Surgeries take 22 per cent longer in teaching hospitals: Ontario study

Patients undergoing common surgeries in teaching hospitals experience significantly longer surgical times, with durations that are 22 per cent longer on average in these academic centres. This is among the findings of a new study from the Institute for Clinical Evaluative Sciences (ICES) and the Lawson Health Research Institute that was published today in theCanadian Journal of Surgery.

“The ability to train new surgeons is undeniably an essential part of a sustainable healthcare system,” says Christopher Vinden, the study’s lead author who is an adjunct scientist at ICES and a surgeon at the London Health Sciences Centre. “However, we see that surgical instruction significantly lengthens the duration of a range of common procedures, raising important questions such as how to minimize patient risk during teaching procedures, and how to address Ontario funding models that currently don’t adjust for academic versus non-academic centres.”

The researchers examined anonymized records for all adult residents of Ontario who underwent any of 14 common surgical procedures from 2002 to 2012. Of the more than 700,000 surgeries looked at, 21 per cent were performed in a teaching hospital. Previous research has shown that teaching can be associated with longer surgeries, but the authors say this is the first study to examine the magnitude of this increase at a population level, and the first to adjust for patient, procedure and surgeon-related factors such as the experience of the attending surgeon.

They found that of the 14 procedures, hip and knee replacements were least impacted by teaching status, respectively taking 8 and 9 per cent longer (less than 10 minutes longer) in academic centres. However, for the more complex laparoscopic right hemicolectomy (removing the right side of the bowel, usually due to colon cancer) the procedure took 33 per cent longer (62 minutes longer) in teaching hospitals.

Overall, every procedure took longer in teaching hospitals, at a mean of 22 per cent longer duration.

To choose which procedures to investigate, the authors consulted a panel of experts who selected representative procedures that are common in both teaching and community settings. Procedures included laparoscopic cholecystectomy, right hemicolectomy, appendectomy, unilateral inguinal hernia repair, hysterectomy, hip hemiarthroplasty, open reduction and internal fixation for hip fracture, hip and knee arthroplasty, and tonsillectomy. Where applicable, they considered open and laparoscopic procedures separately.

The study authors note that academic centres tend to use dedicated surgical teams for hip and knee replacements, compared to community hospitals where these procedures are typically performed by general orthopedic surgeons in non-dedicated units. They say it’s likely that this team-based specialist approach is helping to shave off that excess teaching time for knee and hip surgeries, and suggest that it may be useful to explore whether these efficiencies can be achieved for other common surgeries in teaching hospitals by adopting specialized units.

Noting that longer surgical durations have been linked to negative patient outcomes, Vinden adds: “In addition to addressing funding gaps created by longer procedure durations at teaching hospitals, it will be vitally important to identify at what point, for each type of surgery, this longer duration due to teaching introduces excess patient risk, and to find ways to minimize this risk. Training the next generation of surgeons should not negatively impact the funding of a teaching hospital, or the health of our patients.”

The study “Teaching surgery takes time: the impact of surgical education on time in the operating room” was published today in the Canadian Journal of Surgery.

Author block: Christopher Vinden, Richard Malthaner, Jacob McGee, J Andrew McClure, Jennifer Winick-Ng, Kuan Liu, Danielle M Nash, Blayne Welk, Luc Dubois.

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