Impact of Cardiothoracic Resident Turnover on Mortality After Cardiac Surgery: A Dynamic Human Factor

doi:10.1016/j.athoracsur.2008.03.041

The Annals of Thoracic Surgery

Volume 86, Issue 1, July 2008, Pages 123-131

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.

https://doi.org/10.1016/j.athoracsur.2008.03.041 Get rights and content

Background

The study was designed to determine whether cardiac surgical outcomes are affected during times of major turnover of cardiothoracic resident surgical staff and at the beginning versus the end of their training periods.

Methods

This observational cohort study analyzed data from cardiac operations between April 1996 and March 2006 at a single institution. In-hospital mortality and other outcomes were compared between operations done during months of major change in resident staff rotation (July, August, January, February, n = 5,517) and the rest of the year (n = 10,773). We also compared outcomes at the beginning and end of surgical rotation for cardiothoracic residents. Adjustment was made for EuroSCORE (European System for Cardiac Operative Risk Evaluation), year of operation, and surgeon resident status. Analyses were done within surgery procedure subgroups of isolated coronary artery bypass graft surgery (CABG) and complex operations (CABG combined with other procedures).

Results

Patient populations in the groups were similar. After risk adjustment, there was a significant increase in hospital mortality for the complex cases during months of resident staff change compared with rest of the year (odds ratio 1.3, 95% confidence interval: 1.3, 1.4; p = 0.02). There was, however, no significant difference in mortality for the CABG only cases (odds ratio 1.1, 95% confidence interval: 0.8, 1.4; p = 0.61). Risk-adjusted mortality after operations done by residents was the same at the start and finish of their surgical rotation. During the change months, the surgery time was 2.2 minutes longer on average in CABG operations (95% confidence interval: 0.3, 4.0; p = 0.02), and no different in combined cases.

Conclusions

Periods of major change in resident surgical staff are associated with increased risk-adjusted in-hospital mortality after complex cardiac operations but not after CABG alone.

Section snippets

Material and Methods

We analyzed routinely collected hospital episode data on all cardiac surgical patients undergoing their first operation at our center between April 1996 and March 2006. This study was approved by the Research and Development Board at Papworth Hospital NHS Trust. We categorized the group of patients into complex cardiac surgery and noncomplex cardiac surgery for purposes of stratification and research. We defined complex cardiac surgery as any open heart surgery other than coronary

Resident Change Month

There were 16,290 patients who had a first record of cardiac surgery between April 1, 1996, and March 31, 2006, with 10,263 patients having CABG only and 6,027 patients having another procedure instead of or as well as CABG. Other procedures are shown in Table 1. During the months of cardiothoracic resident turnover, all surgeons performed 5,517 operations. Seventy-three resident surgeons performed 4,599 operations over this 10-year period. There were 2,778 operations performed during the

Comment

Several regulatory bodies, especially in Europe and North America, have taken firm action on the structure and process of cardiac surgery training. As the residents progress through training, they receive direct instruction as well as progressive surgical independence depending on their aptitude, skill and judgement level. Residents need to demonstrate competence in several cardiac procedures over a series of training appointments. The end of a rotation marks an end to an experience with that

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In the cardiac surgery literature, only a handful of studies have specially examined the impact of the July effect. However, none of them have encompassed an array of major cardiac surgery procedures that span the breadth of care on a national scale, thus serving as the main impetus of our study.11-13,25-30 Bakaeen and colleagues12 used the granularity and robustness of the national VA database to find that only operative times were slightly increased for patients cared for in the beginning of the academic year compared with those at the end.
Recent studies in noncardiac surgery have described worse outcomes in the first month of training. However, the “July effect” in the context of cardiac surgery outcomes is not well understood. We examined whether patient outcomes after cardiac surgery were affected by procedure month or academic year quartile.
Using the National Inpatient Sample, we isolated all coronary artery bypass grafting (CABG), surgical aortic valve replacement (AVR), mitral valve repair or replacement (MV), and isolated thoracic aortic aneurysm (TAA) replacement procedures between 2012 and 2014. For each procedure, overall trends in in-hospital mortality and hospital complications were compared by academic year quartiles (ie, between the first academic year quartile vs the fourth quartile) and by procedure month. Outcomes between teaching and nonteaching hospitals were also compared.
Overall, 301,105 CABG, 111,260 AVR, 54,985 MV, and 2,655 TAA procedures met inclusion criteria. In-hospital mortality for each procedure did not vary by procedure month or academic year quartile, even after risk adjustment (all P > .05). Teaching status did not influence risk-adjusted mortality for CABG and isolated TAA replacement (both P > .05). However, teaching hospitals had significantly lower adjusted mortality than nonteaching hospitals for AVR and MV surgery (both P < .01).
The July effect is not evident for cardiac surgery despite preexisting notions. Teaching hospitals performed at least equivalent, if not better, for major cardiac surgery procedures. These findings highlight the pivotal role of hospital support systems to ensure the safe transition of resident classes without compromising on patient outcomes.
Inpatient dermatology consultations and the July effect: A retrospective cohort study
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Outcomes of the patients in the respiratory care center are not associated with the seniority of the caring resident
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Although many studies discuss the impact of physician experience on patients outcomes as mentioned above, these studies compared experienced and inexperienced attending physicians. Through literature review, very few studies discussed this issue in residents, and most of them addressed the learning curve of surgical residents [14,15]. Some studies suggested that inexperienced surgical residents may be associated with worse surgical outcomes [15–17].
Although many studies show that the experience level of physicians is significantly associated with the outcomes of their patients, little evidence exists to show whether junior residents provide worse care than senior residents. This study was conducted to analyze whether the experience level of residents may affect the outcomes of patients cared for in a well-organized setting. We conducted a 7-year retrospective study utilizing statistical data from a respiratory care center (RCC) in a medical center between October 2004 and September 2011. In addition to the two medical residents who had been trained in the intensive care unit (ICU), the RCC team also included attending physicians in charge, a nurse practitioner, a case manager, a dietitian, a pharmacist, a social worker, registered respiratory therapists, and nursing staff. Weaning from mechanical ventilation was done according to an established weaning protocol. The 84 months analyzed were classified into five groups according to the levels of the two residents working in the RCC: R2 + R1, R2 + R2, R3 + R1, R3 + R2, and R3 + R3. The monthly weaning rate and mortality rate were the major outcomes, while the mean ventilator days, rate of return to the ICU, and nosocomial infection incidence rate were the minor outcomes. The groups did not differ significantly in the monthly weaning rate, mortality rate, mean ventilator days, rate of return to the ICU, or nosocomial infection incidence rate (p > 0.1). Further analysis showed no significant difference in the monthly weaning rate and mortality rate between months with a first-year resident (R1) and those with two senior residents (p > 0.2). Although the weaning rate in the RCC gradually improved over time (p < 0.001), there was no significant difference in the monthly weaning rate between the groups after adjusting for time and disease severity (p > 0.7). Thus, we concluded that in a well-organized setting, the levels (experiences) of residents did not significantly affect patient outcomes. This result may be attributed to the well-developed weaning protocol and teamwork processes in place, which avoid a large effect from any single factor and provide stable and high-quality care to the patients.
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Similar and generally favorable findings regarding the involvement of cardiologists and cardiac specialty units in heart failure and myocardial infarction care have been observed in other studies.26-34 Patients with heart failure who were admitted in July or August were significantly more likely to be nonadherent to the angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker measure (OR 2.18; CI, 1.45-3.27) and discharge instructions (OR 1.36; CI, 1.06-1.76), suggesting the inexperience of new house staff.35 Contrary to some previous reports,36 patients with heart failure in our study who were discharged on a weekend were less likely to have failed the angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker measure (OR 0.48; CI, 0.24-0.94).
Understanding factors associated with process measure nonadherence may improve both patient care and future measure design.
We analyzed 3401 patients with heart failure and 2186 patients with pneumonia who were eligible for at least 1 National Hospital Quality Measure at an urban tertiary medical center from July 1, 2004, to June 30, 2008. We investigated the association of socioeconomic, demographic, clinical, and care delivery factors with process measure nonadherence, using multivariable analysis.
Demographic and socioeconomic variables were unrelated to heart failure measure adherence. Nonadherence with angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use was more common in patients with renal failure (odds ratio [OR] 2.56; 95% confidence interval [CI], 1.46-4.49), and patients admitted to noncardiac units more often failed the heart failure all-or-none measure (OR 2.22; 95% CI, 1.79-2.75). Patients with pneumonia who were admitted via the emergency department were less likely to fail antibiotic timing (OR 0.41; 95% CI, 0.27-0.63), whereas those with a history of methicillin-resistant Staphylococcus aureus (OR 2.63; 95% CI, 1.31-5.28) or requiring intensive care unit admission (OR 11.4; 95% CI, 6.3-20.8) were more likely to fail the antibiotic selection measure.
Demographic and socioeconomic factors were generally unrelated to process measure nonadherence, demonstrating that excellent inpatient care can be delivered even to vulnerable populations. Clinical predictors suggest opportunities for improving both medical record documentation of appropriate exclusions and future measure specifications, especially for complex patients. Care delivery factors substantially affect process adherence.
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Original articleAdult cardiacImpact of Cardiothoracic Resident Turnover on Mortality After Cardiac Surgery: A Dynamic Human Factor

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Resident Change Month

Comment

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Surgery

Ann Thorac Surg

J Am Coll Cardiol

Lancet

Ann Thorac Surg

Quality assessment and assurance: unity of purpose, diversity of means

Inquiry

Quality measurement of outcome in general surgery revisited: commentary and proposal

Arch Surg

Coronary surgery in Europe: comparison of the national subsets of the European system for cardiac operative risk evaluation database

Eur J Cardiothorac Surg

Seasonal variation in surgical outcomes as measured by the American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP)

Ann Surg

Is there a “July phenomenon” in pediatric neurosurgery at teaching hospitals?

J Neurosurg

Original article
Adult cardiac
Impact of Cardiothoracic Resident Turnover on Mortality After Cardiac Surgery: A Dynamic Human Factor