D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2019 . No. 5 A NATIONAL COMPARISON OF OPERATIVE OUTCOMES OF NEW AND EXPERIENCED SURGEONS Case-mix, not physician experience, accounts for most differences in outcomes Rachel R. Kelz, Morgan M. Sellers, Bijan A. Niknam, James E. Sharpe, Paul R. Rosenbaum, Alexander S. Hill; Hong Zhou; Lauren L. Hochman; Karl Y. Bilimoria; Kamal Itani; Patrick S. Romano; Jeffrey H. Silber Annals of Surgery – published online June 7, 2019 KEYFINDINGS In this national study, Medicare beneficiaries treated by new surgeons had poorer outcomes than those treated by experienced ones in the same hospitals. However, the type of operation and the patient’s emergency status – rather than physician inexperience – explains nearly all poorer outcomes. Higher-risk cases are disproportionately treated by new surgeons. THE QUESTION Patients treated by new and experienced surgeons differed in meaningful ways. Compared to patients of experienced surgeons, patients of new While prior studies suggest that patients of new surgeons fare worse than surgeons at the same hospital were more likely to have presented at those of experienced surgeons, it is unclear whether outcomes differ due the emergency department (53.9% vs. 25.8%) and to be age 85 or older to surgeon experience level or the context in which care is delivered. This (25.8% vs. 16.3%). The type of operation differed as well: for example, study compares outcomes among fee-for-service Medicare beneficiaries total knee replacement comprised 16.8% of operations for new surgeons, receiving care from new and experienced surgeons at the same hospitals, compared to 47.5% for experienced surgeons. Not surprisingly, patients taking into account operation type, emergency admission status, and of new surgeons, upon admission, had a higher probability of 30-day patient risk factors, including comorbidities. mortality than patients of experienced surgeons. The authors investigated differences in 30-day mortality, as well as other After matching these surgeons by the year of the operation (baseline), clinical and utilization outcomes, among beneficiaries who underwent patients of new surgeons had 42% higher odds of 30-day mortality orthopedic or general surgery between 2009 and 2013. Surgeons were than patients of their more experienced colleagues (6.2% vs. 4.5%). As considered “new” within the first three years of practice, and “experienced” shown in the Figure, matching by the type of operation reduced the if they had at least 10 years of practice experience. difference in odds from 42% to 24%; further matching by emergency status of the patient reduced it to 12%. Further matching by patient risk THE FINDINGS factors and comorbidities reduced the difference to insignificant levels. More than 10,000 surgeons working in over 1,200 hospitals were included Thus, operation type and emergency department admission status – not in the study. After pairing new and experienced surgeons working at the surgeon experience level – explain these differences in the odds of 30- same hospitals, the researchers compared 1,820 surgeons in each group. day mortality rates. New surgeons had an average of 1.6 years of experience at the time of the operation, while experienced surgeons had an average of 21.3 years of experience. COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI Even more importantly, it points to potential ways to minimize or eliminate outcome 42% higher differences. Because new surgeons perform Baseline difference riskier operations, they might benefit from more attention from experienced surgeons 24% prior to and during the operation in terms of Matched on operation operative judgment and technique. Because 12% new surgeons operate on more complex patients, they might also benefit from Matched on operation and guidelines that encourage them to discuss emergency admission status high-risk cases with an experienced colleague. FIGURE. As the US faces an anticipated shortage of Odds of 30-day mortality for 6% higher thousands of surgeons by 2030, the country (not significant) will increasingly need to rely on new surgeons patients of new vs. experienced surgeons, matched within hospitals Matched on operation, emergency for care. Strategies to enhance support for admission status and risk factors new surgeons are needed as they transition to practice. The authors examined a number of other clinical outcomes, such as failure-to-rescue (death after developing a complication) and 30-day THE STUDY readmission and death, and found similar patterns. They also looked at The authors first identified over 760,00 fee-for-service Medicare process and utilization outcomes, including prolonged length of stay, beneficiaries aged 65.5 or older who underwent orthopedic or general anesthesia time, and resource use. They found similar, though more surgery from 2009 to 2013. Surgeons were considered “new” if they were nuanced, patterns, with slight differences in some outcomes remaining within their first three years of independent practice. Those with ten or after matching on different factors. For example, patients of new surgeons more years of independent practice were considered “experienced.” were slightly more likely to experience prolonged length of stay and New and experienced surgeons in the same hospital were paired for require a longer anesthesia time (155.4 vs. 137.6 minutes) than patients of comparison. In total, 1,820 surgeons were identified in each group, and 10 experienced patients, even when matched. Thirty-day resource costs for randomly sampled patients of new surgeons were compared to four sets patients of new surgeons were $2,466 higher than experienced surgeons’ of patients of experienced surgeons. Each set of experienced surgeons’ patients without matching, a difference that was halved ($1,257) after patients was matched to patients of new surgeons by a characteristic matching on the factors included in the study. that may have contributed to differences in patient outcomes, holding constant the matched characteristics from previous sets. The “baseline” THE IMPLICATIONS set of patients was matched on year of operation, for example, while the This is the first national study of surgical outcomes for a comprehensive fourth set of patients was matched on year of operation, type of operation, set of procedures performed by new and experienced surgeons. It reveals emergency department admission status and patient-level risk factors. that poorer outcomes associated with new surgeons can mostly be explained by differences in their operative and case mix. Newer surgeons are typically treating older, sicker patients who are admitted on an Kelz RR, Sellers MM, Niknam BA, Sharpe JE, Rosenbaum PR, et emergency basis. al. A National Comparison of Operative Outcomes of New and Experienced Surgeons. Annals of Surgery. 2019 Jun; DOI: 10.1097/ This study has important implications for both surgical education and SLA.0000000000003388 practice. The matching methods may be useful in developing a robust audit and feedback system to assess the performance of surgical All phases of this study were supported by National Institute on Aging/National Institutes of Health training programs, as graduate medical education programs move to an grant R01 AG049757. NIA/NIH had no role in the design or conduct of the study; collection, outcomes-based system of accreditation. management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript to submit for publication. LEAD AUTHOR DR. RACHEL KELZ Rachel R. Kelz, MD, MSCE, MBA, FACS is a Professor of Surgery at the Perelman School of Medicine at the University of Pennsylvania. She is an Endocrine Surgeon and cares for patients at the Hospital of the University of Pennsylvania. Dr. Kelz serves as the Vice Chair of Clinical Research within the Department of Surgery. Dr. Kelz is recognized as a leader in surgical education and was awarded the Lindback Foundation award for distinguished teaching by the Provost of the University of Pennsylvania. She serves as the Surgeon Champion for the National Surgical Quality Improvement Program at Penn. Her work in outcomes and education has recently merged, and she is focusing on innovative approaches to combine administrative data with chart abstraction to identify opportunities to improve surgical education and performance.