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Evaluating Postoperative Outcomes with
Resident Involvement in Thyroid and
Parathyroid Surgery:
Analysis of National Surgical Quality
Improvement Program
Amy E. Murphy DO, Ashley M. Tameron MD, Lala R. Hussain MSc, Kevin J. Grannan MD
Introduction
• Surgical residency incorporates complex head and neck cases
• Residents as part of the surgical team raise patient’s concerns in
regard to adverse outcomes
• Overall, data has shown residents are viewed by the patient
population as assets however on specific injury about resident
performance, confidence faltered
• Limited outcome data of thyroid and parathyroid surgery
related to resident participation makes relieving concerns
difficult
Introduction
• The impact of resident involvement on postoperative outcomes
in thyroid and parathyroid surgery has not been evaluated on a
national scale with current data
• We hypothesize that resident participation in neck endocrine
surgery does not adversely impact outcomes
Objective
• To test our hypothesis, we utilized data from the
ACS NSQIP and evaluated the influence of
resident participation on postoperative outcomes
following thyroid and parathyroid surgery
Methods
• Retrospective cohort analysis of NSQIP database
• 2007 - 2010
• Identified cases with thyroid and parathyroid surgery
• Primary Current Procedural Terminology (CPT) codes:
• 60200, 60201, 60212, 60220, 60225, 60240, 60252,
60254, 60260, 60270, 60271, 60280, 60281, 60500,
60502 and 60505
• Cases were excluded if information regarding resident
involvement was unknown or missing
Methods
• The outcomes measured included
•
Total operation time in minutes
•
Length of total hospital stay in days
•
Occurrences of unplanned intubation
•
Occurrences on a ventilator greater than 48 hours
•
Return to the operating room within 30 days of
surgery
Methods
• Statistical Analysis
• All variables were analyzed using descriptive statistics
including mean, standard deviation (SD), and frequency
distributions
• The comparison of outcomes, with and without resident
involvement, was performed using t-test for continuous
variables and chi-squared test for categorical variables
• All statistical analysis was performed using SPSS
(version 22.0) with the significance level set at P < 0.05
Results
Cases queried from American College of Surgeons NSQIP database.
Resident Involvement
CPT
60200
60210
60212
60220
60225
60240
60252
60254
60260
60270
60271
60280
60281
60500
60502
60505
All
Yes
144
1082
163
6089
649
9921
2154
323
898
104
729
114
8
10191
542
56
33167
No
123
855
145
3420
321
4844
659
103
274
44
202
108
9
3560
87
28
14782
Total
267
1937
308
9509
970
14765
2813
426
1172
148
931
222
17
13751
629
84
47949
Results
Demographic
Age (yr)
(mean ± SD)
N (%)
47,949
53 ±14.85
Resident
Present
33,167
Resident Not
Present
P value
14,782
53.52 ±14.81 54.35 ±14.93
<0.001
Male
10117 (21.2%)
7085
3032
Female
37696 (78.8%)
25990
11706
Diabetes
5681 (11.8%)
3807 (11.5%)
1874 (12.7%)
<0.001
Smoker
7145 (14.9%)
4925 (14.8%)
2220 (15%)
0.631
Dyspnea
4212 (8.8%)
2918 (8.8%)
1294 (8.8%)
0.875
Ventilator dependent
35 (0.1%)
24 (0.1%)
11 (0.1%)
0.939
History of severe COPD
988 (2.1%)
653 (2%)
335 (2%)
0.034
Current PNA
27 (0.1%)
17 (0.1%)
10 (0.1%)
0.485
History of CHF
96 (0.2%)
69 (0.2%)
27 (0.2%)
0.566
MI (6mo prior to surgery)
96 (0.2%)
51 (0.2%)
13 (0.2%)
0.068
HTN requiring medications
20984 (43.8%)
14394 (43.4%)
6590 (44.6%)
0.016
Acute renal failure
93 (0.2%)
62 (0.2%)
31 (0.2%)
0.601
CVA/stroke
501 (1%)
353 (1.0%)
148 (1.0%)
0.530
Prior operation within 30 days
339 (0.7%)
243 (0.7%)
96 (0.6%)
0.315
Emergency case
146 (0.3%)
96 (0.3%)
50 (0.3%)
0.37
22202 (46.7%)
15178 (46.2%)
7024 (47.9%)
0.001
Obesity (BMI>30)
Results
Outcome
Total operation
time in minutes
(mean ± SD)
Length of
hospital stay
(mean ± SD)
Occurrences of
unplanned
intubation
Occurrences of
ventilator >48
hours
Return to OR
within 30 days
CI: 95% confidence interval
OR: operating room
Resident
Not
P value
Present
Odds
Ratio
95% CI
109.15
114.06 98.24 ±
< 0.001
54.43
± 60.19 ± 61.89
0.13
[14.67-16.98]
N (%)
Resident
Present
1.24 ±
3.55
1.25 ±
2.62
1.27 ±
2.62
0.66
-0.004
[-0.08-0.05]
165
(0.3%)
105
(0.3%)
60
(0.4%)
0.123
0.78
[0.57-1.07]
111
(0.2%)
83 (0.3%)
28
(0.2%)
0.201
1.32
[0.86-2.03]
1015
(2.1%)
657
(1.98%)
358
(2.4%)
0.002
0.81
[0.72-0.93]
Discussion
• Patients do not always anticipate resident’s involvement in their
surgery which may lead to patient dissatisfaction, frustration
and even refusal to allow resident participation
• Our analysis focused on thyroid and parathyroid surgery
• Overall, as similar to previous NSQIP based research regarding
resident involvement, the outcomes were not worsened with
resident involvement
• Although the operative time was significantly increased with
resident present, it did not lead to an increase in return to the
operating room
Discussion
• Strength of this study is the volume of patients included over a
large number of hospitals and over a span of four years
• Limitations of this study include
• Lack of ability to track recurrent laryngeal nerve injury and
or hypoparathyroidism
• Inability to view reasons why OR time was lengthened or
return to OR was needed
• Although the NSQIP database records indicated whether
residents were involved, it does not allow us to quantify the
degree of involvement of that particular resident
Conclusion
• Review of the NSQIP database demonstrates resident
involvement in thyroid and parathyroid operations does not lead
to increased adverse events, but does increase operative time
• Resident participation may in fact lead to reduction of specific
events including return to the operating room
• This information can be conveyed to patients to help them feel
more comfortable participating in the surgical education process
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