Should Open Aortic Surgery Happen Without Trainee Involvement?
Thomas FX O'Donnell, MD, Kirsten D. Dansey, MD, MPH, Melinda S. Schaller, MD, Patric Liang, MD, Mark C. Wyers, MD, Marc L. Schermerhorn, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
OBJECTIVES: Recent studies have highlighted a crucial deficiency in vascular surgery training, as only about 50% of trainees graduate with more than 5 open abdominal aortic aneurysm (oAAA) repairs. New strategies are consequently needed to increase vascular trainee exposure to open aortic surgery. We therefore studied the distribution of open aortic repairs in the United States by hospital teaching status to identify how many oAAA repairs occur without the involvement of vascular trainees.
METHODS: We studied all elective oAAA repairs in the National Inpatient Sample from 2004-2015, which categorizes hospitals as rural, urban nonteaching, and urban teaching. We considered hospitals dedicated as urban nonteaching as those without trainee involvement. In-hospital outcomes were compared using multivariable logistic regression.
RESULTS: We identified 140,933 oAAA repairs during the study period; 4.4% occurred at rural hospitals, 38% at urban non-teaching hospitals, and 58% at urban teaching hospitals. Over time, oAAA repairs fell significantly in all three hospital types. Over time, oAAA volume in rural hospitals fell 89%, urban nonteaching volume dropped 87%, and urban teaching hospitals fell 58%% (P<.01). At the end of the study period, rural hospitals accounted for 2.9% of oAAA volume, urban teaching centers 78%, and urban non-teaching hospitals 19%. Overall mortality was 5%, with no difference between teaching status in crude (rural 5%, urban teaching 5%, urban nonteaching 5%, P=.8), or adjusted analyses (with rural as referent: urban teaching aOR 0.99 [0.8-1.3], P=.9; urban nonteaching aOR 0.9 [0.7-1.2], P=.4).
CONCLUSIONS: Despite concerning decreases in vascular trainee experience with oAAA repair in recent years, a significant proportion of the oAAA repairs in the United States occur without any trainee participation. These data suggest that partnerships between vascular training programs and unaffiliated hospitals offer one potential solution to current deficiencies in open aortic training.
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