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Assessing the Safety of Overlapping Surgery at a Children's Hospital

Hyder, Joseph A., MD, PhD*,†; Hanson, Kristine T., MPH; Storlie, Curtis B., PhD†,‡; Madde, Nageswar R., MS*; Brown, Michael J., MD*; Kor, Daryl J., MD, MSc*,†; Potter, D. Dean, MD§; Cima, Robert R., MD, MA, FACS†,¶; Habermann, Elizabeth B., PhD, MPH†,||

doi: 10.1097/SLA.0000000000002682
Letter-Brief Clinical Reports

Importance: Media reports have questioned the safety of overlapping surgical procedures, and national scrutiny has underscored the necessity of single-center evaluations of its safety; however, sample sizes are likely small. We compared the safety profiles of overlapping and nonoverlapping pediatric procedures at a single children's hospital and discussed methodological considerations of the evaluation.

Data and Design: Retrospective analysis of inpatient pediatric surgical procedures (January 2013 to September 2015) at a single pediatric referral center. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure. Mixed models adjusting for Vizient-predicted risk, case-mix, and surgeon compared inpatient mortality and length of stay (LOS).

Results: Among 315 overlapping procedures, 256 (81.3%) were matched to 645 nonoverlapping procedures. There were 6 deaths in all. The adjusted odds ratio for mortality did not differ significantly between nonoverlapping and overlapping procedures (adjusted odds ratio = 0.94 vs overlapping; 95% CI, 0.02–48.5; P = 0.98). Wide confidence intervals were minimally improved with Bayesian methods (95% CI, 0.07–12.5). Adjusted LOS estimates were not clinically different by overlapping status (0.6% longer for nonoverlapping; 95% CI, 9.7% shorter to 12.2% longer; P = 0.91). Among the 87 overlapping procedures with the greatest overlap (≥60 min or ≥50% of operative duration), there were no deaths.

Conclusions: The safety of overlapping and nonoverlapping surgical procedures did not differ at this children's center. These findings may not extrapolate to other centers. LOS or intraoperative measures may be more appropriate than mortality for safety evaluations due to low event rates for mortality.

*Department of Anesthesiology, Mayo Clinic, Rochester, MN

Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN

Department of Health Sciences Research, Mayo Clinic, Rochester, MN

§Department of Surgery, Division of Pediatric Surgery, Mayo Clinic, Rochester, MN

Department of Surgery, Mayo Clinic, Rochester, MN

||Department of Health Sciences Research and Surgery, Mayo Clinic, Rochester, MN.

Reprints: Joseph A. Hyder, MD, PhD, Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail: hyder.joseph@mayo.edu.

JAH received research support from the Anesthesia Patient Safety Foundation and the Anesthesia Quality Institute. DJK received research support from NIH grants U01-HL108712 and R01- HL121232.

The authors report no conflicts of interest.

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