Does Resident Autonomy In Colectomy Procedures Result In Inferior Clinical Outcomes?
*Celsa Tonelli1, *Isabela Lorenzo2, *Corinne Bunn3, *Sujay Kulshrestha3, *Zaid M Abdelsattar4, *Marshall S Baker1, Frederick A Luchette1
1Department of Surgery, Edward Hines, Jr. Veterans Administration Hospital, Hines, IL;2Loyola University Stritch School of Medicine, Maywood, IL;3Department of Surgery, Loyola University Medical Center, Maywood, IL;4Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
ObjectiveThe absolute amount of time that surgical trainees operate independently and under direct supervision has been reduced by work hour restrictions, practice changes, and shifts in the health care environment. The purpose of this study is to evaluate the effect of resident operative autonomy on clinical outcomes.
MethodsThe Veterans Affairs Surgical Quality Improvement Program (VASQIP) database identifies the level of involvement of residents and attendings in operations performed at VA hospitals. VASQIP was queried to identify patients undergoing partial colectomy for neoplasm between 2005 and 2019. Rectal resections and emergency procedures were excluded, and only cases with PGY 3 and higher were included. Records were categorized as performed with the attending scrubbed (AS) or not scrubbed (ANS). Hierarchical logistic regression (HLR) was used to identify factors associated with attending involvement and operative time, length of stay, morbidity and mortality while controlling for facility differences.
Results7,184 colectomies met inclusion criteria; the AS group included 6724 (93.6%) records and 460 (6.4%) ANS. On univariate comparison, the AS group were less likely to have Charlson Comorbidity Scores >1 (23% vs 29%, p = 0.006) and were more likely to require intestinal diversion (7.9% vs 4.4%, p = 0.016) than the ANS group. There were no differences between cohorts regarding demographics, facility characteristics, and operative times (2.83 hours, 95% CI [2.17, 3.70] vs. 2.87 hours, 95% CI [2.22, 3.58], p = 0.93). On HLR adjusted for age, gender, race, BMI, functional status, cancer location, facility level, wound class, comorbidity score, wound class, OR time, and surgery modality, there were no differences in rates of complications, major morbidity or mortality between AS and ANS cohorts (Figure 1).
ConclusionColectomies performed by residents with appropriate levels of autonomy are efficient and safe. Our results indicate that attending surgeon judgement regarding resident-level cases is appropriate and sound. Educational environments can be designed to foster resident independence and preserve clinical quality, safety and efficiency.
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