Person:

Duclos, Antoine

Background: Efforts to provide a valid picture of surgeons’ individual performance evolution should frame their outcomes in relation to what is expected depending on their experience. We derived the learning curve of young thyroidectomy surgeons as a baseline to enable the accurate assessment of their individual outcomes and avoid erroneous conclusions that may derive from more traditional approaches. Methods: Operative time and postoperative recurrent laryngeal nerve palsy of 2006 patients who underwent a thyroidectomy performed by 19 young surgeons in five academic hospitals were monitored from April 2008 to December 2009. The database was randomly divided into training and testing datasets. The training data served to determine the expected performance curve of surgeons during their career and factors influencing outcome variation using generalized estimating equations (GEEs). To simulate prospective monitoring of individual surgeon outcomes, the testing data were plotted on funnel plots and cumulative sum charts (CUSUM). Performance charting methods were utilized to present outcomes adjusted both for patient case-mix and surgeon experience. Results: Generation of performance curves demonstrated a gradual reduction in operative time from 139 (95% CI, 137 to 141) to 75 (71 to 80) minutes, and from 15.7% (15.1% to 16.3%) to 3.3% (3.0% to 3.6%) regarding the nerve palsy rate. Charts interpretation revealed that a very young surgeon had better outcomes than expected, whereas a more experienced surgeon appeared to be a poor performer given the number of years that he had already spent in practice. Conclusions: Not considering the initial learning curve of surgeons exposes them to biased measurement and to misinterpretation in assessing their individual performance for thyroidectomy. The performance chart represents a valuable tool to monitor the outcome of surgeons with the expectation to provide safe and efficient care to patients.

Objective: To determine the association between surgeons’ experience and postoperative complications in thyroid surgery. Design: Prospective cross sectional multicentre study. Setting: High volume referral centres in five academic hospitals in France. Participants: All patients who underwent a thyroidectomy undertaken by every surgeon in these hospitals from 1 April 2008 to 31 December 2009. Main outcome measures: Presence of two permanent major complications (recurrent laryngeal nerve palsy or hypoparathyroidism), six months after thyroid surgery. We used mixed effects logistic regression to determine the association between length of experience and postoperative complications. Results: 28 surgeons completed 3574 thyroid procedures during a one year period. Overall rates of recurrent laryngeal nerve palsy and hypoparathyroidism were 2.08% (95% confidence interval 1.53% to 2.67%) and 2.69% (2.10% to 3.31%), respectively. In a multivariate analysis, 20 years or more of practice was associated with increased probability of both recurrent laryngeal nerve palsy (odds ratio 3.06 (1.07 to 8.80), P=0.04) and hypoparathyroidism (7.56 (1.79 to 31.99), P=0.01). Surgeons’ performance had a concave association with their length of experience (P=0.036) and age (P=0.035); surgeons aged 35 to 50 years had better outcomes than their younger and older colleagues. Conclusions: Optimum individual performance in thyroid surgery cannot be passively achieved or maintained by accumulating experience. Factors contributing to poor performance in very experienced surgeons should be explored further.

Background: While it is known that increasing surgeon experience is correlated with improved efficiency and safety in the reduction mammaplasty procedure, it is unclear whether these improvements lead to an erosion in patient satisfaction. Methods: The authors distributed the Breast-Q questionnaire to all patients who underwent bilateral reduction mammaplasty at their institution between 1995 and 2007. Univariate and multivariate analyses were performed to assess the relationship between postoperative patient satisfaction scores and surgeon experience, as well as to characterize those patients with particularly high or low satisfaction scores, in general. Results: A total of 279 (26.1%) completed surveys were analyzed. No statistically significant erosion in either Satisfaction with Breasts (SWB) or Satisfaction with Outcomes (SWO) scores were witnessed with increasing surgeon experience or efficiency. Patients older than 40 years demonstrated significantly higher SWB scores than younger patients (P = .004), while patients who suffered postoperative soft tissue necrosis demonstrated significantly lower SWB (P = .003) and SWO (P = .010) scores. Conclusions: Gains in operative efficiency with increasing surgeon experience do not appear to come at the expense of patient satisfaction in the reduction mammaplasty procedure. Younger patients and those who experience postoperative soft tissue necrosis appear to be at higher risk for reporting lower postoperative patient satisfaction scores.

Background: Mass tourism during winter in mountain areas may cause significant clustering of body injuries leading to increasing emergency admissions at hospital. We aimed at assessing if surgical safety and efficiency was maintained in this particular context. Methods: We selected all emergency admissions of open surgery performed in French hospitals between 2010 and 2012. After identifying mountain areas with increasing volume of surgical stays during winter, we considered seasonal variations in surgical outcomes using a difference-in-differences study design. We computed multilevel regressions to evaluate whether significant increase in emergency cases had an effect on surgical mortality, complications and length of stay. Clustering effect of patients within hospitals was integrated in analysis and surgical outcomes were adjusted for both patient and hospital characteristics. Results: A total of 381 hospitals had 559,052 inpatient stays related to emergency open surgery over 3 years. Compared to other geographical areas, a significant peak of activity was noted during winter in mountainous hospitals (Alps, Pyrenees, Vosges), ranging 6-77% volume increase. Peak was mainly explained by tourists’ influx (+124.5%, 4,351/3,496) and increased need for orthopaedic procedures (+36.8%, 4,731/12,873). After controlling for potential confounders, patients did not experience increased risk for postoperative death (ratio of OR 1.01, 95%CI 0.89-1.14, p = 0.891), thromboembolism (0.95, 0.77-1.17, p = 0.621) or sepsis (0.98, 0.85-1.12, p = 0.748). Length of stay was unaltered (1.00, 0.99-1.02, p = 0.716). Conclusion: Surgical outcomes are not compromised during winter in French mountain areas despite a substantial influx of major emergencies.