Abstract
Background
Rotations in hand and upper extremity surgery are a core component of the Orthopaedic and Plastic Surgery resident training curriculums. This study compares short-term outcomes in hand and upper extremity procedures with and without resident involvement.
Methods
The National Surgical Quality Improvement Program database was queried from years 2005–2012 for all procedures distal to the shoulder. Patients were stratified based on whether a resident scrubbed for the procedure. Outcome measures were 30-day mortality, reoperation rate, minor complications, major complications, and length of stay (LOS). Chi-squared tests were used to determine significant variables. Significant variables were included in a binomial multivariate logistic regression model.
Results
A total of 7697 patients were included in the study. Of those, 4509 (59 %) had no resident, and 3188 (41 %) had a resident. Patients with resident involvement were less likely to be Caucasian, ASA classification 3 or higher, and outpatient. Cohorts were similar with respect to age, sex, and emergent status. Operative time was 15 min longer in resident cases. Work relative value units were higher in resident cases. In the multivariate logistic regression model, resident involvement had no statistically significant impact on LOS, mortality, reoperation rate, minor complications, or major complications. Subgroup analysis showed increased odds of superficial surgical site infections in resident cases, although this was statistically insignificant (OR 1.35, p = 0.24).
Conclusions
Hand and upper extremity procedures with resident involvement do not have any increase in overall adverse short-term outcomes. In appropriately selected cases, residents can participate without compromising patient safety.
Keywords: Hand, NSQIP, Outcomes, Residents, Upper extremity
Declaration of funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Availability of data and materials
Public database.
Author contributions
Dustin Biron and Robert DalCortivo contributed to research design, the acquisition, analysis, and interpretation of data, and drafting the paper. Irfan Ahmed and Michael Vosbikian were responsible for the critical analysis and writing of the manuscript and approval of the submitted and final versions. All authors have read and approved the final submitted manuscript.
1. Introduction
The current resident training model is over 130 years old and is based on the concept of graduated responsibility, in which residents reach a point of near-total independence and autonomy by the end of their training period.1 Direct resident involvement in a given procedure is dependent on the level of responsibility granted by the attending surgeon. Among the most important considerations are the level of focus on patient outcomes, desired efficiency, hospital and patient expectations, the resident's clinical skill, and the attending surgeon's confidence in the resident and the procedure.2 Studies have shown that both surgical residents and fellowship program directors lack confidence in graduating resident abilities.3,4 Therefore, an increased focus on resident training is needed.
The Accreditation Council for Graduate Medical Education (ACGME) mandates hand surgery as a core clinical experience within Orthopaedic Surgery and Plastic Surgery residency.5,6 Residents spend an average of 4.8 months rotating on a hand service,7 and roughly one of every five procedures performed by residents are performed on the humerus, elbow, forearm, wrist, hand, and fingers.8 These procedures are notable for their diversity, with volume in tendon, amputation, nerve, soft tissue, and fracture care.
Despite supervision from attending physicians, concerns have been raised over the ethics and safety of resident involvement in surgical procedures.9, 10, 11 Several studies have examined outcomes based on resident inclusion in Orthopaedic Surgery.12, 13, 14, 15, 16, 17, 18, 19, 20, 21 While some of these studies have shown increased morbidity associated with resident involvement, others have shown no difference in outcomes. To our knowledge, no studies have examined the safety of resident involvement in the setting of hand and upper extremity surgery. The purpose of our study is to assess differences in short-term outcomes of hand and upper extremity procedures with and without resident involvement. We hypothesize that outcomes will not be different based on whether a resident was involved.
2. Materials and methods
The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database is a surgical database representing over 700 hospitals in 49 of 50 US States and 11 different countries.22 Each participating hospital employs a trained reviewer who collects data from the preoperative period through the 30-day postoperative period on randomly assigned patients.23 It is a validated, outcome-based, risk-adjusted, peer-controlled database which has shown a high degree of inter-rater reliability.24, 25, 26
We queried the NSQIP database from years 2005–2012 for all records with primary Current Procedure Terminology (CPT) code for every procedure distal to the shoulder (CPT 23930–26989, 29830–29848). We applied several exclusion criteria. First, CPT code descriptions related to peripheral nerves are generally non-specific, with the body part referenced as “arm or leg” or “hand or foot”. As a result, we could not isolate procedures specifically related to the hand and upper extremity, and these procedures were excluded from our analysis. The database also excludes minor procedures such as carpal tunnel release, trigger finger release, ulnar nerve compression, and hardware removal, so these procedures were also excluded from the analysis. Second, only procedures performed by orthopaedic or plastic surgeons were included, given that these are the most common specialties performing hand and upper extremity surgery. Third, in an effort to minimize differences in case complexity, we excluded any procedure with multiple CPT codes listed.
Data were collected for demographics, comorbidities, and outcomes. Demographics included age (≤40, 41–60, 61–80, and 81+), sex, race (Caucasian, African American, or other/not reported), and American Society of Anesthesiologist (ASA) Classification (class <3 or≥3). Comorbidities included smoking status, corticosteroid use, open wound, chronic obstructive pulmonary disease (COPD), coagulopathy, diabetes mellitus, non-morbid obesity, morbid obesity, and hypertension. Open wounds are a preoperative risk factor. They are defined by the NSQIP as a breach in the integrity of the skin or separation of skin edges and include open surgical wounds with or without cellulitis or purulent exudate.27 Other variables collected included whether the procedure was emergent and whether the procedure was performed on an inpatient or outpatient basis. Patients were excluded if they were missing any information. A flow chart showing the development of the final population is shown in Fig. 1.
Fig. 1.
Flow chart for final data after applying inclusion and exclusion criteria.
Records were placed into two categories based on whether a resident scrubbed for the procedure using the PGY variable in the NSQIP database. 30-day mortality, 30-day reoperation, length of stay (LOS), 30-day minor complications, and 30-day major complications were compared between these groups. Length of stay was defined as either routine (less than or equal to the 75th percentile) or extended (greater than the 75th percentile). The 75th percentile was used as a threshold for extended LOS based on prior studies.28, 29, 30 Minor complications were grouped together and included renal insufficiency not requiring dialysis, pneumonia, wound dehiscence, superficial surgical site infection (SSI), and urinary tract infection. Major complications were similarly grouped together and included myocardial infarction, deep vein thrombosis, pulmonary embolism, cerebrovascular accident, sepsis, cardiac arrest, deep surgical site infection, reintubation, and acute renal failure requiring dialysis.
Chi-squared tests were used to identify demographics and comorbidities that were significantly associated with each outcome. Significant variables were then included alongside resident status in a binomial multivariate logistic regression model. Statistical significance was defined as P < 0.05.
This study was retrospective in nature and based on de-identified records. Therefore, it was exempt from Institutional Review Board approval.
3. Results
From an initial 23,507 patients, a total of 7697 patients were included in the analysis after applying exclusion criteria (Fig. 1). Of these, 3188 (41.4 %) had a resident scrubbed for the procedure, and 4509 (58.6 %) had no resident. Patients with resident involvement were less likely to be Caucasian (65.8 % vs. 82.0 %, P < 0.01), American Society of Anesthesiologists (ASA) classification 3 or higher (22.1 % vs. 25.6 %, P < 0.01), and performed on an outpatient basis (75.3 % vs. 80.4 %, P < 0.01). Resident involvement was associated with longer operative time (84.8 vs. 69.5 min, P < 0.01) and higher work relative value units (RVUs) (9.2 vs. 8.7, P < 0.01). Cases with and without residents were similar with respect to age, sex, and emergent status (Table 1). A majority of cases were done by orthopaedic surgeons rather than plastic surgeons (78.9 % vs. 21.1 %).
Table 1.
Descriptive data of hand and upper extremity surgeries.
| Variable | Frequency (%) |
||
|---|---|---|---|
| Overall | No Resident | Resident | |
| Total | 7697 (100.0 %) | 4509 (100.0 %) | 3188 (100.0 %) |
| Resident Status | |||
| No Resident | 4509 (58.6 %) | 4509 (100.0 %) | 0 (0.0 %) |
| Resident | 3188 (41.4 %) | 0 (0.0 %) | 3188 (100.0 %) |
| Age | |||
| ≤40 | 2484 (32.3 %) | 1434 (31.8 %) | 1050 (32.9 %)* |
| 41-60 | 2979 (38.7 %) | 1720 (38.1 %) | 1259 (39.5 %) |
| 61-80 | 1888 (24.5 %) | 1128 (25.0 %) | 760 (23.8 %) |
| 80+ | 346 (4.5 %) | 227 (5.0 %) | 119 (3.7 %) |
| Sex | |||
| Male | 3895 (50.6 %) | 2258 (50.1 %) | 1637 (51.3 %) |
| Female | 3802 (49.4 %) | 2251 (49.9 %) | 1551 (48.7 %) |
| Race | |||
| Caucasian | 5795 (75.3 %) | 3698 (82.0 %) | 2097 (65.8 %)* |
| African American | 590 (7.7 %) | 293 (6.5 %) | 297 (9.3 %) |
| Other/Not Reported | 1312 (17.0 %) | 518 (11.5 %) | 794 (24.9 %) |
| ASA Class | |||
| <3 | 5839 (75.9 %) | 3355 (74.4 %) | 2484 (77.9 %)* |
| ≥ 3 | 1858 (24.1 %) | 1154 (25.6 %) | 704 (22.1 %) |
| Emergency | |||
| No | 7210 (93.7 %) | 4205 (93.3 %) | 3005 (94.3 %) |
| Yes | 487 (6.3 %) | 304 (6.7 %) | 183 (5.7 %) |
| Admission Status | |||
| Outpatient | 6029 (78.3 %) | 3627 (80.4 %) | 2402 (75.3 %)* |
| Inpatient | 1668 (21.7 %) | 882 (19.6 %) | 786 (24.7 %) |
| Variable | Mean (SDa) | ||
| Age (years) | 49.8 (17.9) | 50.1 (18.1) | 49.3 (17.5) |
| Operative Time (minutes) | 75.9 (52.9) | 69.5 (48.0) | 84.8 (58.0)* |
| Work RVUs | 8.9 (3.6) | 8.7 (3.4) | 9.2 (3.7)* |
*Indicates significance, defined as P < 0.05.
Standard deviation.
Hypertension and open wounds were more common in non-resident cases (31.8 % vs. 29.3 %, P = 0.02 and 5.3 % vs. 2.8 %, P < 0.01, respectively). Rates of other comorbidities were similar between the two cohorts (Table 2).
Table 2.
Comorbidities of hand and upper extremity surgeries.
| Comorbidity | Frequency (%) |
||
|---|---|---|---|
| Overall | No Resident | Resident | |
| Smoker | 1837 (23.9 %) | 1101 (24.4 %) | 736 (23.1 %) |
| Corticosteroid user | 212 (2.8 %) | 112 (2.5 %) | 100 (3.1 %) |
| Open Wound | 327 (4.2 %) | 238 (5.3 %) | 89 (2.8 %)* |
| COPD | 210 (2.7 %) | 137 (3.0 %) | 73 (2.3 %) |
| Coagulopathy | 163 (2.1 %) | 102 (2.3 %) | 61 (1.9 %) |
| Diabetes | 699 (9.1 %) | 432 (9.6 %) | 267 (8.4 %) |
| Non-morbid Obesity | 2166 (28.1 %) | 1292 (28.7 %) | 874 (27.4 %) |
| Morbid Obesity | 443 (5.8 %) | 276 (6.1 %) | 167 (5.2 %) |
| Hypertension | 2367 (30.8 %) | 1433 (31.8 %) | 934 (29.3 %)* |
*Indicates significance, defined as P < 0.05.
On a univariate basis, there were no statistical differences between non-resident and resident cases for mortality (0.2 % vs. 0.2 %, P = 1.00), extended LOS (14.1 % vs. 15.4 %, P = 0.12), reoperation (1.7 % vs. 1.7 %, P = 1.00), minor complications (1.3 % vs. 1.5 %, P = 0.49), or major complications (1.0 % vs. 0.9 %, P = 0.86) (Table 3). After controlling for significant demographics and comorbidities via the multivariate logistic regression model, resident involvement had no significant association with mortality (odds ratio (OR) 1.22, 95 % confidence interval (CI) 0.44–3.37, P = 0.70), extended LOS (OR 0.87, CI 0.72–1.06, P = 0.17), reoperation (OR 1.07, CI 0.74–1.53, P = 0.73), minor complications (OR 1.18, OR 0.80–1.76, P = 0.41), or major complications (OR 1.00, CI 0.61–1.63, P = 1.00) (Table 4, Table 5).
Table 3.
Outcomes of hand and upper extremity surgeries.
| Outcome | Frequency (%) |
||
|---|---|---|---|
| Overall | No Resident | Resident | |
| Death | 17 (0.2 %) | 10 (0.2 %) | 7 (0.2 %) |
| Extended LOS | 1129 (14.7 %) | 637 (14.1 %) | 492 (15.4 %) |
| Reoperation | 130 (1.7 %) | 76 (1.7 %) | 54 (1.7 %) |
| Minor Complication | 104 (1.4 %) | 57 (1.3 %) | 47 (1.5 %) |
| Major Complication | 73 (0.9 %) | 44 (1.0 %) | 29 (0.9 %) |
*Indicates significances, defined as P < 0.05.
Table 4.
Predictors of outcomes of hand and upper extremity surgeries.
| Variable | Death |
Extended LOS |
Reoperation |
|---|---|---|---|
| ORa (95 % CIb) | ORa (95 % CIb) | ORa (95 % CIb) | |
| Age | |||
| ≤40 | Ref | Ref | – |
| 41-60 | 0.49 (0.07, 3.51) | 0.84 (0.65, 1.08) | – |
| 61-80 | 0.76 (0.11, 5.09) | 1.20 (0.90, 1.61) | – |
| >80 | 1.05 (0.13, 8.60) | 2.44 (1.56, 3.83) | – |
| Sex Female (vs. Male) | – | 1.15 (0.95, 1.40) | 0.63 (0.44, 0.92)* |
| Race | |||
| Caucasian | – | Ref | – |
| African American | – | 1.19 (0.84, 1.68) | – |
| Other/Not Reported | – | 1.09 (0.83, 1.42) | – |
| ASA Class≥3 | 3.64 (0.76, 17.33) | 2.05 (1.61, 2.59)* | 1.53 (1.00, 2.34)* |
| Emergency | 2.41 (0.78, 7.47) | 1.34 (1.02, 1.77)* | 2.22 (1.40, 3.53)* |
| Inpatient | 6.64 (1.74, 25.41)* | 86.77 (68.62, 109.73)* | 3.41 (2.32, 5.02)* |
| Resident (vs. No Resident) | 1.22 (0.44, 3.37) | 0.87 (0.72, 1.06) | 1.07 (0.74, 1.53) |
| Comorbidities | |||
| Smoker | – | 1.25 (0.99, 1.58) | 1.72 (1.18, 2.52)* |
| Corticosteroid user | – | 1.26 (0.79, 2.00) | – |
| Open Wound | 1.79 (0.48, 6.72) | 2.56 (1.75, 3.75)* | 2.92 (1.80, 4.73)* |
| COPD | 2.93 (0.77, 11.07) | 0.65 (0.39, 1.10) | 1.48 (0.68, 3.21) |
| Coagulopathy | 4.51 (1.45, 14.09) | 1.87 (1.08, 3.22)* | – |
| Diabetes | 1.58 (0.54, 4.65) | 1.25 (0.92, 1.70) | – |
| Hypertension | 2.27 (0.56, 9.09) | 1.42 (1.13, 1.79)* | 1.25 (0.83, 1.89) |
*Indicates significance, defined as P < 0.05.
Odds ratio.
Confidence interval.
Table 5.
Predictors of outcomes of hand and upper extremity surgeries.
| Variable | Minor Complications |
Major Complications |
|---|---|---|
| ORa (95 % CIb) | ORa (95 % CIb) | |
| Age | ||
| ≤40 | Ref | Ref |
| 41-60 | 1.02 (0.56, 1.84) | 0.97 (0.43, 2.20) |
| 61-80 | 1.29 (0.68, 2.46) | 1.11 (0.47, 2.61) |
| >80 | 0.98 (0.38, 2.52) | 0.81 (0.27, 2.42) |
| Sex Female (vs. Male) | – | – |
| Race | ||
| Caucasian | – | – |
| African American | – | – |
| Other/Not Reported | – | – |
| ASA Class≥3 | 1.24 (0.77, 2.02) | 2.95 (1.59, 5.48)* |
| Emergency | – | 1.79 (0.96, 3.32) |
| Inpatient | 2.31 (1.53, 3.51)* | 4.46 (2.59, 7.67)* |
| Resident (vs. No Resident) | 1.18 (0.80, 1.76) | 1.00 (0.61, 1.63) |
| Comorbidities | ||
| Smoker | – | – |
| Corticosteroid user | 1.49 (0.67, 3.36) | 1.63 (0.71, 3.73) |
| Open Wound | 1.76 (0.88, 3.50) | 2.43 (1.26, 4.67)* |
| COPD | 2.32 (1.15, 4.69)* | 1.34 (0.55, 3.24) |
| Coagulopathy | – | 1.67 (0.75, 3.72) |
| Diabetes | 1.01 (0.57, 1.79) | 1.10 (0.61, 1.97) |
| Hypertension | 2.03 (1.26, 3.29)* | 2.04 (1.12, 3.72)* |
*Indicates significance, defined as P < 0.05.
Odds ratio.
Confidence interval.
Superficial SSIs were responsible for more than half of the minor complications for both resident and non-resident cohorts; as such, a subgroup analysis was performed. Resident cases had similar rates of superficial SSI than non-resident cases (0.9 % vs. 0.7 %, P = 0.40). After controlling for significant demographics and comorbidities, resident cases had 35 % increased odds for superficial SSI, although this difference was statistically insignificant (OR 1.35, CI 0.81–2.24, P = 0.24).
4. Discussion
Resident involvement in surgical procedures is critical to the development of well-trained orthopaedic and plastic surgeons. The goal of our study was to determine whether resident involvement was associated with any difference in short-term outcomes in hand and upper extremity surgery. In agreement with our hypothesis, all measured outcomes were similar in cases with and without resident inclusion.
While existing literature examining resident involvement in hand and upper extremity surgery is limited, several fields in orthopaedic surgery have addressed this topic.12, 13, 14, 15, 16, 17, 18, 19, 20, 21 Consistent with our findings, all studies found no difference in mortality based on resident involvement. Most of these studies also found no increase in morbidity based on resident involvement,12,17, 18, 19, 20, 21 which also agrees with our data. However, several found that cases with residents had greater odds for complications.13, 14, 15, 16 A study by Schoenfeld et al. used 12 high-volume index cases to generalize resident involvement in orthopaedics.13 In this study, resident involvement was associated with increased morbidity in joint arthroplasty only. The hand and sports cohort showed no significantly increased morbidity with resident involvement. Mitchell et al. examined resident involvement in orthopaedic trauma.15 In their upper extremity cohort, resident involvement was associated with increased major complications. However, this was specific to trauma and included injuries that were not included in our study. Studies with decreased morbidity based on resident involvement are more limited, but it has been shown in parotidectomies.31 The inconsistent findings between our study and across the literature may relate to differences in the mix of procedures included in each dataset.
Although aggregate minor complications were similar between resident and non-resident cohorts, subgroup analysis revealed 35 % increased odds of superficial SSI in resident cases. Some orthopaedic studies have found no difference in superficial SSI based on resident involvement,14,17, 18, 19, 20, 21 while studies both within and outside of orthopaedic surgery have found increased rates of SSI with resident involvement.32, 33, 34, 35 One systematic review showed that prolonged operative time is a risk factor for infection.36 Given resident cases were over 15 min longer than non-resident cases in our study, this may explain the increased superficial SSI rate.
Length of stay was also similar between resident and non-resident cases in this study. While this finding agrees with some existing studies,15,18,19 others found greater LOS in resident cases, even in multivariate models.12,16,17,21 Interestingly, one study found shorter LOS in resident cases for total shoulder arthroplasty.20 In our study, the resident cohort had significantly more procedures done on an inpatient basis, which may explain our result. After controlling for inpatient status in the multivariate model, the effect of resident involvement on LOS was eliminated. Greater patient and case complexity in resident cases may also contribute to extended LOS.
Our data revealed that cases with residents had a greater mean operative time by over 15 min. This agrees with most of the existing literature that included operative time in their analyses.12,14, 15, 16, 17, 18, 19,21 Traven et al. found that increases in operative time correlated positively with resident postgraduate year level, suggesting that senior residents are given greater operative autonomy, leading to longer operative times.14 Counterintuitively, one study found that in the setting of total shoulder arthroplasty, resident cases were 8 min shorter than non-resident cases.20 They suggested that resident-driven increases in operative time may be offset by residents operating with high-volume shoulder arthroplasty surgeons with greater operative efficiency.
In our study, work RVUs, which reflect time, mental effort and judgment, technical skill and physical effort, and psychological stress,37 were higher in resident cases. Only three of the referenced studies considered RVUs in their analysis, and only the study by Edelstein et al. was explicit in how RVUs differed between residents and non-residents.14,16,21 Contrary to our study, they found no difference in median work RVUs between resident and non-resident cases. Work RVUs have been shown to correlate positively with operative time in hand surgery.38 Therefore, it is reasonable to conclude that at least some of the increased operative time in our study can be attributable to greater case complexity. Other contributing factors may be time spent teaching and less operative efficiency when the resident is the primary surgeon.39
Intuitively, patients generally appreciate the need for trainees to operate prior to the conclusion of their training. However, a study published by Nahhas et al. showed a concerning finding in the realm of orthopaedic surgery.40 While 94.1 % of their surveyed patients felt residents should perform surgeries as part of their training, the proportion of patients not wanting residents involved in their own procedure was 39.7 %, 20.6 %, and 14.7 % for PGY2s, PGY5s, and fellows, respectively. Furthermore, 34.5 % of patients were willing to delay surgery by at least one month if it meant no resident involvement. This poses a substantial challenge to the complete and robust training of residents, and strategies are needed to address this issue. One general surgery study analyzed patient acceptance of surgical trainee involvement in their care before and after the distribution of educational pamphlets.41 They found an increase in willingness to have fifth year residents operate on them independently from 52 % to 65 % after reading pamphlets that presented literature citations and statistics showing the benefit of resident involvement. Thus, studies like ours can be used in a similar fashion. Particularly, in the realm of orthopaedic surgery, and specifically in upper extremity surgery, our study may be cited to support the participation of residents in orthopaedic procedures, ultimately improving trainee experience.
This study has several limitations. While the NSQIP data shows whether a resident scrubbed for a procedure, we were unable to assess the degree of autonomy given to the resident. This makes it challenging to attribute outcomes directly to resident operative skill. The NSQIP does not include some high-volume hand procedures, such as carpal tunnel release and trigger finger release, which could impact complication rates. This study may also be limited by confounding by indication, where residents may be assigned to more complex cases. Given the limitations of the database, procedure complexity and condition severity were not assessed in the quantitative analysis. However, we did attempt to make a qualitative assessment of complexity based on the difference in RVUs between the two groups. The database does not provide outcomes unique to orthopaedic procedures, such as pain, functional status, and radiographic outcomes, so these were not assessed in our study. The NSQIP database is a large, retrospective database lacking randomization. While data is entered by a trained professional, there may be inconsistencies in how the data is entered across hospitals, and entries may be error-prone. The database follows patients for only 30 days; therefore, outcomes beyond the 30-day postoperative period are not considered in this study. Lastly, participation in the NSQIP program is costly, leading to inclusion of primarily large teaching hospitals with greater financial resources.42 While the NSQIP contains data for outpatient surgeries, it was designed to collect data from hospitals; as a result, ambulatory surgery centers are underrepresented in this analysis.
5. Conclusions
Residents play a substantial role in patient care at teaching institutions, and their development as future surgeons is dependent on their participation in procedures as residents. Given our results, attending hand and upper extremity surgeons should be comfortable including residents in appropriately-selected surgical procedures without jeopardizing patient safety. Furthermore, these findings can support productive conversations between physicians and patients on the inclusion of residents in surgeries. In their supervision of residents, attending surgeons should take particular care in prevention of surgical site infections. Further research in the form of prospective, randomized-controlled trials with additional focus on functional and radiographic outcomes is needed to better elucidate the role residents play in surgical outcomes.
Declaration of competing interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:
Michael Vosbikian reports a relationship with Journal of Bone and Joint Surgery Inc that includes: consulting or advisory. Michael Vosbikian reports a relationship with ePlasty that includes: board membership.
Acknowledgements
None.
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Associated Data
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Data Availability Statement
Public database.