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December 7, 2017

Are overlapping surgeries safe? Two new studies reignite the debate.

Daily Briefing

    A study published Monday in JAMA Internal Medicine found that overlapping surgeries can increase the risk of complications for patients undergoing hip surgeries, but those findings conflict with a separate study published last month in JAMA Surgery.

    What do consumers want from surgical care?

    Overlapping surgeries occur when an attending surgeon is responsible for multiple surgeries in multiple operating rooms (ORs) at the same time for at least a portion of the procedures. They are a fairly common practice and are permitted at many teaching hospitals.

    Overlapping surgeries are different from concurrent surgeries, which occur when an attending surgeon is responsible for multiple surgeries in multiple ORs at the same time and the critical portions of the surgeries overlap. Medicare has banned concurrent surgeries.

    One study links overlapping hip surgeries with increased risks for patients

    For the study, researchers examined clinical data from health administrative databases on more than 90,000 hip surgeries that took place in more than 75 hospitals throughout Ontario, Canada. The researchers also looked at data on patient outcomes one year post-surgery.

    The researchers found that of the more than 90,000 surgeries they analyzed, 2,520 overlapped for more than 30 minutes with another procedure being performed by the same surgeon. According to the researchers, most of those surgeries overlapped with other procedures for 30 to 60 minutes, though some overlapped for up to three hours.

    The researchers found that complication rates for the reviewed procedures were:

    • 6.4% for patients undergoing hip fracture surgeries that did not overlap with another procedure, compared with 10.4% for patients' whose hip fracture surgeries did overlap with another procedure; and
    • 1.4% among patients undergoing elective hip replacements that did not overlap with another procedure, compared with 2.3% for patients undergoing elective hip replacements that did overlap.

    The researchers found that the rate of complications for patients undergoing hip replacements or surgeries to repair hip fractures increased by about 90% if the procedure overlapped with another surgery. According to the researchers, the risk of complications rose by 7% for every 10 minutes that surgeries overlapped, meaning the longer surgeries overlapped, the higher the risk of patients experiencing complications.

    Overall, Bheeshma Ravi, a hip surgeon at Sunnybrook Health Sciences Centre and the study's lead author, said, "If your surgeon is in multiple places, there's an increased risk of having a complication."

    James Rickert, an Indiana orthopedic surgeon and president of the Society for Patient Centered Orthopedics, said, "This study shuts the door on the idea that simultaneous surgery is as safe as solo surgery, when the doctor's just concentrating on you."

    Separate study finds no difference in complication rates for overlapping neurosurgeries

    The JAMA Internal Medicine study's findings conflict with the findings of a separate study published last month in JAMA Surgery.

    For the JAMA Surgery study, researchers reviewed data on functional status, mortality, and morbidity for 2,275 neurosurgeries performed at Emory University Hospital from January 2014 to December 2015, both at the time of discharge and at 90 days post-surgery.

    The researchers found no significant difference in complication rates between the 1,303 neurosurgeries that overlapped with other procedures and the 972 neurosurgeries that did not overlap with other procedures. The researchers wrote, "These data suggest that overlapping neurosurgery is safe and has the potential to benefit patients by maximizing efficiency and making highly sought-after specialists available to a greater number of patients."

    David Hoyt, executive director of the American College of Surgeons, in a commentary accompanying the study echoed the researchers, writing that, when executed appropriately, "overlapping surgery is a safe practice with no differences in mortality, complications, and neurologic outcomes." Hoyt argued that the practice bolsters efficiency, patients' access to care, and independence among surgical residents who assist attending surgeons.

    According to the Globe, at least seven other studies at U.S. hospitals have found little variation in complication rates between overlapping and non-overlapping surgeries.


    The Globe reports that the latest JAMA Internal Medicine study "may carry extra weight," because it looks at procedures performed across various hospitals, while the other studies, such as the JAMA Surgery study, typically focused on procedures performed at single teaching hospitals or outpatient clinics. In addition, researchers in the latest study looked at surgical complications for up to one year post-surgery, while the other studies generally focused on complications that occurred in the few weeks following surgery.

    Alan Zhang, an orthopedic surgeon at the University of California-San Francisco Medical Center, in an editorial accompanying the study, wrote, "This seems to be the first study to show an adverse effect from the practice of overlapping surgery."

    Zhang wrote, "The increased length of follow-up is an important factor to consider for complications, which adds value to the results of the current study" (Saltzman, Boston Globe, 12/4; Bean, Becker's Clinical Leadership & Infection Control, 12/4; Swift, Medscape, 11/8; Castellucci, Modern Healthcare, 11/8; JAMA Internal Medicine study, 12/4; JAMA Surgery study, 11/8).

    What do consumers want from surgical care?

    To win surgical business today, you need to understand what consumers expect from their care, what trade-offs they will make to protect their priorities, and how their willingness to travel impacts who you’re competing against.

    Here are 12 insights we discovered after asking nearly 2,500 consumers about their surgical care preferences.

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