Gross Christopher E, Chang David, Adams Samuel B, Parekh Selene G, Bohnen Jordan D
Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC, United States.
Department of Surgery, Massachusetts General Hospital, Boston, MA, United States.
Foot Ankle Surg. 2017 Dec;23(4):261-267. doi: 10.1016/j.fas.2016.08.001. Epub 2016 Aug 26.
Surgical resident participation in the operating room is necessary for education and progression toward safe and independent practice. However, the impact of resident involvement on patient outcomes in foot and ankle surgery is unknown.
The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012) was used to identify common foot and ankle procedures (by Current Procedural Taxonomy (CPT) code) performed by orthopedic surgeons. Resident participation was determined using the NSQIP-collected variable 'pgy'; cases missing the pgy variable were excluded. Multivariate regression models were constructed to determine an association between resident involvement and 30-day morbidity (total, medical, and surgical complications) and 30-day mortality, when controlling for patient demographics, comorbidities, American Society for Anesthesiologist (ASA) status, body mass index (BMI), and smoking status.
A total of 13,685 cases were analyzed for 24 common foot and ankle operations. Overall mortality rate was 3.60%. Overall complication rate was 16.9%; 10.9% had medical and 8.3% had surgical complications. Residents were involved in 55.6% of cases. In unadjusted analyses, resident cases were less likely to be emergent, but were performed on more complicated patients (i.e. higher comorbidity burden, higher ASA scores). Resident cases had increased total morbidity (18.8% vs. 14.6%, p<0.001), medical complications (12.5% vs. 9.0%, p<0.001), and surgical complications (8.7% vs. 7.7%, p=0.03), but similar mortality frequency (3.8% vs. 3.3%, p=0.2). In multivariable analyses, resident cases did not correlate with 30-day mortality, 30-day total morbidity, or 30-day surgical complications; resident cases were, however, associated with increased medical complications [Odds Ratio (OR) 1.18 (95% Confidence Interval (CI) 1.02-1.37, p=0.03)] and longer length of stay [Coeff 2.38 (1.68-3.09), p<0.001]. Subgroup analyses of orthopedic-only cases demonstrated no statistical association between resident involvement and mortality, total morbidity, or medical complications; a decrease in surgical complications was observed for open reduction internal fixation cases [OR 0.23 (0.06-0.82), p=0.02].
Resident involvement in foot and ankle surgery is not associated with changes in 30-day mortality, 30-day total morbidity, or 30-day surgical complication rates. Residents operate on more medically complex patients who experience higher medical complication rates and longer postoperative length of stay; however, the cause and directionality of this relationship remains to be determined. Efforts to improve the quality of foot and ankle surgery with resident involvement should target reductions in post-operative medical complications.
Prognostic study, Level II.
外科住院医师参与手术室工作对于教育以及迈向安全和独立执业进程而言是必要的。然而，住院医师参与对足踝外科手术患者预后的影响尚不清楚。
利用美国外科医师学会-国家外科质量改进计划（ACS-NSQIP）数据库（2005 - 2012年），识别骨科医生实施的常见足踝手术（按现行手术操作分类法（CPT）编码）。使用NSQIP收集的变量“pgy”确定住院医师参与情况；缺失pgy变量的病例被排除。构建多变量回归模型，在控制患者人口统计学特征、合并症、美国麻醉医师协会（ASA）分级、体重指数（BMI）和吸烟状况的情况下，确定住院医师参与与30天发病率（总体、医疗和手术并发症）及30天死亡率之间的关联。
共分析了24种常见足踝手术的13,685例病例。总体死亡率为3.60%。总体并发症发生率为16.9%；10.9%有医疗并发症，8.3%有手术并发症。住院医师参与了55.6%的病例。在未校正分析中，住院医师参与的病例急诊可能性较小，但手术对象为病情更复杂的患者（即合并症负担更高、ASA评分更高）。住院医师参与的病例总体发病率增加（18.8%对14.6%，p<0.001）、医疗并发症增加（12.5%对9.0%，p<0.001）、手术并发症增加（8.7%对7.7%，p = 0.03），但死亡率频率相似（3.8%对3.3%，p = 0.2）。在多变量分析中，住院医师参与的病例与30天死亡率、30天总体发病率或30天手术并发症无相关性；然而，住院医师参与的病例与医疗并发症增加相关[比值比（OR）1.18（95%置信区间（CI）1.02 - 1.37，p = 0.03）]以及住院时间延长相关[系数2.38（1.68 - 3.09），p<0.001]。仅骨科病例的亚组分析显示住院医师参与与死亡率、总体发病率或医疗并发症之间无统计学关联；对于切开复位内固定病例，观察到手术并发症有所减少[OR 0.23（0.06 - 0.82），p = 0.02]。
住院医师参与足踝手术与30天死亡率、30天总体发病率或30天手术并发症发生率的变化无关。住院医师为病情更复杂的医疗患者实施手术，这些患者医疗并发症发生率更高且术后住院时间更长；然而，这种关系的原因和方向性仍有待确定。在住院医师参与下提高足踝手术质量的努力应着眼于降低术后医疗并发症。
预后研究，二级。
