Received 2020 May 5; Accepted 2020 Aug 28. All surgeon-level data were collected from 2014-2016 New York State outcomes data, the latest New York State surgeon-level outcomes report.
The .gov means its official. official website and that any information you provide is encrypted Statistical analysis was performed using surgeon-level outcome data, surgeon case volumes, and surgeon years in practice. This finding was consistent after adjusting for case volume. Most findings on this topic are based on investigations of general surgery cases. The median surgeon annual case volume was 160.0 (IQR, 92.5-245.0) for CABG procedures and 104.0 (IQR, 43.0-210.0) for valve procedures. Prestige of training programs and experience of bypass surgeons as factors in adjusted patient mortality rates, Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy, Systematic review: the relationship between clinical experience and quality of health care, Association of increasing surgeon age with decreasing in-hospital mortality after coronary artery bypass graft surgery. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies. 1972) Yale University School of Medicine (M.D. Years in practice was treated as a continuous variable and was modeled as a linear term for the CABG model and cubic term for the valve model to account for the nonlinear association with outcomes in valve operations. Surgeon years in practice were categorized as early career (<10 years) and late career (10 years).
Therefore, such an association was not evaluated. An official website of the United States government. We obtained surgeon-level outcomes and case volume data from the publicly available 2014-2016 New York State Cardiac Data Reporting System.10 Reported outcomes were observed mortality rate, expected mortality rate, and risk-adjusted mortality rate (RAMR) for isolated CABG and isolated valve or concomitant valve/CABG operations. The median observed mortality rate for CABG was 1.3 (IQR, 0.6-2.16) and the expected mortality rate for CABG was 1.44 (IQR, 1.22-1.65). New York State Department of Health Adult cardiac surgery in New York State 2014-2016. 1976) government site. This approach may offer standardized training and mentoring structures within select centers while surgeons are in the early stage of their careers. The median number of years in practice was 20.0 (IQR, 12.0-28.5) years (Table 1 and Figure 2). Yale University (B.A. A total of 112 CABG surgeons and 120 valve surgeons performed 39436 CABG and 18596 valve operations, respectively. Further, a variety of factors may affect surgeon-level outcomes that we were not able to measure, such as cases with cosurgeons, number of revision operations, quality of residency training, and size of hospital program. Cardiac diseases The Cardiothoracic Surgery Network. All analyses were 2-tailed with statistical significance set at P<.05. Gonzalez AA, Dimick JB, Birkmeyer JD, Ghaferi AA. JAMA Network Open. Bethesda, MD 20894, Web Policies Before
Smoothed cubic spline associating mortality and the number of years was estimated using vcov package in Python 3.6 (Python Software Foundation). Our data set was a mandatory statewide outcome reporting system, which minimized potential selection bias or a narrow scope of payer-specific databases such as Medicare data. This difference is especially notable because valve surgeries have approximately twice the mortality of CABG10 and are more often performed by surgeons with a greater number of years in practice.9 Worse valve surgery outcomes for early-career surgeons may indicate the need for exposure to complex valve operations during training and appropriate supervision on patient selection and referrals during early years of clinical practice. Thoracic surgery Several options may address this potential gap in valve expertise. In contrast, the lack of association between CABG outcome and surgeon years in practice suggests that current training models adequately prepare early-career surgeons to perform CABG. The median surgeon annual case volume was 160.0 for CABG (IQR, 92.5-245.0) and 104.0 (IQR, 43.0-210.0) for valve procedures. To assess the association between cardiac surgeons time in practice and operative outcomes for coronary artery bypass grafting (CABG) and valve surgery. Maruthappu M, Gilbert BJ, El-Harasis MA, et al.. Both the expected mortality rate and RAMR were calculated from a multivariable risk model developed by the New York State Department of Public Health, accounting for patient demographic characteristics and comorbidities.10 Mortality was defined as all-cause death within 30 days of surgery or within the index hospitalization, whichever was longer. The median RAMR was 1.3% (IQR, 0.2%-2.2%) for CABG and 3.1% (IQR, 1.7%-5.1%) for valve procedures (Table 1). Left ventricular aneurysmectomy Higher case volume was associated with lower RAMR (0.300 per 50-case increase; 95% CI, 0.531 to 0.070, P=.01). Arrythmia surgery Wilcoxon rank sum test and 2 test were used to compare early-career with late-career surgeon status. Author Contributions: Mr Weininger and Dr Mori had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Participants were 120 cardiothoracic surgeons who performed CABG and 112 cardiothoracic surgeons who performed valve procedures between 2014 and 2016. A lower number of years in practice was significantly associated with higher RAMR for valve procedures (RAMR estimates for linear term: 1.144; 95% CI, 1.955 to 0.332; P=.006; quadratic term: 0.059; 95% CI, 0.015 to 1.102; P=.008; and cubic term: 0.001; 95% CI, 0.002 to 0.000; P=.01). The valve model adjusting for case volume showed that lower number of years in practice was associated with higher RAMR in valve cases (RAMR estimates for linear term: 1.144; 95% CI, 1.955 to 0.332; P=.006; quadratic term: 0.059; 95% CI, 0.015 to 1.102; P=.008; and cubic term: 0.001; 95% CI, 0.002 to 0.000; P=.01). This finding suggests certain competence deficiency for valve surgery early after finishing training in cardiac surgery. The association between surgeons number of years in practice and outcomes remains unclear in cardiac surgery, which has high-risk operations that may warrant examination. Data were analyzed in April 2020. 1Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, 2Center for Outcomes Research and Evaluation, YaleNew Haven Hospital, New Haven, Connecticut, 3Section of Surgical Outcomes and Epidemiology, Yale School of Medicine, Yale School of Public Health, New Haven, Connecticut, 4Yale Aortic Institute, Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut. Surgeons who trained outside of the United States or had unclear training history were excluded. In this cross-sectional study, early-career status in surgeons with fewer than 10 years in practice have worse risk-adjusted mortality for valve operations but not for CABG surgery.
Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue, https://health.ny.gov/statistics/diseases/cardiovascular/heart_disease/docs/2014-2016_adult_cardiac_surgery.pdf, https://www.ctsnet.org/surgeons?ln=Search. Statistical analysis: Weininger, Mori, Brooks II, Shang, Zhang, Vallabhajosyula. The median number of surgeon years in practice was 20.0 (interquartile range [IQR], 12.0-28.5) years. Cross-sectional analysis performed of surgeon-level outcomes data from the 2014-2016 New York State Cardiac Data Reporting System across the 38 New York cardiac surgery centers. This site is not optimized for Internet Explorer 8 (or older). Accessed October 7, 2020. Surgeon age and operative mortality in the United States. 2020 Weininger G et al. Years in practice were characterized as early career (<10 years) and late career (10 years). Learn more Healthgrades Operating Co. Accessed October 8, 2020. This is an open access article distributed under the terms of the CC-BY License. Of the 122 total surgeons, 112 were included in coronary artery bypass graft (CABG) model and 120 were included in the valve model. The site is secure. Cardiothoracic diseases, Yale University School of Medicine, Department of Cardiothoracic Surgery, 333 Cedar Street, Room 121FMB, PO Box 208039 FMB, You need to be logged in to see this email (, Surgical Correction of a Giant Left Atrial Myxoma Producing Critical Mitral Stenosis, Giants of Cardiothoracic Surgery: An Interview with John Elefteriades, Circulatory Support for Aortic Surgery: Ten Tips, Evolving Strategies in Acute Type-A Dissection Surgery, American Association for Thoracic Surgery, European Association for Cardio-Thoracic Surgery. Although cumulative case volume in a surgeons career may mediate the association between experience and surgical outcomes, information on the cumulative case volume was not available in this cross-sectional data set. Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer JD. This association was not observed for CABG. Risk adjustment was performed by a multivariable risk model developed by the New York State Department of Public Health. Advanced left ventricular dysfunction The new PMC design is here! Acquisition, analysis, or interpretation of data: Weininger, Mori, Brooks II, Shang, Faggion Vinholo, Zhang, Geirsson, Vallabhajosyula.
However, the limitations of this data set include the use of single-state data, which has a limited sample size of surgeons and may not represent states with practice and referral patterns different from New York. The association between surgeon experience and operative outcomes has been the subject of debate, with some studies suggesting worse outcomes with increasing surgeon age,1,2,3 while others report the opposite.4,5 A concave association, in which outcomes improve for the first number of years a surgeon is in practice, then plateau for a long period and worsen when surgeons approach retirement has also been reported.3,6 Many of these studies have used surgeon age, which may be confounded by various factors, including different training pathways and medical school starting age, as a surrogate for surgeon experience.4,7,8,9 A few studies have used years in practice, which measures surgeon experience more precisely.3,5. The RAMR for surgeons with less than 10 years of practice was similar compared with surgeons with more than 10 years of practice for CABG procedures (1.3 [IQR, 0.3-2.1] vs 1.3 [IQR, 0.0-2.2]; P=.73). The median RAMR was 1.3% (IQR, 0.2%-2.2%) for CABG procedures and 3.1% (IQR, 1.7%-5.1%) for valve procedures. Valve and combined valve/CABG cases were also grouped into a single category such that these 2 case types could not be evaluated individually. Accepted for Publication: August 28, 2020. 8600 Rockville Pike Mortality was defined as all-cause death within 30 days of surgery or within the index hospitalization, whichever was longer. Analyses were performed using SAS, version 9.4 (SAS Institute Inc). This association was not observed for CABG (Table 2). Abbreviations: CABG, coronary artery bypass graft; IQR, interquartile range; RAMR, risk-adjusted mortality rate.
Drafting of the manuscript: Weininger, Mori, Shang. The PMC legacy view In this study, early-career status in cardiac surgeons was associated with worse surgical outcomes for valve operations, which suggests that additional complex valve surgery training in residency and mentorship guidance in early practice may be warranted. A total of 112 CABG surgeons and 120 valve surgeons performed 39436 CABG and 18596 valve procedures between 2014 and 2016. These findings suggest that additional valve surgery training in residency or close mentorship for early-career surgeons on valve operations may be warranted. sharing sensitive information, make sure youre on a federal National Library of Medicine Aortic Surgery Restricted cubic spline curve identified the association between risk-adjusted mortality rate and surgeon number of years in practice. Valve surgery carries a higher risk profile than CABG and is more often performed by more experienced surgeons.9,10 With more than half of the US cardiothoracic surgeons older than 55 years and nearing retirement,11 understanding this association is timely. For surgeons practicing at multiple hospitals, we combined surgeon-level outcomes at those hospitals.
IMG indicates international medical graduates. One option may be regionalization of complex valve operations, especially mitral valve. The https:// ensures that you are connecting to the Another option may be broader adoption of additional subspecialty fellowships after the general cardiothoracic surgery training, in which surgeons intending to specialize in valve operations would be encouraged to pursue additional training. The 10-year threshold was determined by the inflection point that occurred in the smoothed plot of risk-adjusted mortality and the number of years in practice. These findings are notable for several reasons.
The RAMR was similar across the number of years in practice for CABG (1.3 [IQR, 0.3-2.1] vs 1.3 [IQR, 0.0-2.2; P=.73) (Figure 3). The risk-adjusted mortality rate was similar across different numbers of years in practice for CABG procedures. Restricted cubic spline fit of risk-adjusted mortality rate by years in practice for valve and CABG procedures. In this cross-sectional study of data from early-career (<10 years) and late-career (>10 years) cardiac surgeons practicing between 2014 and 2016 in New York, a lower number of years in practice for cardiac surgeons was significantly associated with a higher risk-adjusted mortality rate in valve procedures. Current cardiac surgery residency and fellowship programs may need to increase trainee exposure to complex valve operations. For surgeons whose training history was not listed on the Cardiothoracic Surgery Network website, we searched other online resources, such as the website of the surgeons current hospital and the Healthgrades website.13 We excluded international medical graduates because international medical graduates may have practiced as surgeons overseas, which may have obscured the actual years in practice. Because the data were publicly available, the Yale institutional review board waived approval and the need for patient consent. Concept and design: Weininger, Mori, Faggion Vinholo, Assi, Geirsson, Vallabhajosyula. In addition, late-career surgeons who receive many valve referrals could be encouraged to involve and share cases with early-career surgeons who receive fewer valve referrals and may learn from increased exposure. In addition, extremely long years in practice was not associated with changes in outcome. We examined the association between surgeon-level RAMR and surgeon years of practice via linear regression models for CABG and valve procedures, adjusting for annual surgeon volume for respective case types. In this cross-sectional study, compared with late-career cardiac surgeons, early-career cardiac surgeons were associated with worse risk-adjusted outcomes for valve operations but not for CABG. Risk-adjusted operative mortality rate (RAMR). Accessed October 8, 2020. Two studies that found worse CABG outcomes to be associated with older surgeons used outcome data from 1989 to 1992 and from 1998 to 1999,1,9 which may not reflect contemporary practice patterns and training paradigms. What is the association between cardiac surgeons years in practice and operative outcomes on coronary artery bypass grafting (CABG) and valve surgery? FOIA HHS Vulnerability Disclosure, Help More than half of US cardiothoracic surgeons are older than 55 years, and the association between surgeon number of years in practice and surgical outcomes remains unclear. Yale New Haven Hospital/Yale University Cardiothoracic Surgery Residency (1981 - 1983), Cardiac surgery Please upgrade to a newer version of Internet Explorer or use an alternate browser such as Chrome or Firefox. Open Access: This is an open access article distributed under the terms of the CC-BY License. Surgeon volume and operative mortality in the United States. This study has limitations. Continuous variables were summarized by median (interquartile range [IQR]) and categorical variables by percentages. Administrative, technical, or material support: Mori, Shang, Geirsson, Vallabhajosyula. Yale-New Haven Hospital/Yale University General Surgery Residency (1976-1983) A few studies in cardiac surgery have examined coronary artery bypass grafting (CABG) outcome variation with conflicting results.1,4,7 However, to our knowledge, differences in the surgeon experienceoutcome association for CABG and valve procedures have not yet been studied. Data were analyzed in April 2020.
Supervision: Mori, Assi, Geirsson, Vallabhajosyula. Our results are consistent with studies reporting low case volume being associated with worse outcomes in valve surgery.14,15 However, our finding that CABG outcomes are not significantly associated with surgeon experience differs from previous studies that have reported mixed results, some of which show worse outcomes for older surgeons and some of which show improved outcomes.5,7,9. Shortage of cardiothoracic surgeons is likely by 2020. will also be available for a limited time. Careers. Federal government websites often end in .gov or .mil. Tsugawa and colleagues7 used Medicare data from 2011 to 2014 and reported that older surgeon status was associated with obtaining better CABG outcomes. The influence of volume and experience on individual surgical performance: a systematic review, Factors determining the quality of physician performance in patient care, Age and sex of surgeons and mortality of older surgical patients: observational study. The bands represent 95% CIs. First, we were able to investigate the outcomes of valve operations in addition to CABG and show that these operations differ in their outcome association with surgeon experience, which, to our knowledge, has not been shown before. and transmitted securely. Published: November 3, 2020. doi:10.1001/jamanetworkopen.2020.23671. Early-career status in surgeons had higher RAMR compared with late-career status in surgeons for valve procedures (4.0 [IQR, 1.5-7.7] vs 2.9 [IQR, 1.7-4.7]; P=.20), but the finding was not statistically significant. Surgeons with less than 10 years of practice had higher RAMR for valve procedures compared with surgeons with more than 10 years of practice (4.0 [IQR, 1.5-7.7] vs 2.9 [IQR, 1.7-4.7]; P=.20), but the finding was not statistically signficant. To determine surgeons number of years in practice, we obtained each surgeons medical school graduation year as well as residency and fellowship completion years from the Cardiothoracic Surgery Network website.12 Each surgeons final year of schooling was subtracted from 2016 (when the latest New York data were published) to determine number of years in practice. Figure 1 depicts the inclusion criteria for surgeons. Conflict of Interest Disclosures: None reported. about navigating our updated article layout. In addition, the valve surgery outcome data are reported as a combination of mitral, aortic, and tricuspid valve operations, and risk-adjusted outcomes for each valve operation type could not be evaluated. Differences between this study and ours may owe to the Tsugawa and colleagues7 data set including only nonelective procedures for Medicare patients (age 65 years) in contrast to our data, which included elective and nonelective procedures performed on patients of all ages. Critical revision of the manuscript for important intellectual content: All authors. In this cross-sectional study using a large statewide data set, fewer years in practice was associated with worse risk-adjusted outcomes in valve surgery within the first 10 years in practice, but not for CABG. Abbreviations: CABG, coronary artery bypass graft; RAMR, risk-adjusted mortality rate. The sample size of surgeons with less than 10 years in practice was 28 for the valve model, which could be subject to variability, although statistical tests show significant results.