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Original Investigation
November 8, 2017

Association of Overlapping Surgery With Patient Outcomes in a Large Series of Neurosurgical Cases

Author Affiliations
  • 1Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
  • 2Carolina Neurosurgery and Spine Associates, Concord, North Carolina
  • 3Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
  • 4Emory University School of Medicine, Atlanta, Georgia
JAMA Surg. Published online November 8, 2017. doi:10.1001/jamasurg.2017.4502
Key Points

Question  Is overlapping surgery associated with increased morbidity and mortality and worsened outcome measures compared with nonoverlapping surgery?

Findings  In this retrospective cohort study that included 2275 neurosurgical cases, no difference between overlapping and nonoverlapping surgery was identified for mortality, morbidity, or worsened functional status at discharge and follow-up.

Meaning  These data suggest that overlapping surgery can be safely done without risking patient safety in a large series of mostly complex neurosurgical cases.


Importance  Overlapping surgery (OS) is common. However, there is a dearth of evidence to support or refute the safety of this practice.

Objective  To determine whether OS is associated with worsened morbidity and mortality in a large series of neurosurgical cases.

Design, Setting, and Participants  A retrospective cohort study was completed for patients who underwent neurosurgical procedures at Emory University Hospital, a large academic referral hospital, between January 1, 2014, and December 31, 2015. Patients were operated on for pathologies across the spectrum of neurosurgical disorders. Propensity score weighting and logistic regression models were executed to compare outcomes for patients who received nonoverlapping surgery and OS. Investigators were blinded to study cohorts during data collection and analysis.

Main Outcomes and Measures  The primary outcome measures were 90-day postoperative mortality, morbidity, and functional status.

Results  In this cohort of 2275 patients who underwent neurosurgery, 1259 (55.3%) were female, and the mean (SD) age was 52.1 (16.4) years. A total of 972 surgeries (42.7%) were nonoverlapping while 1303 (57.3%) were overlapping. The distribution of American Society of Anesthesiologists score was similar between nonoverlapping surgery and OS cohorts. Median surgical times were significantly longer for patients in the OS cohort vs the nonoverlapping surgery cohort (in-room time, 219 vs 188 minutes; skin-to-skin time, 141 vs 113 minutes; both P < .001). Overlapping surgery was more frequently elective (93% vs 87%; P < .001). Regression analysis failed to demonstrate an association between OS and complications, such as mortality, morbidity, or worsened functional status. Measures of baseline severity of illness, such as admission to the intensive care unit and increased length of stay, were associated with mortality (intensive care unit: odds ratio [OR], 25.5; 95% CI, 6.22-104.67; length of stay: OR, 1.03; 95% CI, 1.00-1.05), morbidity (intensive care unit: OR, 1.85; 95% CI, 1.43-2.40; length of stay: OR, 1.06; 95% CI, 1.04-1.08), and unfavorable functional status (length of stay: OR, 1.03; 95% CI, 1.02-1.05).

Conclusions and Relevance  These data suggest that OS can be safely performed if appropriate precautions and patient selection are followed. Data such as these will help determine health care policy to maximize patient safety.