Teaching surgery takes time: the impact of surgical education on time in the operating room

Teaching surgery takes time: the impact of surgical education on time in the operating room

Can J Surg 2016;59(1):87-92 | PDF | Appendix

Christopher Vinden, MD; Richard Malthaner, MD, MSc; Jacob McGee, MD, MSc; J. Andrew McClure, MSc; Jennifer Winick-Ng, MSc; Kuan Liu, MMath; Danielle M. Nash, MSc; Blayne Welk, MD, MSc; Luc Dubois, MD, MSc

Abstract

Background: It is generally accepted that surgical training is associated with increased surgical duration. The purpose of this study was to determine the magnitude of this increase for common surgical procedures by comparing surgery duration in teaching and nonteaching hospitals.

Methods: This retrospective population-based cohort study included all adult residents of Ontario, Canada, who underwent 1 of 14 surgical procedures between 2002 and 2012. We used several linked administrative databases to identify the study cohort in addition to patient-, surgeon- and procedure-related variables. We determined surgery duration using anesthesiology billing records. Negative binomial regression was used to model the association between teaching versus nonteaching hospital status and surgery duration.

Results: Of the 713 573 surgical cases included in this study, 20.8% were performed in a teaching hospital. For each procedure, the mean surgery duration was significantly longer for teaching hospitals, with differences ranging from 5 to 62 minutes across individual procedures in unadjusted analyses (all p < 0.001). In regression analysis, procedures performed in teaching hospitals were associated with an overall 22% (95% confidence interval 20%–24%) increase in surgery duration, adjusting for patient-, surgeon- and procedure-related variables as well as the clustering of patients within surgeons and hospitals.

Conclusion: Our results show that a wide range of surgical procedures require significantly more time to perform in teaching than nonteaching hospitals. Given the magnitude of this difference, the impact of surgical training on health care costs and clinical outcomes should be a priority for future studies.

Résumé

Contexte : Il est généralement admis que la formation chirurgicale est associée à des interventions plus longues. L’objectif de la présente étude était de déterminer l’ampleur de cette augmentation pour les chirurgies courantes en comparant la durée des interventions dans les hôpitaux universitaires et les autres hôpitaux.

Méthodes : Dans le cadre d’une étude de cohorte rétrospective basée sur la population, nous avons recensé tous les résidents adultes de l’Ontario (Canada) qui ont subi une intervention chirurgicale parmi une liste de 14 entre 2002 et 2012. À l’aide de plusieurs bases de données administratives reliées, nous avons constitué la cohorte de l’étude et recueilli des variables associées aux patients, aux chirurgiens et aux interventions. Nous avons déterminé la durée des opérations à partir des dossiers de facturation d’anesthésiologie. Une régression binomiale négative a été utilisée pour modéliser le lien entre le statut des hôpitaux — universitaires ou non — et la durée.

Résultats : Des 713 573 chirurgies à l’étude, 20,8 % ont eu lieu dans un hôpital universitaire. Dans tous les cas, la durée moyenne était significativement plus longue dans les hôpitaux universitaires, les écarts variant de 5 à 62 minutes pour chaque intervention dans les analyses non corrigées (p < 0,001 dans tous les cas). Selon l’analyse de régression, les chirurgies effectuées dans les hôpitaux universitaires étaient associées à une augmentation globale de la durée de 22 % (intervalle de confiance à 95 %, 20 %–24 %), après ajustement pour les variables liées aux patients, aux chirurgiens et aux interventions ainsi que pour la densité de patients pris en charge par les chirurgiens et les hôpitaux. Conclusion : Nos résultats montrent que de nombreuses interventions chirurgicales durent considérablement plus longtemps dans les hôpitaux universitaires que dans les autres hôpitaux. Étant donné l’ampleur de cet écart, l’étude de l’incidence de la formation chirurgicale sur les coûts des soins de santé et les résultats cliniques devrait être une priorité pour les recherches futures.


Submitted on behalf of the Surgical Investigators Group at ICES Western: Sumit Dave, Eric Frechette, Sarah Jones, Sarah Knowles, Danielle MacNeil, Dave Nagpal, Stephen E. Pautler, Kelly Vogt.

Accepted for publication Dec. 23, 2015

Acknowledgements: The authors thank Drs. Amit Garg, David Urbach and Salimah Shariff for their support and input throughout the study process and Kathryn Barber for providing input regarding hospital coding procedures. This study was funded in part by the Academic Medical Organization of Southwestern Ontario (AMOSO) AHSC AFP Innovation Fund and the London Health Sciences Centre Department of Surgery. This study was supported by the ICES Western site. ICES is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Core funding for ICES Western is provided by AMOSO, the Schulich School of Medicine and Dentistry (SSMD), Western University, and the Lawson Health Research Institute (LHRI). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES, AMOSO, SSMD, LHRI, or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of CIHI.

Affiliations: From the Department of Surgery, Divisions of General Surgery (Vinden), Thoracic Surgery (Malthaner), Urology (Welk) and Vascular Surgery (Dubois), and the Department of Obstetrics and Gynaecology (McGee), Western University, London, Ont.; and the Institute for Clinical Evaluative Sciences, Toronto, Ont. (Vinden, McClure, Winick-Ng, Liu, Nash, Welk).

Competing interests: None declared.

Contributors: All authors designed the study and interpreted the results. J. Winick-Ng was responsible for data extraction and analysis. C. Vinden wrote the article, which all authors reviewed and approved for publication.

DOI: 10.1503/cjs.017515

Correspondence to: C. Vinden, London Health Sciences Centre, Victoria
Hospital, 800 Commissioners Rd E, Rm E2-218, London, ON, N6A 5W9; chris.vinden@lhsc.on.ca