Impact of a more restrictive overlapping surgery policy: an analysis of pre- and postimplementation complication rates, resident involvement, and surgical wait times at a high-volume neurosurgical department

Abstract

OBJECTIVE Recently, overlapping surgery has been a source of controversy both in the popular press and within the academic medical community. There have been no studies examining the possible effects of more stringent overlapping surgery restrictions. At the authors' institution, a new policy was implemented that restricts attending surgeons from starting a second case until all critical portions of the first case that could require the attending surgeon's involvement are completed. The authors examined the impact of this policy on complication rates, neurosurgical resident education, and wait times for neurosurgical procedures. METHODS The authors performed a retrospective chart review of nonemergency neurosurgical procedures performed over two periods-from June 1, 2014, to October 31, 2014 (pre-policy change) and from June 1, 2016, to October 31, 2016 (post-policy change)-by any of 4 senior neurosurgeons at a single institution who were authorized to schedule overlapping cases. Information on preoperative evaluation, patient demographics, premorbid conditions, surgical variables, and postoperative course were collected and analyzed. RESULTS Six hundred fifty-three patients met inclusion criteria for complications analysis. Of these, 378 (57.9%) underwent surgery before the policy change. On multivariable regression analysis, neither overlapping surgery (odds ratio [OR] 1.072, 95% confidence interval [CI] 0.710-1.620) nor the overlapping surgery policy change (OR 1.057, 95% CI 0.700-1.596) was associated with overall complication rates. Similarly, neither overlapping surgery (OR 1.472, 95% CI 0.883-2.454) nor the overlapping surgery policy change (OR 1.251, 95% CI 0.748-2.091) was associated with numbers of serious complications. After the policy change, the percentage of procedures in which the senior assistant was a postresidency fellow increased significantly, from 11.9% to 34.2% (p< 0.001). In a multiple linear regression analysis of surgery wait times, patients undergoing surgery after the policy change had significantly longer delays from the decision to operate until the actual neurosurgical procedure (p < 0.001). CONCLUSIONS At the authors' institution, further restriction of overlapping surgery was not associated with a reduction in overall or serious complications. Resident involvement in neurosurgical procedures decreased significantly after the policy change, and this study suggests that wait times for neurosurgical procedures also significantly lengthened.

Analysis of an overlapping surgery policy change on costs in a high-volume neurosurgical department

“…The more restrictive policy did appear effective in limiting overlapping surgery, as the rate of overlapping cases declined from 46% prechange to 26.9% postchange. 9 Our study has several limitations. As with any retrospective study, ours is vulnerable to confounding.…”

“…8 Case mix prior to the policy change and after the policy change was not significantly different in our cohort, as previously reported. 9 The total number of cases performed before the policy change (378) was more than that performed after the change (275), and thus the sum total of direct hospital costs after the policy change was only 73.4% of costs before the policy change. The more restrictive policy did appear effective in limiting overlapping surgery, as the rate of overlapping cases declined from 46% prechange to 26.9% postchange.…”

“…The data collection methods for this study were previously published. 9 The pre-policy change period extended from June 1, 2014, to October 31, 2014, and the post-policy change period lasted from June 1, 2016, to October 31, 2016. The full pre-and postchange policies can be found in our prior publication, 9 but the most substantive modifications were 1) a new rule mandating that an overlapping case could not be initiated until after the completion of all critical portions of the first case, and 2) another rule dictating that the attending physician could not return to the first case after beginning a second (barring unforeseen circumstances).…”

“…9 The pre-policy change period extended from June 1, 2014, to October 31, 2014, and the post-policy change period lasted from June 1, 2016, to October 31, 2016. The full pre-and postchange policies can be found in our prior publication, 9 but the most substantive modifications were 1) a new rule mandating that an overlapping case could not be initiated until after the completion of all critical portions of the first case, and 2) another rule dictating that the attending physician could not return to the first case after beginning a second (barring unforeseen circumstances). We dichotomized all neurosurgical cases involving patients 10 years and older that were performed by any of 4 neurosurgeons at our institution who were authorized to run overlapping surgery during both timeframes into overlapping and nonoverlapping for both periods.…”

Editorial. Neurosurgery program building at its best: Dr. Charles Wilson (1929–2018)

“…On 2 or 3 days each week, Dr. Wilson would perform up to 8 major cases each day, by virtue of his operating in 3 different rooms each day. Overlapping or simultaneous surgery has become an important topic in the recent neurosurgical literature, 2,3,8 but it is probably fair to say that Dr. Wilson was one of the earliest proponents and masters of this approach to neurosurgical cases.…”