Specialization Linked to Surgical Survival

Surgeon specialization in a given cardiovascular or cancer procedure may be important for patient survival, independent of case volume, a study suggested.

All four cardiovascular procedures and two of four cancer resections examined in Medicare data showed a significant link between 1-year mortality and specialization, Nikhil R. Sahni, MBA, of Harvard University and McKinsey & Co. in Boston, and colleagues reported online in The BMJ.

The relative risk reduction in 1-year mortality for the top versus bottom quarters of surgeons as measured by ratio of number of times doing a specific procedure to total operative volume was:

• For carotid endarterectomy, 28% (95% CI 0%-48%)
• For coronary artery bypass grafting, 15% (95% CI 4%-25%)
• For coronary valve replacement, 46% (95% CI 37%-53%)
• For abdominal aortic aneurysm repair, 42% (95% CI 29%-53%)
• For lung resection, 28% (95% CI 5%-46%)
• For cystectomy, 41% (95% CI 8%-63%)

The risk reduction attributed to surgeon specialization was greater than the benefit of procedural volume alone for five procedures: carotid endarterectomy, valve replacement, lung resection, cystectomy, and esophagectomy.

"The specialization-outcomes relation accounted for some portion, if not all, of the volume-outcomes relation," Sahni's group wrote.

"The degree to which a surgeon specializes in a specific procedure may be as important as the number of times that he or she performs it. A surgeon who specializes in one operation may have better outcomes owing to muscle memory built from repetition, higher attention and faster recall as a result of less switching between different procedures, and knowledge transfer of outcomes for the same procedure performed in different patients."

Sahni and colleagues suggested that "when selecting a surgeon, patients, referring physicians, and administrators assigning operative workload may want to consider a surgeon's procedure-specific volume as well as the degree to which a surgeon specializes in that procedure."

The retrospective study took Medicare data from 695,987 patients who went under the knife of 25,152 U.S. surgeons.

There was no observed benefit to specialization in pancreatic resection or esophagectomy, though the authors suggested that their sample size was too small for both procedures.

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