Association Between Surgeon Technical Skills and Patient Outcomes
Association Between Surgeon Technical Skills and Patient Outcomes
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DOI：
10.1001/jamasurg.2020.3007
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发表时间：
2021-02-10
期刊：
影响因子：
16.9
通讯作者：
Bilimoria, Karl Y.
中科院分区：
文献类型：
--
作者：
Stulberg, Jonah J.;Huang, Reiping;Bilimoria, Karl Y.
手术后并发症仍然很常见，但对手术技术差异的程度以及差异是否与患者预后相关知之甚少。目的探讨(1)执业外科医生技术技能得分的变化，(2)技术技能与患者预后的关系，以及(3)外科医生技术技能对患者预后的影响程度。设计、设置和参与者在这项质量改进研究中，17名执业外科医生提交了腹腔镜右半结肠切除术的视频，然后由至少10名盲法同行外科医生和2名专家评分。使用美国外科医师学会国家外科质量改进计划的数据，对外科医生技术技能评分与风险调整结果之间的关系进行了检查。对结直肠手术和非结直肠手术的技术技能评分与结果之间的关系进行了检查（即，评估结肠切除术期间展示的技术技能是否与其他病例的患者结果相关）。此外，使用稳健回归技术检查了由技术技能分数解释的患者结果的比例。该研究于2016年9月23日至2018年2月10日进行；数据分析时间为2018年11月至2019年1月。结直肠和非结直肠手术。任何并发症、死亡率、非计划住院再入院、与主要手术相关的非计划再手术、手术部位感染、死亡或严重发病率。结果纳入研究的17名外科医生中，男性13名（76%）。参与者的手术经验从1年到28年不等（中位数为11年）。每个视频有10个或更多的评论者，最高质量得分为5分，总体技术技能得分在2.8到4.6之间。从2014年到2016年，研究参与者共进行了3063例手术（1120例结肠切除术）。较高的技术技能得分与结肠切除术后较低的并发症发生率（15.5% vs 20.6%, P = 0.03； Spearman秩序相关系数r = -0.54, P = 0.03）、计划外再手术（4.7% vs 7.2%, P = 0.02; r = -0.60, P = 0.01）和死亡或严重发病率（15.9% vs 21.4%, P = 0.02; r = -0.60, P = 0.01）显著相关。结肠切除术技术技能评分与外科医生所做的所有手术的患者预后之间也发现了类似的关联。总体而言，技术技能得分似乎占结肠切除术后并发症发生率变化的25.8%，当包括非结肠切除术并发症发生率变化时，占27.5%。结论和相关性本研究的结果表明，执业外科医生的技术水平存在很大差异，占患者预后差异的25%以上。结肠切除术技术技能得分越高，结肠切除术和外科医生进行的所有其他手术的并发症发生率越低。努力提高外科医生的技术技能可能会带来更好的患者预后。外科医生的技术水平是否与病人的治疗结果有关？在这项质量改进研究中，包括17名执业外科医生和来自美国外科医师学会国家外科质量改进计划的结果数据作为参照组，通过术中视频评估的更好的技术技能评分与较低的并发症、计划外再手术、死亡或严重发病率有统计学意义上的显著相关。总体而言，技术技能得分与风险调整并发症发生率的变化有关，约占26%。意味着旨在改善患者预后的质量改进工作应包括重点提高外科医生水平的技术技能。这项质量改进研究考察了外科医生进行结肠切除术的技术技能。
Importance Postoperative complications remain common after surgery, but little is known about the extent of variation in operative technical skill and whether variation is associated with patient outcomes. Objectives To examine the (1) variation in technical skill scores of practicing surgeons, (2) association between technical skills and patient outcomes, and (3) amount of variation in patient outcomes explained by a surgeon's technical skill. Design, Setting, and Participants In this quality improvement study, 17 practicing surgeons submitted a video of a laparoscopic right hemicolectomy that was then rated by at least 10 blinded peer surgeons and 2 expert raters. The association between surgeon technical skill scores and risk-adjusted outcomes was examined using data from the American College of Surgeons National Surgical Quality Improvement Program. The association between technical skill scores and outcomes was examined for colorectal procedures and noncolorectal procedures (ie, assessed on whether technical skills demonstrated during colectomy were associated with patient outcomes across other cases). In addition, the proportion of patient outcomes explained by technical skill scores was examined using robust regression techniques. The study was conducted from September 23, 2016, to February 10, 2018; data analysis was performed from November 2018 to January 2019. Exposures Colorectal and noncolorectal procedures. Main Outcomes and Measures Any complication, mortality, unplanned hospital readmission, unplanned reoperation related to principal procedure, surgical site infection, and death or serious morbidity. Results Of the 17 surgeons included in the study, 13 were men (76%). The participants had a range from 1 to 28 years in surgical practice (median, 11 years). Based on 10 or more reviewers per video and with a maximum quality score of 5, overall technical skill scores ranged from 2.8 to 4.6. From 2014 to 2016, study participants performed a total of 3063 procedures (1120 colectomies). Higher technical skill scores were significantly associated with lower rates of any complication (15.5% vs 20.6%, P = .03; Spearman rank-order correlation coefficient r = -0.54, P = .03), unplanned reoperation (4.7% vs 7.2%, P = .02; r = -0.60, P = .01), and a composite measure of death or serious morbidity (15.9% vs 21.4%, P = .02; r = -0.60, P = .01) following colectomy. Similar associations were found between colectomy technical skill scores and patient outcomes for all types of procedures performed by a surgeon. Overall, technical skill scores appeared to account for 25.8% of the variation in postcolectomy complication rates and 27.5% of the variation when including noncolectomy complication rates. Conclusions and Relevance The findings of this study suggest that there is wide variation in technical skill among practicing surgeons, accounting for more than 25% of the variation in patient outcomes. Higher colectomy technical skill scores appear to be associated with lower complication rates for colectomy and for all other procedures performed by a surgeon. Efforts to improve surgeon technical skills may result in better patient outcomes.Question Is the technical skill of a surgeon associated with patient outcomes? Findings In this quality improvement study including 17 practicing surgeons and outcome data from the American College of Surgeons National Surgical Quality Improvement Program as a reference group, better technical skill scores, assessed via intraoperative video, were statistically significantly associated with lower rates of any complication, unplanned reoperation, and death or serious morbidity. Overall, technical skill scores were associated with approximately 26% of the variation in risk-adjusted complication rates. Meaning Quality improvement efforts aimed at improving patient outcomes should include a focus on improving surgeon-level technical skill.This quality improvement study examines the technical skills of surgeons performing colectomies.