The impact of individual physicians on outcomes after trauma: is it the system or the surgeon?

Udyavar, N. Rhea; Salim, Ali; Havens, Joaquim M.; Cooper, Zara; Cornwell, Edward E.; Lipsitz, Stuart R.; Scott, John W.; Haider, Adil H.

doi:10.1016/j.jss.2018.02.051

Cited by 4 publications

(7 citation statements)

References 42 publications

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“…Of the 55 studies, three were randomized controlled trials, 37 , 80 , 93 and 52 were observational cohort studies. The studies included various surgical specialties or aggregates thereof, including 8 or more specialties, 81 , 91 breast surgery, 59 , 73 , 74 , 101 cardiac surgery, 44 , 45 , 52 , 53 , 56 , 65–67 , 70 , 89 , 90 , 99 , 100 colorectal surgery, 34 , 61 , 68 , 71 , 78 , 85 , 92 , 103 , 104 ENT surgery, 75 gastrointestinal surgery, 34 , 83 general surgery, 34 , 37 , 57 , 77 , 79 , 82 , 86 , 93 , 95 , 96 , 102 obstetrics, 80 ophthalmology, 97 orthopedic surgery, 55 , 76 , 84 , 102 rectal surgery, 72 , 98 spinal surgery, 58 trauma surgery, 87 and urology. 62–64 , 69 , 88 , 94 , 102 38 studies were conducted in the USA, 10 in the UK, two in Austria and Sweden, one each in Canada, France, and Germany.…”

Section: Resultsmentioning

confidence: 99%

Is There a Surgeons’ Effect on Patients’ Physical Health, Beyond the Intervention, That Requires Further Investigation? A Systematic Review

Schnelle¹,

Clark²,

Mascord³

et al. 2022

TCRM

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Objective To find and review published papers researching surgeons’ effects on patients’ physical health. Clinical outcomes of surgery patients with similar prognoses cannot be fully explained by surgeon skill or experience. Just as there are “hospital” and “psychotherapist” effects, there may be “surgeons” effects that persist after controlling for known variables like patient health and operation riskiness. Methods Cohort studies and randomized controlled trials (RCTs) of any surgical intervention, which, after multivariate adjustment, either showed proportion of variance in patients’ physical health outcomes due to surgeons (random effects) or graded surgeons from best to worst (fixed effects). Studies with <15 surgeons or only ascribing surgeons’ effects to known variables excluded. Medline, PubMed, Embase, and PsycINFO were used for search until June 2020. Manual search for papers referring/referred by resulting studies. Risk of bias assessed by Cochrane risk-of-bias tool and Newcastle–Ottawa Scale. Results Included studies: 52 cohort studies and three RCTs of 52,436+ surgeons covering 102 outcomes (33 unique). Studies either graded surgeons from best to worst or calculated the intra-class correlation coefficient (ICC), the percentage of patients’ variation due to surgeons, in diverse ways. Sixteen studies showed exceptionally good and/or bad performers with confidence intervals wholly above or below the average performance. ICCs ranged from 0 to 47%, median 4.0%. There are no well-established reporting standards; highly heterogeneous reporting, therefore no meta-analysis. Discussion Interpretation: There is a surgeons' effect on patients’ physical health for many types of surgeries and outcomes, ranging from small to substantial. Surgeons with exceptional patient outcomes appear regularly even after accounting for all known confounding variables. Many existing cohort studies and RCTs could be reanalyzed for surgeons’ effects especially after methodological reporting guidelines are published. Conclusion In terms of patient outcomes, it can matter which surgeon is chosen. Surgeons with exceptional patient outcomes are worth studying further.

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Section: Resultsmentioning

confidence: 99%

Is There a Surgeons’ Effect on Patients’ Physical Health, Beyond the Intervention, That Requires Further Investigation? A Systematic Review

Schnelle¹,

Clark²,

Mascord³

et al. 2022

TCRM

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“…It has been demonstrated that there are differences in outcomes among hospitals performing emergency surgery and caring for trauma patients. 7,23 However, the mechanisms that underlie these findings have not been clearly elucidated. The reasons for these differences may exist at the institution level, but they are also found at the surgeon level.…”

Section: Discussionmentioning

confidence: 99%

“…The reasons for these differences may exist at the institution level, but they are also found at the surgeon level. 7,14,24 Such differ- ences have been demonstrated in both operative cases and in the nonoperative treatment of trauma patients, suggesting clinical decision-making is at least partially responsible for these differences. The specific effect of operative care has not been well examined in emergency surgical interventions.…”

Section: Discussionmentioning

confidence: 99%

“…It has been demonstrated that there are differences in outcomes among hospitals performing emergency surgery and caring for trauma patients . However, the mechanisms that underlie these findings have not been clearly elucidated.…”

Section: Discussionmentioning

confidence: 99%

“…One study identified trauma management by trainees compared with fully trained trauma surgeons as predictive of increased mortality . Another study examining trauma mortality at Florida hospitals attributed 9% of mortality to the treating surgeon, although no characteristics of the surgeons other than volume were measured . How trauma surgeon volume, experience, and other characteristics interact to affect outcomes remains uncertain.…”

Section: Introductionmentioning

confidence: 99%

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Association of Acute Care Surgeon Experience With Emergency Surgery Patient Outcomes and Mortality

et al. 2021

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IMPORTANCE Previous studies comparing emergency surgery outcomes with surgeon experience have been small or used administrative databases without controlling for patient physiology or operative complexity.OBJECTIVE To evaluate the association of acute care surgeon experience with patient morbidity and mortality after emergency surgical procedures. DESIGN, SETTING, AND PARTICIPANTSThis cohort study evaluated the association of surgeon experience with emergency surgery outcomes at 5 US academic level 1 trauma centers where the same surgeons provided emergency general surgical care. A total of 772 patients who presented with a traumatic injury and required an emergency surgical procedure or who presented with or developed a condition requiring an emergency general surgical intervention were operated on by 1 of 56 acute care surgeons. Surgeon groups were divided by experience of less than 6 years (early career), 6 to 10 years (early midcareer), 11 to 30 years (late midcareer), and 30 years or more (late career) from the end of training. Surgeons with less than 3 years of experience were also compared with the entire cohort. Hierarchical logistic regression models were constructed controlling for Emergency Surgery Score, case complexity, preoperative transfusion, and trauma or emergency general surgery. Data were collected from May 2015 to July 2017 and analyzed from February to May 2020.MAIN OUTCOMES AND MEASURES Mortality, complications, length of stay, blood loss, and unplanned return to the operating room. RESULTSOf 772 included patients, 469 (60.8%) were male, and the mean (SD) age was 50.1 (20.0) years. Of 772 operations, 618 were by surgeons with less than 10 years of experience. Early-and late-midcareer surgeons generally operated on older patients and patients with more septic shock, acute kidney failure, and higher Emergency Surgery Scores. Patient mortality, complications, postoperative transfusion, organ-space surgical site infection, and length of stay were similar between surgeon groups. Patients operated on by early-career surgeons had higher rates of unplanned return to the operating room compared with those operated on by early-midcareer surgeons (odds ratio [OR], 0.66; 95% CI, 0.40-1.09), late-midcareer surgeons (OR, 0.34; 95% CI, 0.13-0.90), and late-career surgeons (OR, 1.11; 95% CI,. Patients operated on by surgeons with less than 3 years of experience had similar mortality compared with the rest of the cohort (OR, 1.97; 95% CI, 0.85-4.57) but higher rates of complications (OR, 2.07; 95% CI, 1.05-4.07). CONCLUSIONS AND RELEVANCEIn this study, experienced surgeons generally operated on older patients with more septic shock and kidney failure without affecting risk-adjusted mortality. Increased complications and unplanned return to the operating room may improve with experience. Early-career surgeons' outcomes may be improved if they are supported while experience is garnered.

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Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Perrone,

Giuffrida,

Abu-Zidan

et al. 2024

World J Emerg Surg

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Background Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann’s procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions After 100 years since the first Hartmann’s procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment’s choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

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The impact of individual physicians on outcomes after trauma: is it the system or the surgeon?

Cited by 4 publications

References 42 publications

Is There a Surgeons’ Effect on Patients’ Physical Health, Beyond the Intervention, That Requires Further Investigation? A Systematic Review

Is There a Surgeons’ Effect on Patients’ Physical Health, Beyond the Intervention, That Requires Further Investigation? A Systematic Review

Association of Acute Care Surgeon Experience With Emergency Surgery Patient Outcomes and Mortality

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

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