Elsevier

Journal of Clinical Neuroscience

Volume 56, October 2018, Pages 131-136
Journal of Clinical Neuroscience

Clinical study
Impact of resident participation on outcomes following lumbar fusion: An analysis of 5655 patients from the ACS-NSQIP database

https://doi.org/10.1016/j.jocn.2018.06.030Get rights and content

Highlights

  • There was no increased risk of mortality or reoperation in association with resident involvement in the operating room.

  • In operative characteristics, resident involvement was associated with an increase in length of stay & operative duration.

  • Resident involvement was associated with increased risk of 30-day post-operative overall & medical complications.

  • Specifically, resident involvement was associated with increased risk in sepsis, VTE, & superficial SSI.

Abstract

The role of resident involvement on patient safety, morbidity, and mortality in lumbar spinal surgery has been poorly defined in the literature. The objective of this study is to investigate the relationship between resident involvement in the operating room and 30-day complication rates in patients undergoing lumbar spinal fusion procedures. We used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to retrospectively identify all patients who underwent a lumbar spinal fusion from 2006 to 2013. A propensity score matching algorithm was employed to minimize baseline differences. Multivariate logistic regression analysis of unadjusted and propensity-matched groups was performed to examine the effect of resident participation on operative details and 30-day complication rates. A total of 5655 patients met the inclusion criteria and propensity score matching yielded 1965 well-matched pairs. Resident involvement in lumbar fusion procedures was not found to be a significant predictor for mortality or reoperation. It was found to be a significant predictor for increased hospital stay (matched non-resident 4.0 ± 5.8 days vs. resident 4.6 ± 4.3 days, p < 0.001), operative time (matched non-resident 198 ± 102 min vs. resident 243 ± 118 min, p < 0.001), sepsis (matched OR 4.36, 95% CI 2.10–9.05, p < 0.001), development of DVT/PE (matched OR 2.02, 95% CI 1.10–3.70, p = 0.023), and superficial surgical site infections (matched OR 1.78, 95% CI 1.04–3.06, p = 0.037). In conclusion, this large-scale, population-based study found that resident participation in the operating room was safe but increased the risk of 30-day complications and increased operative duration and length of hospital stay.

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

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