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Original Investigation
February 26, 2019

Association of Overlapping Surgery With Perioperative Outcomes

Author Affiliations
  • 1Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
  • 2Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
  • 3Stanford Law School, Stanford, California
  • 4Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor
  • 5Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 6Department of Otolaryngology, Stanford University School of Medicine, Stanford, California
  • 7Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 8Department of Medicine, Massachusetts General Hospital, Boston
  • 9National Bureau of Economic Research, Cambridge, Massachusetts
JAMA. 2019;321(8):762-772. doi:10.1001/jama.2019.0711
Key Points

Question  Is overlapping surgery, in which a primary surgeon is involved in more than 1 case simultaneously, associated with worse perioperative outcomes compared with nonoverlapping surgery?

Findings  In this retrospective cohort study of 66 430 adults undergoing common operations, overlapping surgery was not significantly associated with differences in in-hospital mortality (adjusted rate, 1.9% vs 1.6%) or postoperative complications (adjusted rate, 12.8% vs 11.8%) but was significantly associated with increased surgery length (adjusted length, 204 vs 173 minutes).

Meaning  Overlapping surgery was not significantly associated with differences in in-hospital mortality or postoperative complication rates but was significantly associated with increased surgery length. Further research is needed to understand the association of overlapping surgery with these outcomes among specific patient subgroups.

Abstract

Importance  Overlapping surgery, in which more than 1 procedure performed by the same primary surgeon is scheduled so the start time of one procedure overlaps with the end time of another, is of concern because of potential adverse outcomes.

Objective  To determine the association between overlapping surgery and mortality, complications, and length of surgery.

Design, Setting, and Participants  Retrospective cohort study of 66 430 operations in patients aged 18 to 90 years undergoing total knee or hip arthroplasty; spine surgery; coronary artery bypass graft (CABG) surgery; and craniotomy at 8 centers between January 1, 2010, and May 31, 2018. Patients were followed up until discharge.

Exposures  Overlapping surgery (≥2 operations performed by the same surgeon in which ≥1 hour of 1 case, or the entire case for those <1 hour, occurs when another procedure is being performed).

Main Outcomes and Measures  Primary outcomes were in-hospital mortality or complications (major: thromboembolic event, pneumonia, sepsis, stroke, or myocardial infarction; minor: urinary tract or surgical site infection) and surgery duration.

Results  The final sample consisted of 66 430 operations (mean patient age, 59 [SD, 15] years; 31 915 women [48%]), of which 8224 (12%) were overlapping. After adjusting for confounders, overlapping surgery was not associated with a significant difference in in-hospital mortality (1.9% overlapping vs 1.6% nonoverlapping; difference, 0.3% [95% CI, −0.2% to 0.7%]; P = .21) or risk of complications (12.8% overlapping vs 11.8% nonoverlapping; difference, 0.9% [95% CI, −0.1% to 1.9%]; P = .08). Overlapping surgery was associated with increased surgery length (204 vs 173 minutes; difference, 30 minutes [95% CI, 24 to 37 minutes]; P < .001). Overlapping surgery was significantly associated with increased mortality and increased complications among patients having a high preoperative predicted risk for mortality and complications, compared with low-risk patients (mortality: 5.8% vs 4.7%; difference, 1.2% [95% CI, 0.1% to 2.2%]; P = .03; complications: 29.2% vs 27.0%; difference, 2.3% [95% CI, 0.3% to 4.3%]; P = .03).

Conclusions and Relevance  Among adults undergoing common operations, overlapping surgery was not significantly associated with differences in in-hospital mortality or postoperative complication rates but was significantly associated with increased surgery length. Further research is needed to understand the association of overlapping surgery with these outcomes among specific patient subgroups.

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