Surgeon experience association with patient selection and outcomes after open abdominal aortic aneurysm repair

• Published in: Journal of vascular surgery 2020-10, Vol.72 (4), p.1325-1336.e2
• Main Authors: Arnaoutakis, Dean J., Scali, Salvatore T., Neal, Dan, Giles, Kristina A., Huber, Thomas S., Powell, Richard J., Goodney, Philip P., Suckow, Bjoern D., Kang, Jeanwan, Columbo, Jesse A., Stone, David H.
• Format: Article
• Language: English
• Subjects: Abdominal aortic aneurysm repair; Aged; Aged, 80 and over; Aorta, Abdominal - surgery; Aortic Aneurysm, Abdominal - diagnosis; Aortic Aneurysm, Abdominal - mortality; Aortic Aneurysm, Abdominal - surgery; Clinical Competence - statistics & numerical data; Clinical Decision-Making; Elective Surgical Procedures - adverse effects; Elective Surgical Procedures - instrumentation; Elective Surgical Procedures - methods; Elective Surgical Procedures - statistics & numerical data; Female; Hospital Mortality; Humans; Male; Middle Aged; Outcomes; Patient Selection; Postoperative Complications - epidemiology; Postoperative Complications - etiology; Retrospective Studies; Risk Factors; Severity of Illness Index; Surgeon experience; Surgeons; Vascular Surgical Procedures - adverse effects; Vascular Surgical Procedures - instrumentation; Vascular Surgical Procedures - methods; Vascular Surgical Procedures - statistics & numerical data; Volume
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2019.12.031

Growing calls for guidelines advocating minimum annual case volumes for surgeon credentialing remain controversial. Although most attention to date has focused on the impact of obligatory case volume, less attention has been devoted to the more complex association between surgeon years of independent practice experience and procedure outcomes after open abdominal aortic aneurysm repair (OAR). Therefore, the purpose of this study was to explore the association of surgeon experience with case selection and real-world outcomes after OAR. All Society for Vascular Surgery-Vascular Quality Initiative infrarenal and juxtarenal OARs (n = 11,900; 71% elective; 29% nonelective) from 2003 to 2019 were examined. Surgeon experience was defined by years in practice after training completion. Experience level at time of repair was categorized (≤5 years, n = 1048; 6-10 years, n = 1309; 11-15 years, n = 1244; and ≥16 years, n = 4772) and intergroup univariate comparisons were made. Logistic regression identified independent predictors of complications, 30-day death, and 1-year mortality. Models were constructed with or without surgeon experience strata to determine association with outcomes. Increasing surgeon experience was associated with performing greater proportions of elective procedures, whereas less experienced surgeons had disproportionate exposure to nonelective operations (elective, 73% ≥16 years vs 62% ≤5 years [P < .0001]; nonelective, ≤5 years, 38% vs 27%, ≥16-years [P < .0001]). Among surgeons who perform five or fewer cases per year, the risk of any aggregate major complication after elective OAR decreased significantly as experience increased (P = .0004), although no differences were detected in nonelective cases or among higher volume surgeons. Similarly, the risk of in-hospital death decreased with increasing experience (P = .004), but only among low-volume surgeons performing elective procedures. Comorbidities were similar across all experience strata for both elective and nonelective presentations; however, more experienced surgeons operated on higher proportions of nonelective patients with coronary disease (P = .04). Early career surgeons more frequently operated on patients with American Society of Anesthesiologists IV designation, larger abdominal aortic aneurysm diameters and used suprarenal/celiac cross-clamps more frequently than later career surgeons. The 1-year survival after elective and nonelective OAR was not impacted by surgeon experience