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Fragmentation of practice: The adverse effect of surgeons moving around

  • J. Madison Hyer
    Affiliations
    Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH

    Secondary Data Core, Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
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  • Adrian Diaz
    Affiliations
    Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
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  • Aslam Ejaz
    Affiliations
    Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
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  • Diamantis I. Tsilimigras
    Affiliations
    Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
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  • Djhenne Dalmacy
    Affiliations
    Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
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  • Alessandro Paro
    Affiliations
    Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
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  • Timothy M. Pawlik
    Correspondence
    Reprint requests: Timothy M. Pawlik, MD, MPH, PhD, Professor and Chair, Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Wexner Medical Center, 395 W. 12th Ave, Suite 670, Columbus, OH.
    Affiliations
    Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
    Search for articles by this author
Published:January 22, 2022DOI:https://doi.org/10.1016/j.surg.2021.12.010

      Abstract

      Background

      Whether surgical team familiarity is associated with improved postoperative outcomes remains unknown. We sought to characterize the impact of fragmented surgical practice on the likelihood that a patient would experience a textbook outcome, which is a validated patient-centric composite outcome representing an “ideal” postoperative outcome.

      Method

      Medicare beneficiaries aged 65 and older who underwent elective inpatient abdominal aortic aneurysm repair, coronary artery bypass graft, cholecystectomy, colectomy, or lung resection were identified. Rate of fragmented practice was calculated based on the total number of surgical procedures of interest performed over the study period (2013–2017) divided by the number of different hospitals in which the surgeon operated. Surgeons were categorized into “low,” “average,” “above average,” or “high” rate of fragmented practice categories using an unsupervised machine learning technique known k-medians cluster analysis.

      Results

      Among 546,422 Medicare beneficiaries who underwent an elective surgical procedure of interest (coronary artery bypass graft: n = 156,384, 28.6%; lung resection: n = 83,164, 15.2%; abdominal aortic aneurysm: n = 112,578, 20.6%; cholecystectomy: n = 42,955, 7.9%; colectomy: n = 151,341, 27.7%), median patient age was 74 years (interquartile range: 69–80), and most patients were male (n = 319,153, 58.4%). Machine learning identified 3 cutoffs to categorize rate of fragmented practice: 2.8%, 5.6%, and 10.6%. Overall, the majority of surgical procedures were performed by surgeons with a low rate of fragmented practice (n = 382,504, 70.0%); other surgical procedures were performed by surgeons with average (n = 109,141, 20.0%), above average (n = 44,249, 8.1%), or high (n = 10,528, 1.9%) rate of fragmented practice. On multivariable analyses, after controlling for patient demographics, individual surgeon volume, procedure type, and a random effect for hospital, patients who underwent a surgical procedure by a high versus low rate of fragmented practice surgeon had lower odds to achieve a postoperative textbook outcome (odds ratio 0.71, 95% confidence interval 0.77–0.84). Patients who underwent a procedure by a high rate of fragmented practice surgeon also had increased odds of a perioperative complication (odds ratio 1.30, 95% confidence interval: 1.23–1.37), extended length of stay (odds ratio 1.17, 95% confidence interval: 1.11–1.24), 90-day readmission (odds ratio 1.17, 95% confidence interval: 1.11–1.23), and 90-day mortality (odds ratio 1.29, 95% confidence interval: 1.17–1.42) (all P < .05).

      Conclusion

      Patients undergoing a surgical procedure by a surgeon with a high rate of fragmented practice had lower odds of achieving an optimal postoperative textbook outcome. Surgical team familiarity, measured by a surgeon rate of fragmented practice, may represent a modifiable mechanism to improve surgical outcomes.
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      Linked Article

      • Invited Commentary on “Fragmentation of Practice: The Adverse Effect of Surgeons Moving Around”
        SurgeryVol. 172Issue 2
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          Innumerable factors contribute to postoperative outcome. Various patient, physician, health system, and infrastructure-level variables have been shown to influence these outcomes and impact health care cost and delivery.1 However, the level to which surgeon-driven factors, such as procedure-specific case volume across different hospitals, and familiarity with a specific operating room team/hospital system affect outcomes is relatively unknown. While it has been previously shown that outcomes improve with increased case volumes, the potential patient, surgeon, and system-level impact of surgeons operating at multiple hospitals has yet to be studied.
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