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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Article info
Publication history
Published online: January 22, 2022
Accepted:
December 13,
2021
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Invited Commentary on “Fragmentation of Practice: The Adverse Effect of Surgeons Moving Around”SurgeryVol. 172Issue 2
- PreviewInnumerable 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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