Introduction: There is conflicting literature on the effect of intraoperative resident involvement on surgical outcomes in various subspecialties. The aim of our study is to assess the effect of resident involvement on surgical outcomes in patients undergoing neurosurgery.
Methods: We identified 33,977 adult neurosurgical cases from 374 hospitals from the 2006-2012 American College of Surgeons National Surgical Quality Improvement Program, a prospectively-collected, national database with established reproducibility and validity. Outcomes were compared according to resident involvement before and after 1:1 matching on procedure and preoperative risk factors, including comorbidities and functional status.
Results: Resident involvement was documented in 13,323 cases. To isolate the effect of resident involvement on outcomes, we matched 10,170 cases with resident involvement with 10,170 cases with attending alone on procedure and preoperative risk factors. In the matched sample, resident involvement was associated with increased duration of surgery, by an average of 34 minutes, and with increased odds for infection (OR = 1.4; 95% CI 1.2-1.7). This increased risk persisted after controlling for duration of surgery (OR = 1.3; 95% CI 1.1-1.5). In sensitivity analyses, PGY level of residents was not associated with differences in outcomes and our findings persisted in subgroups of neurosurgical patients such as those undergoing aneurysm treatment.
Conclusions: Resident involvement is more common in patients with preoperative risk factors undergoing complex surgical procedures, which is consistent with academic centers undertaking more complex cases. After controlling for both patient and intraoperative characteristic, resident involvement continued to be associated with longer surgical durations and higher infection rates. Longer duration of surgery did not account for the difference in infection rates. Given the morbidity, prolonged length of hospital stay, changes in healthcare reimbursement associated with surgical site infections, it is important to understand and remedy the increase infection rate associated with resident involvement in neurosurgical cases.
Patient Care: This project identified resident presence in the operating room as an independent risk factor for prolonged length of surgery and for surgical site infection in spine and cranial neurosurgical patients. Controlling for duration of surgery did not account for the increase in infection rate associated with resident participation. Given the morbidity, prolonged length of hospital stay, changes in healthcare reimbursement associated with surgical site infections, it is important to understand and remedy the increase infection rate associated with resident involvement in neurosurgical cases.
Learning Objectives: 1. Resident involvement is more common in patients with preoperative risk factors undergoing complex surgical procedures, thus comparing frequencies of adverse outcomes between surgeries done by the attending alone vs with resident involvement is not appropriate.
2. Resident involvement in neurosurgery cases is independently associated with longer duration of surgery and slightly higher odds for postoperative infections compared to surgeries done by the attending alone.