Clinical studyImpact of resident participation on outcomes following lumbar fusion: An analysis of 5655 patients from the ACS-NSQIP database
Introduction
Arthrodesis of the lumbar spine is one of the most common procedures used for treatment of traumatic, neoplastic, infectious, and degenerative disorders [1], [2]. This popularity could be due to the myriad of surgical approaches that have recently evolved such as the addition of minimally invasive techniques. With the aging population, the use of these surgeries is steadily increasing [3], [4]. Yoshihara et al. determined that surgical treatment for lumbar disc degenerative disease has increased 2.4-fold from 2000 to 2009 in the United States [5]. This increase in spinal fusion utilization provides a greater opportunity for resident trainee involvement but the role of resident involvement on patient outcomes has not been well defined in the literature.
The effect of resident training on patient safety remains controversial especially after the adoption of resident duty hour regulations by the Accreditation Committee on Graduate Medical Education (ACGME) in 2003 and the refusal of some patients to be treated by residents [6], [7], [8], [9], [10], [11]. The surgical techniques for lumbar fusion vary by difficulty and require experience to be performed safely [12]. The impact of resident involvement on clinical outcomes remains controversial [13], [14], [15], [16], [17]. Within spine literature, studies relate predominantly to cervical spine surgery and shows no change in mortality with resident involvement [18], [19], [20], [21], [22]. However, there are other studies that show increased operative times and post-operative complications when residents are involved [15], [23], [24].
At the lumbar level, however, there is currently lack of data denoting the relationship between resident training in spine surgery and perioperative outcomes in patients that undergo lumbar spinal fusion. In the present study, we investigated the role of resident involvement on lumbar fusions using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), a nationally validated multi-institutional database, to determine if there were associations between resident involvement and patient outcomes. The purpose of this study is to isolate lumbar fusions as a procedure and to analyze how resident involvement impacts these common operations.
Section snippets
Data source and population
The ACS-NSQIP database is a nationwide program that collects data on major surgical procedures in both the inpatient and outpatient settings. Patients are selected by a billable Current Procedural Terminology (CPT) code. Trained surgical clinical reviewers extract variables from the preoperative period and up to 30 days after the procedure in systematic sampling process described elsewhere. Every case is assigned an International Classification of Diseases Version 9 (ICD-9) code corresponding
Unmatched unadjusted patient population
There were a total of 5655 patients from the 2006–2013 ACS-NSQIP database that were identified and met our inclusion criteria. There were 3659 patients in the non-resident subgroup and 2006 patients in the resident subgroup. The clinical characteristics were relatively similar between the two subgroups with several exceptions shown in Table 1. Patients in the non-resident subgroup had lower age at the time of surgery (p = 0.003), a greater mean BMI (p = 0.002), and with a predominant number of
Discussion
In this study, we investigated the impact of resident involvement on 30-day morbidity and mortality among patients undergoing lumbar spinal fusion. We found that cases with resident participants had higher mean LOS (p < 0.001) and operative time (p < 0.001) than cases without residents; the only patient clinical or operative characteristics to remain statistically significant after propensity score matching (Table 2). After propensity score matching, the multivariate analysis demonstrated that
Conclusion
Resident education continues to play an extensive role in academic medical centers with conflicting results about its impact on clinical measurements. Through this ACS-NSQIP database study of 5655 patients, we determined that resident participation in lumbar spinal fusions was relatively safe with no increase in mortality or reoperation. However, it is associated with longer operative times and longer hospital stays. In addition, there is an increased risk of post-operative complications such
References (41)
- et al.
Trends in the surgical treatment of lumbar spine disease in the United States
Spine J
(2015) - et al.
National trends in the surgical treatment for lumbar degenerative disc disease: United States, 2000 to 2009
Spine J
(2015) - et al.
And doctor, no residents please!
J Am Coll Surg
(2003) - et al.
The impact of work hour restrictions on surgical resident education
J Surg Edu
(2008) - et al.
Impact of Resident Involvement in Surgery (IRIS-NSQIP): Looking at the Bigger Picture Based on the American College of Surgeons-NSQIP Database
J Am Coll Surg
(2016) - et al.
Impact of residents on surgical outcomes in high-complexity procedures
J Am Coll Surg
(2016) - et al.
Surgical site infection prevention: the importance of operative duration and blood transfusion–results of the first American College of Surgeons-National Surgical Quality Improvement Program Best Practices Initiative
J Am Coll Surg
(2008) - et al.
Shorter duration of femoral-popliteal bypass is associated with decreased surgical site infection and shorter hospital length of stay
J Am Coll Surg
(2012) - et al.
Identifying risk factors for surgical site infections in mastectomy patients using the National Surgical Quality Improvement Program database
Am J Surg
(2013) - et al.
How slow is too slow? Correlation of operative time to complications: an analysis from the Tennessee Surgical Quality Collaborative
J Am Coll Surg
(2015)
The influence of tourniquet use and operative time on the incidence of deep vein thrombosis in total knee arthroplasty
Clinics (Sao Paulo, Brazil)
Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF
J Spine Surg
Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7: lumbar fusion for intractable low-back pain without stenosis or spondylolisthesis
J Neurosurg Spine
United States' trends and regional variations in lumbar spine surgery: 1992–2003
Spine
The effect of duty hour regulations on outcomes of neurological surgery in training hospitals in the United States: duty hour regulations and patient outcomes
J Neurosurg
Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance
JAMA
Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform: clinical article
J Neurosurg Spine
A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes
Ann Surg
Resident learning curve for minimal-access transforaminal lumbar interbody fusion in a military training program
Neurosurg Focus
Surgical outcomes and cost basis for resident-performed cataract surgery in an uninsured patient population
JAMA Ophthalmol
Cited by (15)
Resident involvement in hand and upper extremity surgery: An analysis of 30-day complications
2023, Journal of Clinical Orthopaedics and TraumaTrends in national utilization of posterior lumbar fusion and 30-day reoperation and readmission rates from 2006–2016
2020, Clinical Neurology and NeurosurgeryCitation Excerpt :Other studies have found that computer-assisted surgery improves pedicle screw placement accuracy, while also decreasing postoperative complications [19]. However, despite the significant number of studies published on PLF utilizing the NSQIP database, there has been no study evaluating 30-day outcomes over time among patients undergoing PLF in NSQIP [20–23]. The increase in lumbar spinal fusion utilization, when taken in the context of NSQIP data, provides a great opportunity for targeting and improving quality of care following PLF.
Impact of Resident Participation During Surgery on Neurosurgical Outcomes: A Meta-Analysis
2020, World NeurosurgeryCitation Excerpt :However, recently, there has been much debate on the impact of resident training on patient safety and quality of outcomes, fueled partially by work-hour restrictions, reluctance of some patients to involve residents in their surgeries, and the availability of new large databases on surgical details and patient outcomes.1,4-6 On the basis of available data, multiple studies have attempted to elucidate the link between resident involvement and patient outcomes, with conflicting results.1,4,6-16 A portion of these studies suggest that resident involvement is not associated with increased mortality or morbidity in neurosurgical procedures.
Role of interprofessional teams in emergency general surgery patient outcomes
2020, Surgery (United States)Citation Excerpt :Further, lower rates of perioperative bleeding complications have been found for thyroid procedures.17 However, higher rates of surgical site infections for ventral hernia repairs and anastomotic leak for bariatric procedures have also been noted.8.17-21 This might be owing to the fact that bleeding is an immediate perioperative complication and having the extra set of eyes of the resident may indeed be protective.
Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopaedic Sports Medicine: A Matched-Pair Analysis
2020, Arthroscopy - Journal of Arthroscopic and Related Surgery