Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA.
J Am Coll Surg. 2011 May;212(5):889-98. doi: 10.1016/j.jamcollsurg.2010.12.029. Epub 2011 Mar 12.
Although the training of surgical residents is often considered in national policy addressing complications and safety, the influence of resident intraoperative involvement on surgical outcomes has not been well studied.
We identified 607,683 surgical cases from 234 hospitals from the 2006 to 2009 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Outcomes were compared by resident involvement for all general and vascular cases as well as for specific general surgical procedures.
After typical ACS NSQIP comorbidity risk adjustment and further adjustment for hospital teaching status and operative time in modeling, resident intraoperative involvement was associated with slightly increased morbidity when assessing overall general or vascular procedures (odds ratio [OR] 1.06; 95% CI 1.04 to 1.09), pancreatectomy or esophagectomy (OR 1.26; 95% CI 1.08 to 1.45), and colorectal resections (OR 1.15; 95% CI 1.09 to 1.22). In contrast, for mortality, resident intraoperative involvement was associated with reductions for overall general and vascular procedures (OR 0.91; 95% CI 0.84 to 0.99), colorectal resections (OR 0.88; 95% CI 0.78 to 0.99), and abdominal aortic aneurysm repair (OR 0.71; 95% CI 0.53 to 0.95). Results were moderated somewhat after hierarchical modeling was performed to account for hospital-level variation, with mortality results no longer reaching significance (overall morbidity OR 1.07; 95% CI 1.03 to 1.10, overall mortality OR 0.97; 95% CI 0.90 to 1.05). Based on risk-adjusted event rates, resident intraoperative involvement is associated with approximately 6.1 additional morbidity events but 1.4 fewer deaths per 1,000 general and vascular surgery procedures.
Resident intraoperative participation is associated with slightly higher morbidity rates but slightly decreased mortality rates across a variety of procedures and is minimized further after taking into account hospital-level variation. These clinically small effects may serve to reassure patients and others that resident involvement in surgical care is safe and possibly protective with regard to mortality.
尽管国家政策经常考虑到外科住院医师的培训以解决并发症和安全性问题，但住院医师术中参与对手术结果的影响尚未得到充分研究。
我们从 2006 年至 2009 年美国外科医师学院国家外科质量改进计划（ACS NSQIP）的 234 家医院中确定了 607683 例手术病例。通过对所有普通和血管手术以及特定普通外科手术中住院医师的参与情况进行比较，评估了结果。
在对 ACS NSQIP 合并症风险进行典型调整，并在建模中进一步调整医院教学状态和手术时间后，当评估普通或血管手术的整体情况时，住院医师术中参与与发病率略有增加相关（比值比 [OR] 1.06；95%置信区间 1.04 至 1.09）、胰切除术或食管切除术（OR 1.26；95%置信区间 1.08 至 1.45）和结直肠切除术（OR 1.15；95%置信区间 1.09 至 1.22）。相比之下，对于死亡率，住院医师术中参与与普通和血管手术的整体（OR 0.91；95%置信区间 0.84 至 0.99）、结直肠切除术（OR 0.88；95%置信区间 0.78 至 0.99）和腹主动脉瘤修复（OR 0.71；95%置信区间 0.53 至 0.95）的降低相关。在对医院层面的变异性进行分层建模后，死亡率结果不再具有统计学意义，结果略有缓和（整体发病率 OR 1.07；95%置信区间 1.03 至 1.10，整体死亡率 OR 0.97；95%置信区间 0.90 至 1.05）。基于风险调整后的事件发生率，住院医师术中参与与每 1000 例普通和血管手术大约增加 6.1 例额外发病率事件，但每 1000 例手术减少 1.4 例死亡。
住院医师术中参与与各种手术的发病率略有增加相关，但死亡率略有下降，在考虑到医院层面的变异性后，这种影响进一步降低。这些临床影响很小，可能有助于让患者和其他人放心，即住院医师参与外科护理是安全的，并且可能对死亡率有保护作用。
