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Original Investigation |

Using Patient Outcomes to Evaluate General Surgery Residency Program Performance

Neha Bansal, MD1,2; Kristina D. Simmons, PhD2; Andrew J. Epstein, PhD, MPP1,3,4; Jon B. Morris, MD1,2; Rachel R. Kelz, MD, MSCE1,2,3
[+] Author Affiliations
1Perelman School of Medicine at the University of Pennsylvania, Philadelphia
2Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania Health System, Philadelphia
3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
4Department of Veterans Affairs’ Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
JAMA Surg. 2016;151(2):111-119. doi:10.1001/jamasurg.2015.3637.
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Importance  To evaluate and financially reward general surgery residency programs based on performance, performance must first be defined and measureable.

Objective  To assess general surgery residency program performance using the objective clinical outcomes of patients operated on by program graduates.

Design, Setting, and Participants  A retrospective cohort study was conducted of discharge records from 349 New York and Florida hospitals between January 1, 2008, and December 31, 2011. The records comprised 230 769 patients undergoing 1 of 24 general surgical procedures performed by 454 surgeons from 73 general surgery residency programs. Analysis was conducted from June 4, 2014, to June 16, 2015.

Main Outcomes and Measures  In-hospital death; development of 1 or more postoperative complications before discharge; prolonged length of stay, defined as length of stay greater than the 75th percentile when compared with patients undergoing the same procedure type at the same hospital; and failure to rescue, defined as in-hospital death after the development of 1 or more postoperative complications.

Results  Patients operated on by surgeons trained in residency programs that were ranked in the top tertile were significantly less likely to experience an adverse event than were patients operated on by surgeons trained in residency programs that were ranked in the bottom tertile. Adjusted adverse event rates for patients operated on by surgeons trained in programs that were ranked in the top tertile and those who were operated on by surgeons trained in programs that were ranked in the bottom tertile were, respectively, 0.483% vs 0.476% for death, 9.68% vs 10.79% for complications, 16.76% vs 17.60% for prolonged length of stay, and 2.68% vs 2.98% for failure to rescue (all P < .001). The differences remained significant in procedure-specific subset analyses. The rankings were significantly correlated among some but not all outcome measures. The magnitude of the effect of the residency program on the outcomes achieved by the graduates decreased with increasing years of practice. Within the analyses of surgeons within 20, 10, and 5 years of practice, the relative difference in adjusted adverse event rates across the individual models between the top and bottom tertiles ranged from 1.5% to 12.3% (20 years), 9.1% to 33.8% (10 years), and 8.0% to 44.4% (5 years).

Conclusions and Relevance  Objective data were successfully used to rank the clinical outcomes achieved by graduates of general surgery residency programs. Program rankings differed by the outcome measured. The magnitude of differences across programs was small. Careful consideration must be used when identifying potential targets for payment-for-performance initiatives in graduate medical education.

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