Association between Operative Autonomy of Surgical Residents and Patient Outcomes

Abstract

Importance: Resident operative autonomy has been steadily decreasing. Whether this reduction in autonomy has been associated with changes in patient outcomes is unclear. Objective: To assess whether surgical procedures performed by residents without an attending surgeon scrubbed are associated with differences in patient outcomes compared with procedures performed by attending surgeons alone or by residents with the assistance of attending surgeons. Design, Setting, and Participants: This retrospective propensity score-matched cohort study analyzed 30-day outcomes among patients who received operations at US Veterans Affairs (VA) medical centers and were recorded within the VA Surgical Quality Improvement Program (VASQIP) database from July 1, 2004, to September 30, 2019. Among 1797056 operations recorded in the VASQIP during that period, 1319020 were eligible for inclusion. Operations performed by a surgical resident without an attending surgeon scrubbed (resident primary) were propensity score matched on a 1:1 ratio (based on year of procedure and patient age, race, sex, American Society of Anesthesiologists physical status classification, functional status, emergency status, inpatient status, presence of multiple comorbidities, and Current Procedural Terminology code) to operations performed by an attending surgeon only (surgeon primary) and operations performed by a resident with assistance from an attending surgeon (resident plus surgeon). Exposures: Level of resident involvement. Main Outcomes and Measures: Thirty-day adjusted all-cause mortality. Results: Among 1319020 surgical procedures included, 138750 were performed by residents only, 308724 were performed by surgeons only, and 871546 were performed by residents and surgeons. For the 1319020 total cases, patients' mean (SD) age was 61.6 (12.9) years; 1223051 patients (92.7%) were male; and 212315 (16.1%) were Black or African American, 63817 (4.9%) were Hispanic, 830704 (63.0%) were White, and 212814 (16.1%) were of other or unknown race and ethnicity. Propensity score matching produced 101130 pairs of resident-primary and surgeon-primary procedures and 137749 pairs of resident-primary and resident plus surgeon procedures. Patient all-cause mortality and morbidity were no different among those who received surgeon-primary procedures (mortality: odds ratio [OR], 1.03 [95% CI, 0.95-1.12]; morbidity: OR, 1.01 [95% CI, 0.97-1.05]) vs resident plus surgeon procedures (mortality: OR, 1.03 [95% CI, 0.97-1.11]; all-cause morbidity: OR, 0.97 [95% CI, 0.95-1.00]). Resident-primary procedures had longer operative times than surgeon-primary procedures (median, 80 minutes [IQR, 50-123 minutes] vs 70 minutes [IQR, 41-114 minutes], respectively; P