Overlapping Surgeries Safe, Mayo Study Suggests

Troy Brown, RN

December 07, 2016

One surgeon can safely be responsible for two overlapping surgeries when critical parts of the procedures are not coincident, a retrospective study from Mayo Clinic suggests. Overlapping surgeries showed no difference in patient outcomes, but increased effectiveness and time management.

Overlapping surgeries are common and differ from "concurrent" surgeries, during which critical portions of the procedure are performed at the same time. Concurrent surgery is rare and "is not payable under the Centers for Medicare and Medicaid physician fee schedule," Joseph A. Hyder, MD, PhD, from the Department of Anesthesiology, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, and colleagues write in an article published online December 5 in the Annals of Surgery.

"These results suggest that patients informed of an overlapping procedure need not interpret this component of the consent process as a safety tradeoff for timely access to a needed procedure," the researchers write. "In our high-volume surgical practice, we conclude based on the presented evidence that salaried surgeons may continue to apply their surgical judgement when scheduling elective, overlapping procedures with the expectation of equivalent or superior outcomes for patients."

For the primary analysis, Dr Hyder and colleagues matched 10,614 overlapping surgeries to 16,111 nonoverlapping procedures from the University HealthSystem Consortium. All surgeries were elective inpatient procedures performed between January 2013 and September 2015.

Overall, inpatient mortality was higher for nonoverlapping procedures compared with overlapping procedures (adjusted odds ratio, 2.14; 95% confidence interval [CI], 1.23 - 3.73; P = .007), and length of stay did not differ significantly (+1% for nonoverlapping cases; 95% CI, −1% to +2%; P = .50).

In a confirmatory analysis, the researchers examined data from the American College of Surgeons–National Surgical Quality Improvement Program on elective surgical procedures from January 2011 to December 2014. Of those, they could match 93.7% (3712/3961) of overlapping procedures with 5637 nonoverlapping procedures.

The 30-day mortality (adjusted odds ratio, 0.69 nonoverlapping vs overlapping procedures; 95% CI, 0.13 - 3.57; P = .65), morbidity (adjusted odds ratio, 1.11 nonoverlapping vs overlapping procedures; 95% CI, 0.92 - 1.35; P = .27), and length of stay (4% less among nonoverlapping surgeries; 95% CI, −4% to −2%; P < .001) were statistically different but "not clinically different," the authors write.

"Our data shows that overlapping surgery as practiced here is safe," coauthor Robert Cima, MD, a colorectal surgeon and chair of surgical quality at Mayo Clinic's Rochester campus, said in a Mayo Clinic news release. "We think it provides value to our patients because it allows more patients timely access to surgery and care by expert teams."

"[Operating room (OR)] efficiency is not merely a matter of efficiency or financial gain, but also patient safety, as [overlapping surgery] tends to bring patients into the main flow of the OR when the main experienced teams/personnel are most available. Therefore, if done appropriately, it is good for the doctors, good for the hospital, and good for the patient," Paul Kurlansky, MD, assistant professor of surgery, Columbia University, New York City, told Medscape Medical News.

Not everyone agrees with the idea of having one physician conducting surgeries in two separate ORs. As previously reported by Medscape Medical News, an investigation by the Boston Globe in 2015 found that attending surgeons at Massachusetts General Hospital were double-booking procedures and sometimes leaving residents and fellows to perform the surgeries by themselves.

The revelation roiled medicine and led to changes in the American College of Surgeons guidelines as to when it is appropriate to use overlapping surgeries and what patients need to know for informed consent.

The US Senate Finance Committee has just released a report on overlapping and concurrent surgeries. The Boston Globe reports that the committee wants to explicitly ban the practice of concurrent surgeries.

But Dr Kurlansky emphasizes that there is a big difference between overlapping and concurrent surgery. With overlapping surgeries, "[s]urgeon[s] cannot be booked to perform critical parts of two operations at the same time," he said. "Realistic expectations in scheduling, flexibility for unforeseen and emergency situations, and availability of skilled surgical alternative for those unforeseen or emergency situations are critical. If such flexibility and/or back-up does not exist, then overlapping surgery should not be scheduled."

Craig Smith, MD, surgeon-in-chief, New York-Presbyterian Hospital/Columbia University Medical Center, New York City, told Medscape Medical News he has been performing overlapping surgery routinely for more than 30 years, and he believes his judgment should be trusted with regard to when and how to perform overlapping procedures.

"An important question not directly addressed is whether informed consent should be required for overlap. An unstated implication of the Mayo report is that overlap is simply another part of surgical routine that doesn't necessarily need to be spelled out in the consent form, a position that is supported indirectly by the absence of impact on mortality and morbidity," Dr Smith said. "Personally, I think consent is unnecessary, but has been driven into being by [the] hullaballoo surrounding the [Massachusetts General Hospital] case."

"[It is also important…for the patient to understand that he is being cared for by a surgical team under the direction of the primary surgeon with whom he is 'contracting' to perform the surgery," Dr Kurlansky told Medscape Medical News.

"There is frequently in medicine, and perhaps more so in surgery, a discrepancy between what seems to the public as intuitively obvious and what is actually clinically accurate. We have seen this recently with the demonstration that work hour restrictions for residents...may actually impair patient care [through increased hand-offs] and [less experiential training]," Dr Kurlansky explained. "It is therefore extremely important to permit the facts to enter the discussion. In this regard, the Mayo study is a major contribution toward an intelligent discussion of the topic."

"Separate analyses utilizing nationally organized and standardized administrative and clinical data registries found that the practice of overlapping surgery in our institution was associated with no greater risk of adverse patient outcomes, as measured by mortality and major morbidity," the researchers explain. "These findings are robust and consistent in approximately 50% of overlapping procedures with the greatest overlap. In addition, the patient-reported experience of surgical care did not differ between overlapping and non-overlapping procedures."

"There are cases for which overlap should not be planned, but should be allowed once it's clear that a very challenging case is doing well and winding down in routine closure maneuvers," Dr Smith said. "There are occasional nightmare cases that should occupy one's schedule for the day, because of difficulty, length, or both," he added.

"As regional and national policymakers work to improve surgical care, the focus should remain on understanding sources of surgical quality variation, whether and when a procedure is appropriate, what specific procedure is best, [and] which surgeon and facility are best prepared to perform a specific procedure and provide coordinated postoperative care," the researchers conclude.

The authors and commentators have disclosed no relevant financial relationships.

Ann Surg. Published Online December 5, 2016. Abstract

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