NEW YORK (Reuters Health) – The risk of complications increases significantly when a single attending surgeon supervises two or more hip surgeries in different operating rooms at the same time.
“Risks may be reduced by having surgeries overlap only when absolutely necessary and by limiting the duration of overlap,” Dr. Bheeshma Ravi from Sunnybrook Health Sciences Center, Toronto, Canada, told Reuters Health by email.
Dr. Ravi’s team reviewed data on nearly 38,000 hip-fracture surgeries and 53,000 total hip arthroplasties (THAs) from several Ontario health administrative databases to assess how often hip surgeons double-book, whether overlapping procedures are at increased risk for relevant surgical complications, and whether the duration of overlap matters.
“This study is unique because of our matching strategy – after matching, we compared the same procedure, performed by the same surgeon, at the same hospital, in a similar patient (in terms of age, sex, and comorbidity), with one group overlapping and the other not overlapping,” Dr. Ravi said.
The findings were published online December 4 in JAMA Internal Medicine.
About 2.5% of hip-fracture procedures and 3% of THAs included in the study overlapped with another procedure.
“I found it most interesting that this practice was so rare in Ontario, at least for hip surgery,” Dr. Ravi said.
In all, 89% of overlapping hip-fracture procedures and 93% of overlapping THAs were successfully matched to non-overlapping procedures. In these matched comparisons, the risk for surgical complications was 85% higher for overlapping hip fractures and 79% higher for overlapping THAs, compared with non-overlapping surgeries.
Actual complication rates, however, were low with both overlapping (2.3%) and non-overlapping (1.4%) THAs – and somewhat higher for hip-fracture surgeries (10.2% vs. 6.2%, respectively).
Increased duration of overlap was associated with an increased risk for complications in hip-fracture procedures, with each additional 10 minutes of overlap bringing 7% increased odds of complications.
“The most likely mechanism for increased risk arises from having less experienced surgeons or surgical trainees perform portions of the case,” the researchers speculate.
“The possibility of provision of overlapping surgery should be discussed with patients as part of obtaining informed consent,” Dr. Ravi said.
“Currently, this seems to be the first study to show an adverse effect from the practice of overlapping surgery,” writes Alan L. Zhang from University of California-San Francisco, in a related invited commentary. “Prior studies, including those performed at my institution, have found no association between patient complications and overlapping surgery.”
Late last month, Reuters Health reported on a study in JAMA Surgery in which rates of complications and deaths were no higher when neurosurgeons were involved in more than one operation at a time.
“Despite contrasting perspectives by many sides, there is agreement that perhaps the most important aspect of this practice involves transparency and consent,” Dr. Zhang said. “If given full disclosure by the surgeon, some patients may be averse to having their surgery overlap while others ambivalent, but informed consent should be necessary for all. In fact, the final U.S. Senate Finance Committee report on concurrent and overlapping surgery deemed informed patient consent to be a necessary element for any hospital using this practice. Therefore, it is both ethical and crucial for surgeons to properly disclose to their patients when overlapping surgery will occur, while including a thorough discussion of the roles of team members as well as the coordination of care.”
Dr. Richard Schmidt from University of Utah, Salt Lake City, who has examined various aspects of overlapping neurosurgery, told Reuters Health by email, “This is the first study I have seen in a growing body of evidence that detects what may be a negative impact of overlapping or concurrent surgery on patient outcomes and thus bears careful scrutiny.”
“Although the study tried to control for a number of variables, the question that will arise in a study of this type is whether or not the observed relationship was truly cause and effect, or merely a correlation with other variables that are the real culprits, such as surgery time of day or case order on a surgeons list,” he said. “Only further study will give a final answer.”
“Our group recently has presented evidence that restrictions (on overlapping surgery) enacted at our hospital have led to increased wait times for some surgeries and decreased case involvement by residents,” he said. “The latter effect could potentially lead to less experienced and qualified surgeons entering the work force in the future.”
“In my opinion, there is still a lot of work to be done to understand and control the circumstances in which the practice of overlapping surgery may be detrimental,” Dr. Schmidt said. “Likewise, we must understand where it may be advantageous, for example, in improved access to care by subspecialist master surgeons, or in the training of the next generation of surgeons. Surgical professional societies should be at the forefront of understanding this issue and acting to assure that patient safety is protected, both in the near and long term.”
SOURCES: http://bit.ly/2kmVRdd and http://bit.ly/2ijVpsc
JAMA Intern Med 2017.
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