Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor.
Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor.
JAMA Netw Open. 2021 Oct 1;4(10):e2128765. doi: 10.1001/jamanetworkopen.2021.28765.
Risk-adjusted variation in surgeon outcomes has been traditionally explained by surgeon volume and hospital infrastructure, yet it is unclear how a surgeon's operative proficiency directly contributes to their patients' outcomes.
To assess the variation of surgeons' operative proficiency and investigate its association with surgical outcomes.
DESIGN, SETTING, AND PARTICIPANTS: This case series was a retrospective analysis of all digit replantations and revascularizations at a single US university medical center between January 2000 and August 2020. Surgeons were assigned a proficiency score based on the expected procedure difficulty and outcomes from a sample of their cases. Surgeon proficiency scores were then used to determine associations with outcomes from subsequent cases. The expected difficulty of each case was calculated using a novel scoring system that applied pooled relative risks from a meta-analysis of risk factors for replantation and revascularization failure.
Digit replantation and revascularization.
Digit survival at 1-month follow up (case success) and number of complications.
A total of 145 patients and 226 digits were treated by 11 surgeons with training in hand or microsurgery (mean [SD] age, 41.9 [15.2] years; 204 [90%] men); there were 116 replantations and 110 revascularizations. Surgeon proficiency scores ranged from 1.3 to 5.7, with a mean (SD) of 3.4 (1.4). Case success rates among surgeons varied from 20.0% to 90.5%, with a mean (SD) of 64.9%. Higher proficiency scores were associated with fewer case failures: each point increase was associated with 40% decreased odds of failure (odds ratio, 0.60; 95% CI, 0.38-0.94). Every 3-point increase in proficiency score was associated with 1 less complication (effect estimate, -0.29; 95% CI, -0.56 to 0.02). Surgeon proficiency score had a greater association with case failure than surgeon volume (16.7% vs 12.0%). The final model's association with case failure had an area under the receiver operating characteristics curve of 0.93.
Operative proficiency varied widely among practicing surgeons and accounted for 17% of estimative ability for success of digit replantation and revascularization. Greater surgeon proficiency was associated with better outcomes, indicating that the value of surgical care may be optimized by improving surgeon proficiency.
传统上，外科医生手术结果的风险调整差异可以通过外科医生的手术量和医院基础设施来解释，但尚不清楚外科医生的手术熟练程度如何直接影响患者的手术结果。
评估外科医生手术熟练程度的差异，并研究其与手术结果的关联。
设计、地点和参与者：本病例系列研究是对 2000 年 1 月至 2020 年 8 月期间美国一家大学医疗中心的所有指尖再植和血运重建手术的回顾性分析。根据他们的一部分病例的预期手术难度和结果，为每位外科医生分配一个熟练程度评分。然后，使用熟练程度评分来确定与随后病例结果的关联。每个病例的预期难度是使用一种新的评分系统计算的，该系统应用了再植和血运重建失败危险因素的荟萃分析中的 pooled relative risks。
指尖再植和血运重建。
1 个月随访时的指尖存活情况（病例成功）和并发症数量。
共有 11 名接受过手部或显微外科培训的外科医生治疗了 145 名患者和 226 个指尖（平均[标准差]年龄，41.9[15.2]岁；204[90%]为男性）；其中有 116 例再植术和 110 例血运重建术。外科医生的熟练程度评分范围为 1.3 至 5.7，平均（标准差）为 3.4（1.4）。外科医生的病例成功率从 20.0%到 90.5%不等，平均（标准差）为 64.9%。熟练程度评分较高与较低的病例失败率相关：评分每增加 1 分，失败的几率就会降低 40%（优势比，0.60；95%CI，0.38-0.94）。熟练程度评分每增加 3 分，并发症就会减少 1 个（效应估计值，-0.29；95%CI，-0.56 至 0.02）。外科医生的熟练程度评分与病例失败的关联大于外科医生的手术量（16.7%比 12.0%）。最终模型与病例失败的关联的受试者工作特征曲线下面积为 0.93。
手术熟练程度在实际操作的外科医生中差异很大，占指尖再植和血运重建成功的估计能力的 17%。更高的外科医生熟练程度与更好的结果相关，这表明通过提高外科医生的熟练程度，可以优化手术护理的价值。
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