A propensity score matching analysis: Impact of senior resident versus fellow participation on outcomes of complex surgical oncology

Abstract Background: The incidence of surgical site infection (SSI) across surgical procedures, specialties, and conditions is reported to vary from 0.1% to 50%. Operative duration is often cited as an independent and potentially modifiable risk factor for SSI. The objective of this systematic review was to provide an in-depth understanding of the relation between operating time and SSI. Patients and Methods: This review included 81 prospective and retrospective studies. Along with study design, likelihood of SSI, mean operative times, time thresholds, effect measures, confidence intervals, and p values were extracted. Three meta-analyses were conducted, whereby odds ratios were pooled by hourly operative time thresholds, increments of increasing operative time, and surgical specialty. Results: Pooled analyses demonstrated that the association between extended operative time and SSI typically remained statistically significant, with close to twice the likelihood of SSI observed across various time thresholds. The likelihood of SSI increased with increasing time increments; for example, a 13%, 17%, and 37% increased likelihood for every 15 min, 30 min, and 60 min of surgery, respectively. On average, across various procedures, the mean operative time was approximately 30 min longer in patients with SSIs compared with those patients without. Conclusions: Prolonged operative time can increase the risk of SSI. Given the importance of SSIs on patient outcomes and health care economics, hospitals should focus efforts to reduce operative time.

Simulation may reduce the risks associated with the complex operations of cardiothoracic surgery and help create a more efficient, thorough, and uniform curriculum for cardiothoracic surgery fellowship. Here, we review the current status of simulation in cardiothoracic surgical training and provide an overview of all simulation models applicable to cardiothoracic surgery that have been published to date.

There has been concern that a reduced level of surgical resident supervision in the operating room (OR) is correlated with worse patient outcomes. Until September 2004, Veterans' Affairs (VA) hospitals entered in the surgical record level 3 supervision on every surgical case when the attending physician was available but not physically present in the OR or the OR suite. In this study, we assessed the impact of level 3 on risk-adjusted morbidity and mortality in the VA system. Surgical cases entered into the National Surgical Quality Improvement Program database between 1998 and 2004, from 99 VA teaching facilities, were included in a logistic regression analysis for each year. Level 3 versus all other levels of supervision were forced into the model, and patient characteristics then were selected stepwise to arrive at a final model. Confidence limits for the odds ratios were calculated by profile likelihood. A total of 610,660 cases were available for analysis. Thirty-day mortality and morbidity rates were reported in 14,441 (2.36%) and 63,079 (10.33%) cases, respectively. Level 3 supervision decreased from 8.72% in 1998 to 2.69% in 2004. In the logistic regression analysis, the odds ratios for mortality for level 3 ranged from .72 to 1.03. Only in the year 2000 were the odds ratio for mortality statistically significant at the .05 level (odds ratio, .72; 95% confidence interval, .594-.858). For morbidity, the odds ratios for level 3 supervision ranged from .66 to 1.01, and all odds ratios except for the year 2004 were statistically significant. Between 1998 and 2004, the level of resident supervision in the OR did not affect clinical outcomes adversely for surgical patients in the VA teaching hospitals.