Bethesda, MD 20894, Web Policies 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. Tsugawa and colleagues7 used Medicare data from 2011 to 2014 and reported that older surgeon status was associated with obtaining better CABG outcomes. Published: November 3, 2020. doi:10.1001/jamanetworkopen.2020.23671. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies. Received 2020 May 5; Accepted 2020 Aug 28. Statistical analysis: Weininger, Mori, Brooks II, Shang, Zhang, Vallabhajosyula. The bands represent 95% CIs. 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. Yale New Haven Hospital/Yale University Cardiothoracic Surgery Residency (1981 - 1983), Cardiac surgery Surgeon age and operative mortality in the United States. IMG indicates international medical graduates. Left ventricular aneurysmectomy Data were analyzed in April 2020. 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. 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. 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. Higher case volume was associated with lower RAMR (0.300 per 50-case increase; 95% CI, 0.531 to 0.070, P=.01). This approach may offer standardized training and mentoring structures within select centers while surgeons are in the early stage of their careers. Continuous variables were summarized by median (interquartile range [IQR]) and categorical variables by percentages. 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.
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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. 
Arrythmia surgery The Cardiothoracic Surgery Network. The risk-adjusted mortality rate was similar across different numbers of years in practice for CABG procedures. about navigating our updated article layout. This site is not optimized for Internet Explorer 8 (or older). 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. 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 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). Therefore, such an association was not evaluated. 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 procedures and 3.1% (IQR, 1.7%-5.1%) for valve procedures. Participants were 120 cardiothoracic surgeons who performed CABG and 112 cardiothoracic surgeons who performed valve procedures between 2014 and 2016. The new PMC design is here! All analyses were 2-tailed with statistical significance set at P<.05. Surgeon volume and operative mortality in the United States. This finding suggests certain competence deficiency for valve surgery early after finishing training in cardiac surgery. Analyses were performed using SAS, version 9.4 (SAS Institute Inc). 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. 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.
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. The site is secure. Accessibility 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. Yale-New Haven Hospital/Yale University General Surgery Residency (1976-1983) Of the 122 total surgeons, 112 were included in coronary artery bypass graft (CABG) model and 120 were included in the valve model. Accepted for Publication: August 28, 2020. Aortic Surgery 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. Drafting of the manuscript: Weininger, Mori, Shang. Surgeon years in practice were categorized as early career (<10 years) and late career (10 years). National Library of Medicine Risk-adjusted operative mortality rate (RAMR). Thoracic surgery HHS Vulnerability Disclosure, Help To assess the association between cardiac surgeons time in practice and operative outcomes for coronary artery bypass grafting (CABG) and valve surgery. and transmitted securely. Restricted cubic spline fit of risk-adjusted mortality rate by years in practice for valve and CABG procedures. 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.
Mortality was defined as all-cause death within 30 days of surgery or within the index hospitalization, whichever was longer. sharing sensitive information, make sure youre on a federal Accessed October 7, 2020. Current cardiac surgery residency and fellowship programs may need to increase trainee exposure to complex valve operations. 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. PMC legacy view This association was not observed for CABG (Table 2).
New York State Department of Health Adult cardiac surgery in New York State 2014-2016. Supervision: Mori, Assi, Geirsson, Vallabhajosyula. Maruthappu M, Gilbert BJ, El-Harasis MA, et al.. 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). 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. 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 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. This study has limitations. Critical revision of the manuscript for important intellectual content: All authors. 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). The two groups overlap because most surgeons perform CABG and valve surgery. Open Access: This is an open access article distributed under the terms of the CC-BY License.
Advanced left ventricular dysfunction One option may be regionalization of complex valve operations, especially mitral valve. Smoothed cubic spline associating mortality and the number of years was estimated using vcov package in Python 3.6 (Python Software Foundation). 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. 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. 1972) 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. Administrative, technical, or material support: Mori, Shang, Geirsson, Vallabhajosyula. 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). This is an open access article distributed under the terms of the CC-BY License.
A total of 112 CABG surgeons and 120 valve surgeons performed 39436 CABG and 18596 valve procedures between 2014 and 2016. A total of 112 CABG surgeons and 120 valve surgeons performed 39436 CABG and 18596 valve operations, respectively. 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. 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. These findings suggest that additional valve surgery training in residency or close mentorship for early-career surgeons on valve operations may be warranted. Are young surgeons competent to perform alimentary tract surgery? 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. 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. What is the association between cardiac surgeons years in practice and operative outcomes on coronary artery bypass grafting (CABG) and valve surgery? 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. For surgeons practicing at multiple hospitals, we combined surgeon-level outcomes at those hospitals. Accessed October 8, 2020. Healthgrades Operating Co. Accessed October 8, 2020. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. 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.
The median number of surgeon years in practice was 20.0 (interquartile range [IQR], 12.0-28.5) years. 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. Most findings on this topic are based on investigations of general surgery cases. 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. 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. Several options may address this potential gap in valve expertise. official website and that any information you provide is encrypted Wilcoxon rank sum test and 2 test were used to compare early-career with late-career surgeon status. Valve and combined valve/CABG cases were also grouped into a single category such that these 2 case types could not be evaluated individually. Linear regression models adjusted for surgeons annual case volumes. government site. Please upgrade to a newer version of Internet Explorer or use an alternate browser such as Chrome or Firefox. Yale University School of Medicine (M.D. Figure 1 depicts the inclusion criteria for surgeons. 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. 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. Acquisition, analysis, or interpretation of data: Weininger, Mori, Brooks II, Shang, Faggion Vinholo, Zhang, Geirsson, Vallabhajosyula. will also be available for a limited time. All valve operations, excluding transcatheter procedures, were grouped into a single valve category in the New York State data. Risk adjustment was performed by a multivariable risk model developed by the New York State Department of Public Health. These findings are notable for several reasons. Federal government websites often end in .gov or .mil. Yale University (B.A. 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. 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. FOIA 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). Restricted cubic spline curve identified the association between risk-adjusted mortality rate and surgeon number of years in practice. 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. Gonzalez AA, Dimick JB, Birkmeyer JD, Ghaferi AA. Abbreviations: CABG, coronary artery bypass graft; IQR, interquartile range; RAMR, risk-adjusted mortality rate.
Conflict of Interest Disclosures: None reported. 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. An official website of the United States government. 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. Concept and design: Weininger, Mori, Faggion Vinholo, Assi, Geirsson, Vallabhajosyula. Cardiac diseases The median number of years in practice was 20.0 (IQR, 12.0-28.5) years (Table 1 and Figure 2). April 2019. The https:// ensures that you are connecting to the 2020 Weininger G et al. This association was not observed for CABG. Because the data were publicly available, the Yale institutional review board waived approval and the need for patient consent. JAMA Network Open. Careers. Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer JD.
This finding was consistent after adjusting for case volume.
Statistical analysis was performed using surgeon-level outcome data, surgeon case volumes, and surgeon years in practice. In addition, extremely long years in practice was not associated with changes in outcome. Surgeons who trained outside of the United States or had unclear training history were excluded.
Before 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. Learn more Years in practice were characterized as early career (<10 years) and late career (10 years).
Data were analyzed in April 2020. 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). 8600 Rockville Pike Shortage of cardiothoracic surgeons is likely by 2020. Abbreviations: CABG, coronary artery bypass graft; RAMR, risk-adjusted mortality rate.
All surgeon-level data were collected from 2014-2016 New York State outcomes data, the latest New York State surgeon-level outcomes report. 1976) 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. The 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.