Observations on Surgeons’ Case Selection, Morbidity, and Mortality Following Board Certification

Abstract

Objective The purpose of this study is to determine if patient selection varies based on years of surgical practice. Summary Background Data The impact of hospital and surgeon volume as a marker of experience has demonstrated an inverse association with surgical outcomes. However, temporal measures of experience often demonstrate no effect. Additionally, a self-reporting survey demonstrated decreasing case complexity over time, suggesting that changes in patient selection may account for some of these observed discrepancies. Methods General surgery cases at a single tertiary care center reported to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) over a 10-year period were identified. Additionally general surgery cases from the ACS NSQIP 2008 PUF data were used to create risk models for any complications, 30-day mortality or a composite complication or mortality outcome. These models then estimated risk for our local data. Years of experience after American Board of Surgery (ABS) certification were calculated for each surgeon for each case. Multivariate linear regression, controlling for surgeon clustering, was used to determine the association between years of surgical experience and preoperative risk of complications and mortality. Results 18,688 cases were identified from our institution. Surgeons selected patients of increasing operative risk until 15 years of practice before selecting lower risk patients throughout the rest of their career. After adjusting for risk, no association was observed between years from board certification and mortality. However, there was a trend toward decreasing complication rates with increasing experience. Conclusions Surgical experience significantly impacts patient selection. Surgeons with over 25 years of experience had lower complication rates. Experience had no impact on mortality.

The relationship between cardiac surgeon experience and average patient risk profile: CA and NY statewide analysis

“…This stands in contrast to the findings in other specialties, such as The Cognitive Changes and Retirement among Senior Surgeons Study (CCRASS), which found that surgeons self‐reported an increase in case volume and a decrease in case‐complexity over time 5 . The CCRASS was supported by a study that showed that general surgeons with fewer than 15 years in practice operated on patients of higher preoperative risk 6 . Another study of vascular surgeons showed that surgeons within their first 5 years of practice had a greater proportion of nonelective cases with a higher degree of comorbidities and larger aneurysms 11 .…”

“…There have been very few studies on this topic, however, the little evidence that exists in general surgery points to earlier‐career surgeons receiving more challenging and higher‐risk cases 5–7 . In cardiac surgery, a prior study showed that surgeons with lower risk‐adjusted mortality rates tended to perform CABG surgery on higher risk patients 8 .…”

The Relationship Between Cardiac Surgeon Experience and Patient Complexity: CA and NY statewide analysis

“…This stands in contrast to the findings in other specialties, such as The Cognitive Changes and Retirement among Senior Surgeons Study (CCRASS), which found that surgeons self-reported an increase in case volume and a decrease in case complexity over time 4 . The CCRASS was supported by a study which showed that general surgeons with fewer than 15 years in practice operated on patients of higher pre-operative risk 5 . Another study of vascular surgeons showed that surgeons within their first 5 years of practice had a greater proportion of nonelective cases with a higher degree of comorbidities and larger aneurysms 10 .…”

“…There have been very few studies on this topic, however the little evidence that exists in general surgery points to earlier-career surgeons receiving more challenging and higher-risk cases [4][5][6] . In cardiac surgery, a prior study showed that surgeons with lower risk-adjusted mortality rates tended to perform CABG surgery on higher risk patients 7 .…”