs. 1.3%, P≤ 0.01). Resident independent operating during below-the-knee amputation at VA hospitals is associated with an increased length of stay and blood transfusion. There was no statistically significant increase in operative time, 30-day mortality, or total complication rate. Further research is required to assess the risks associated with surgical training, resident supervision, and resident preparedness for independent practice.

Risks and Risk Factors for Contralateral Amputation in Patients who have Undergone Amputation for Chronic Limb Threatening Ischaemia

The aim of this study was to determine the cumulative incidence of, and the risk factors associated with, contralateral amputation in patients with chronic limb threatening ischaemia (CLTI). This was a retrospective cohort study of patients with incident unilateral transmetatarsal (TM), transtibial (TT), or transfemoral (TF) amputation secondary to CLTI, identified from the National Veterans Affairs Surgical Quality Improvement Program database (2004 - 2014). Thirteen potential pre-operative risk factors for contralateral amputation were considered. A competing risk analysis to estimate the cumulative incidence of contralateral amputation was performed using a Fine-Gray subdistribution hazard model. The effect of risk factors on contralateral amputation was estimated by computing subdistribution hazard ratios (sub-HR) with 95% confidence intervals (CI). From the database, 7 360 patients met the inclusion criteria. The contralateral amputation risk was 7.7% and was greatest in those who underwent a TF amputation (9.7%), followed by TT (7.4%) and TM amputation (6.6%) (p < .001). Among the 588 contralateral amputations, 50% were at the TF level, 34% at the TT level, and 16% at the TM level. The adjusted risk of contralateral amputation was greater in those who underwent an incident TF amputation or were Black or Hispanic. The factor that contributed to risk of contralateral amputation to the greatest extent was dialysis (sub-HR, 2.3; 95% CI 1.7 - 3.0; p < .001) while those who were obese (compared with underweight) were at lowest risk (0.67; 95% CI 0.46 - 0.97; p= .030). The one year risk of contralateral amputation in patients with CLTI is related to incident amputation level, medical comorbidities, correlates with race/ethnicity, and body mass index at the time of the incident amputation. The identified risk factors are largely not modifiable; however, they can be used to help identify populations at elevated risk.

Operative Autonomy: Assessing Resident Impact on Surgical Outcomes In Below The Knee Amputations

INTRODUCTION AND OBJECTIVES Gradual increases in autonomy with attending physician oversight are consider crucial to successful training in surgery as well as safe patient care. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) follows patient outcomes and has yet to be examined for outcomes of specialty and includes information about attending surgeon oversight in the operation room (OR). We set forth to examine VASQIP database to determine the frequency of resident operative independence during below the knee amputations (BKA). METHODS All VASQIP records for BKA from 1990 to 2018 were examined and categorized based on if the attending was scrubbed during case. Case matching was performed based on gender, diabetes, preoperative renal failure, smoking status, steroid use, CHF, COPD, and open wound infections. Comorbidities, pre- and postoperative outcomes for each procedure within 30 days were tabulated. 30 day post-operative outcomes including return to the operating room, wound infections mortality were assessed in addition to operative time, hospital length of stay and transfusion requirements. Student t-test* and Fisher's Exact Test⁎⁎ were utilized. RESULTS A total of 28,768 BKA VASQIP records were obtained. After case control matching, 5,234 cases remained. Cases were identified with the attending surgeon noted as being scrubbed during the case (n=2617), or not scrubbed (n=2617). Patients were similar in comorbidities across both. CONCLUSIONS Increased resident independence during BKA at VA hospitals is associated with a statistically significant length of stay, return to OR, blood transfusion, and sepsis. There was no statistically significant increase in operative time, 30-day mortality, wound infection, or total complication. Further research is required in assessing the risks associated with surgical training, resident supervision, and resident preparedness for independent practice. Gradual increases in autonomy with attending physician oversight are consider crucial to successful training in surgery as well as safe patient care. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) follows patient outcomes and has yet to be examined for outcomes of specialty and includes information about attending surgeon oversight in the operation room (OR). We set forth to examine VASQIP database to determine the frequency of resident operative independence during below the knee amputations (BKA). All VASQIP records for BKA from 1990 to 2018 were examined and categorized based on if the attending was scrubbed during case. Case matching was performed based on gender, diabetes, preoperative renal failure, smoking status, steroid use, CHF, COPD, and open wound infections. Comorbidities, pre- and postoperative outcomes for each procedure within 30 days were tabulated. 30 day post-operative outcomes including return to the operating room, wound infections mortality were assessed in addition to operative time, hospital length of stay and transfusion requirements. Student t-test* and Fisher's Exact Test⁎⁎ were utilized. A total of 28,768 BKA VASQIP records were obtained. After case control matching, 5,234 cases remained. Cases were identified with the attending surgeon noted as being scrubbed during the case (n=2617), or not scrubbed (n=2617). Patients were similar in comorbidities across both. Increased resident independence during BKA at VA hospitals is associated with a statistically significant length of stay, return to OR, blood transfusion, and sepsis. There was no statistically significant increase in operative time, 30-day mortality, wound infection, or total complication. Further research is required in assessing the risks associated with surgical training, resident supervision, and resident preparedness for independent practice.

Association Between Hospital Perioperative Quality and Long-term Survival After Noncardiac Surgery

There is known variation in perioperative mortality rates across hospitals. However, the extent to which this variation is associated with hospital-level differences in longer-term survival has not been characterized. To evaluate the association between hospital perioperative quality and long-term survival after noncardiac surgery. This national cohort study included 654 093 US veterans who underwent noncardiac surgery at 98 hospitals using data from the Veterans Affairs Surgical Quality Improvement Program from January 1, 2011, to December 31, 2016. Data were analyzed between January 1 and November 1, 2021. Hospitals were stratified separately into quintiles of reliability-adjusted failure to rescue (FTR) and mortality rates. Patients were further categorized as having a complicated or uncomplicated postoperative course. The association between hospital FTR or mortality performance quintile (with quintile 1 representing low FTR or mortality and quintile 5 representing very high FTR or mortality) and overall risk of death was evaluated separately using multivariable shared frailty modeling among patients with a complicated and uncomplicated postoperative course. For the overall cohort of 654 093 patients, the mean (SD) age was 61.1 (13.2) years; 597 515 (91.4%) were men and 56 578 (8.7%) were women; 111 077 (17.0%) were Black, 5953 (0.9%) were Native American, 467 969 (71.5%) were White, 42 219 (6.5%) were missing a racial category, and 26 875 (4.1%) were of another race; and 37 538 (5.7%) were Hispanic. Hospital-level 5-year survival for patients with a complicated course ranged from 42.7% (95% CI, 38.1%-46.9%) to 82.4% (95% CI, 59.0%-93.2%) and from 76.2% (95% CI, 74.4%-78.0%) to 95.2% (95% CI, 92.5%-97.7%) for patients with an uncomplicated course. Overall, 47 (48.0%) and 83 (84.7%) of 98 hospitals were either in the same or within 1 performance quintile for FTR and mortality, respectively. Among patients who had a postoperative complication, there was a dose-dependent association between care at hospitals with higher FTR rates and risk of death (compared with quintile 1: quintile 2 hazard ratio [HR], 1.05 [95% CI, 0.99-1.12]; quintile 3 HR, 1.17 [95% CI, 1.10-1.26]; quintile 4 HR, 1.30 [95% CI, 1.22-1.38]; and quintile 5 HR, 1.34 [95% CI, 1.22-1.43]). Similarly, increasing hospital FTR rates were associated with increasing risk of death among patients without complications (compared with quintile 1: quintile 2 HR, 1.07 [95% CI, 1.01-1.14]; quintile 3 HR, 1.10 [95% CI, 1.04-1.16]; quintile 4 HR, 1.15 [95% CI, 1.09-1.21]; and quintile 5 HR, 1.10 [95% CI, 1.05-1.19]). These findings were similar across hospital mortality quintiles for patients with complicated and uncomplicated courses. The findings of this cohort study suggest that the structures, processes, and systems of care that underlie the association between FTR and worse short-term outcomes may also have an influence on long-term survival through a pathway other than rescue from complications. A better understanding of these differences could lead to strategies that address variation in both perioperative and longer-term outcomes.

Frailty Index Comparison in Gastric, Pancreatic, and Hepatobiliary Surgeries for Malignancy

Introduction: Surgical resection continues to be a central tenant of multimodal cancer care for patients with gastrointestinal malignancies treated with curative intent. However, several studies have shown that surgical complications can often interfere with the completion of chemotherapy. This highlights the need for better patient selection. We compared the predictive ability of various frailty tools for 30-day outcomes in patients undergoing elective surgical oncology procedures for gastric and hepatopancreatic-biliary malignancies within the VA system. Methods: Using the Veteran Affairs Surgical Quality Improvement Program database, we performed a retrospective study of patients who underwent gastrectomy, pancreatectomy, hepatectomy, or laparoscopic cholecystectomy for malignant indications from 1999-2019. Emergency cases were excluded. RAI-rev, mFI-5, MFI-11, MELD, Childs-Pugh, and Whipple-ABACUS scores were calculated. Pearson's χ2 tests, one-way ANOVA, ROC, and C-statistics were used to assess the predictive accuracy of each frailty index for 30-day mortality. Results: In the cohort, 3,976 surgeries were performed for malignancy. 49.1% were hepatectomies, 38.6% were pancreatectomies, 6.5% were cholecystectomies, and 5.8% were gastrectomies. RAI performed the best overall, C-statistic 0.688. RAI outperformed all other frailty indices, as determined by comparing the AUC of the respective ROC curves (p <0.001). In analyzing each surgery independently, RAI remained superior for pancreatectomy (C-statistic 0.673), gastrectomy (C-statistic 0.727), and laparoscopic cholecystectomy (C-statistic 0.823). However, Childs-Pugh performed the best for hepatectomies (C-statistic 0.633). Conclusion: RAI-rev is a good predictor of 30-day mortality when applied to pancreatectomy, gastrectomy, and laparoscopic cholecystectomy for cancer indications. However, Childs-Pugh performed better than RAI-rev in patients undergoing hepatectomy for malignancy.Tabled 1Frailty Index ComparisonC-statisticAUC DifferenceP-valueRAI0.688refrefMELD0.605-0.083<0.001Childs-Pugh0.632-0.053<0.001MFI-110.592-0.096<0.001MFI-50.590-0.098<0.001Whipple-ABACUS0.645-0.043<0.001 Open table in a new tab

Comparing Veterans Affairs and Private Sector Perioperative Outcomes After Noncardiac Surgery

Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. However, contemporary data comparing the quality and safety of VA and non-VA surgical care are lacking. To compare perioperative outcomes among veterans treated in VA hospitals with patients treated in private-sector hospitals. This cohort study took place across 8 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 1, 2015, through December 31, 2018. Multivariable log-binomial modeling was used to evaluate the association between VA vs private sector care settings and 30-day mortality. Unmeasured confounding was quantified using the E-value. Patients 18 years and older undergoing a noncardiac procedures were included. Surgical care in either a VA or private sector setting. Primary outcome was 30-day postoperative mortality. Secondary outcome was failure to rescue, defined as a postoperative death after a complication. Of 3 910 752 operations (3 174 274 from NSQIP and 736 477 from VASQIP), 1 498 984 (92.1%) participants in NSQIP were male vs 678 382 (47.2%) in VASQIP (mean difference, -0.449 [95% CI, -0.450 to -0.448]; P < .001), and 441 894 (60.0%) participants in VASQIP were frail or very frail vs 676 525 (21.3%) in NSQIP (mean difference, -0.387 [95% CI, -0.388 to -0.386]; P < .001). Overall, rates of 30-day mortality, complications, and failure to rescue were 0.8%, 9.5%, and 4.7%, respectively, in NSQIP (n = 3 174 274 operations) and 1.1%, 17.1%, and 6.7%, respectively in VASQIP (736 477) (differences in proportions, -0.003 [95% CI, -0.003 to -0.002]; -0.076 [95% CI, -0.077 to -0.075]; 0.020 [95% CI, 0.018-0.021], respectively; P < .001). Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P < .001). This finding was robust in multiple sensitivity analyses performed, including among patients who were frail and nonfrail, with or without complications, and undergoing low and high physiologic stress procedures. These findings were also consistent when year was included as a covariate and in nonparsimonious modeling for patient-level factors. Compared with private sector care, VA surgical care was also associated with a lower risk of failure to rescue (adjusted relative risk, 0.55 [95% CI, 0.44-0.68]). An unmeasured confounder (present disproportionately in NSQIP data) would require a relative risk of 2.78 [95% CI, 2.04-3.68] to obviate the main finding. VA surgical care is associated with lower perioperative mortality and decreased failure to rescue despite veterans having higher-risk characteristics. Given the unique needs and composition of the veteran population, health policy decisions and budgetary appropriations should reflect these important differences.

Does resident autonomy in colectomy procedures result in inferior clinical outcomes?

BackgroundThe amount of time surgical trainees spend operating independently has been reduced by work-hour restrictions and shifts in the health care environment that impede autonomy. Few studies evaluate the association between clinical outcome and resident autonomy. MethodsThe Veterans Affairs Surgical Quality Improvement Program database was queried to identify patients undergoing partial colectomy for neoplasm between 2004 and 2019. Rectal resections, emergency procedures, and those involving postgraduate year 1 and 2 residents were excluded. Records were categorized as performed with the attending scrubbed or not scrubbed. Hierarchical logistic regression was used to identify factors independently associated with operative time, morbidity, and mortality. ResultsIn total, 7,347 patients met inclusion criteria; 6,890 (93.6%) were categorized as attending scrubbed and 457 (6.4%) as attending not scrubbed. The cohorts were similar in terms of patient demographics, including age, race, body mass index, and American Society of Anesthesiologists class. There were no differences between cohorts in terms of operative time (attending not scrubbed 3.02 hours, attending scrubbed 3.07 hours, P = .42). On hierarchical logistic regression adjusted for age, gender, race, body mass index, functional status, cancer location, facility operative level, wound class, American Society of Anesthesiologists class, length of operation, operative modality (open or minimally invasive), postgraduate year of resident, and year, there were no differences in odds of complications, major morbidity, or mortality based on attending involvement. ConclusionColectomies performed by residents with appropriate levels of autonomy are efficient and safe. Our results indicate that attending surgeon judgment regarding resident autonomy is sound and that educational environments can be designed to foster resident independence and preserve clinical quality, safety, and efficiency.

Early Postoperative Mortality Among US Veterans With a Robust Physiologic Reserve Undergoing Open or Endovascular Abdominal Aortic Aneurysm Repair

This cohort study uses data from the Veterans Affairs Surgical Quality Improvement Program database to examine the risk of early postoperative mortality among US veterans with a robust physiologic reserve undergoing open or endovascular abdominal aortic aneurysm repair.

Using the risk analysis index to assess frailty in a veteran cohort undergoing endovascular aortic aneurysm repair

ObjectiveSurgical frailty is strongly associated with increased perioperative morbidity and mortality. The risk analysis index (RAI) is a validated frailty score system, which has been shown to predict for short-term outcomes and long-term mortality in various surgical subspecialties. In the present study, we applied the frailty score to a veteran aneurysm population who had undergone nonemergent endovascular aortic aneurysm repair (EVAR). MethodsAfter obtaining institutional review board approval, the Veteran Affairs Surgical Quality Improvement Program data were queried for endovascular repair of infrarenal abdominal aortic aneurysm or dissection using the Current Procedural Terminology codes 34,800, 34,803, and 34,805 from 2001 to 2018. The preoperative variables were used to calculate the RAI score. The patients were placed into six cohorts according to the RAI score (≤20, 21-25, 26-30, 31-35, 35-40, and ≥41). The χ2 test and analysis of variance test were used compare the cohorts. Forward logistic regression modeling was used to determine the risks of each cohort. ResultsFrom 2001 to 2018, 5568 patients had undergone EVAR. Of the 5568 patients, 99.6% were male, with a mean age of 71 ± 8 years. Of these patients, 4.5%, 43.8%, 33.9%, 11.7%, 4.2%, and 1.8% were included in the following RAI groups: ≤20, 21 to 25, 26 to 30, 31 to 35, 35 to 40, and ≥41, respectively. Frailty was associated with increased rates of overall complications, death, and an increased length of stay. When risk adjusted, frailty at the highest vs lowest level was associated with 2.7 times the odds of any complication developing and 4.4 times the odds of mortality ≤30 days. ConclusionsFrailty, as determined by the RAI, was associated with postoperative outcomes in a dose-dependent manner. Frailty was associated with higher rates of major cardiac (myocardial infarction, cardiac arrest), pulmonary (pneumonia, failure to wean from ventilation, reintubation), renal (renal failure), overall complications, length of stay, and death. We recommend the use of this frailty index as a screening tool to guide discussions with patients scheduled to undergo EVAR.

General Surgical Resident Operative Autonomy vs Patient Outcomes: Are we Compromising Training without Net Benefit to Hospitals or Patients?

Resident operative autonomy has been steadily declining. The reasons are multifactorial and include concerns related to patient safety and operating room efficiency. Simultaneously, faculty have expressed that residents are less prepared for independent practice. We sought to understand the effect of decreasing resident autonomy on patient outcomes and operative duration. Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Operative cases within the VASQIP database from July 1, 2004-September 30, 2019 were analyzed. All adult patients who underwent a surgical procedure from July 1, 2004 to September 30, 2019 were analyzed. The subpopulation of patients that underwent a surgical procedure in General Surgery or Peripheral Vascular Surgery were identified based on the code of the specialty surgeon. Within these subgroups, the most frequent cases by current procedural terminology (CPT) code were selected for study inclusion. The principle CPT code of all cases was further coded by level of supervision: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). Baseline demographics, operative variables, and outcomes were compared between groups. The VASQIP database included 698,391 total general/vascular surgery cases. 38,483 (6%) of them were RP cases. Analysis revealed that the top 5 RP cases account for 73% of total RP volume-these include: 1) Hernias (55% total; 33% open inguinal, 13% umbilical, 5% open ventral/incisional, and 4% laparoscopic) 2) cholecystectomy (18%), 3) Amputations (17% total; 10% above knee, 7% below knee), 4) Appendectomy (7%) and 5) Open colectomy (3%). The percentage of cases at teaching hospitals that were RP cases significantly decreased from 15% in 2004 to 5% in 2019 (p < 0.001). RP cases were generally sicker as demonstrated by higher ASA classifications and more likely to be emergent cases. Operative times were also increased with resident involvement, but RP cases were faster than AR cases on average. After adjusting for baseline demographics, case type, and year of procedure, mortality was no different between groups. Complications were higher in the AR group but not in the RP group. The rate of resident autonomy in routine general surgery cases has decreased by two-thirds over the 15-year study period. Cases performed by residents without an attending surgeon scrubbed were performed faster than cases performed by a resident and attending together and there was no increase in patient morbidity or mortality when residents performed cases independently. The erosion of resident autonomy is not justified based upon operative time or patient outcomes. Efforts to increase surgical resident operative autonomy are needed.