Relation between patient mortality
and the birthdays of a surgeon?
Interesting study to determine the relation between mortality and the birthdays of the operating surgeon compared to other regular days in USA acute care setting and critical access hospitals. A 30-day mortality based on 980,876 procedures by 47,489 surgeons. 0.2% (2064) of the procedures were performed on surgeon’s birthdays. Medicare beneficiaries aged 65 to 99 were the most involved and had a higher mortality rate compared to patients who underwent surgery on other days. This study suggest that the surgeons may have been distracted by life events not related to work.
The quality of surgical care is not always optimal, however less than 10% of patients undergoing inpatient surgery die after the procedure while less than 30% experience complications. More than 60% of those complications are avoidable. Around 40% die after these surgical procedures which were estimated preventable. The role of distraction has received little investigation. Calls from wards, pages from beepers conversations in the operating room. noise have factored to bringing an atmosphere of distraction. Indoor temperature, loss of local sport team etc can become a diversion.
Personal distraction and patient outcomes appear to have a close relationship in the way a surgeon can feel a rush to finish a procedure on his birthday. Using a national data base from Medicare to assess whether the performance of a surgeon is influenced by life events outside of his or her work environment on patients undergoing emergent surgical procedures, this study found out a higher risk of 30-day mortality when a procedure is performed on a surgeon birthday. The study does have limitations because surgeons may postpone less urgent cases and operate only on the most severe. It is also difficult to identify the fact that indeed there may have been a reduction in operating times… or which patients experienced a higher mortality rate while undergoing the surgical procedure on the surgeon’s birthday. Lastly, the inability to pinpoint the cause of death because of a lack of information although the study focused on the 17 most common procedures received by Medicare aged 65-99 years not compared to the general population who underwent other procedures
Certainly, the way the study was set up may bring some limitations between the different ways to select patients and hospitals surgeons during the observational phases, especially. When surgeons may postpone less severe cases and operate on the more severe cases to attend the festivities of their birthday party. There may be a lack of details in the clinical information’s or the reasons for the cancellations explaining the higher mortality rate once the patient underwent the surgical procedure. Lastly, the cause of death was unknown because of lack of information for the cause of death were not available on Medicare patients aged between 65 and 99. Therefore, no comparisons were made with other patients in the population.
In the cohort of patients, all were between 65 and 99 being treated at an acute care facility or a critical access hospital during a three years period 2011 and 2014. The selection was made on the illness severity or even on the surgeon’s preference. Emergency procedures were defined as emergent or urgent on patient admitted from trauma center to ensure that procedures were considered as emergencies while the surgical procedure was also reviewed assuring that the surgical procedure was performed within 3 days of hospital admission. Patients who left the hospital against medical advices were not included in the study. Cases were catalogued in 17 major surgical procedures like carotid endarterectomy, valve procedures, coronary by-pass grafting and bilateral abdominal aortic aneurysm repair for cardiovascular teams and 13 most common non-cardiovascular procedures in the Medicare population like Hip and femur fractures, colorectal resection, cholecystectomy, peritoneal adhesions other fracture and dislocations of the lower extremities. Nephrectomy, appendectomy or small bowel resection. Spinal fusion, amputation of extremities etc. Each performer surgeon was identified by their national provider identifier and other characteristics were obtained from Medicare and Medicaid centers MD and PPA’s files providing the surgeon birthdate.
A 30-day mortality was defined as death within the 30 days after surgery as the primary outcome of the study. Information on death dates was available through the Medicare Beneficiary Summary files using the death certificates. Patient characteristics included the type of procedure, the age, sex, race and ethnicity with specific co-morbidities. Other variables for insurance coverage Medicaid or Medicare or hospital variable to patient population treated in hospital by the same or different surgeon.
The statistical analysis whether the surgeon’s birthday was distributed through the year, compared to the patient’s illness severity was taken in consideration to see if the illness severity differed based on the date of surgery. Also, the amount of procedure performed per surgeons around his/her birthday was also taken in consideration. Whether surgeon changed their mind to perform surgery on their birthdays. Finally, the characteristics of the surgeons performing the surgical procedures on their birthdays were compared to the one who did not perform a procedure. More, the operative mortality was compared on patients who underwent surgery on an operating surgeon birthday with patients whose operation was performed on other days of the year.
Three models resulted. A model 1 which adjusted only the patient’s characteristics. A model 2 which constructed all variable in model 1 but also added hospital effects and patient outcome in the same hospital and also a model 3 which adjusted all the variable found in model but also added the surgeon effects on any day of surgery versus the day of his birthday. A 30-day-mortality around surgeon’s birthdays was conducted as an event study analysis and indicators were set within 2 weeks of the surgeon’s birthday. Secondary analyses were also conducted in relation to follow-up period for calculating patient mortality or to address the possibility that some surgeons may manipulate the timing of the operations or chose not to work the day of their birthday. The association between surgeons’ birthdays and patient mortality for elective surgery were also analyzed. The difference between patient mortality between birthday and non-birthday surgeries were also estimated. Etc…
The study sample included 980,876 procedures performed by 47,489 surgeons with birthdays evenly distributed through the year. Among those cases, 2064(.2%) were performed on surgeons’ birthdays. All patients had similar characteristics as of comorbidities, procedure type and predicted mortality to those who underwent operations on other days. Surgeons who worked on their birthdays were in general older and more likely to be male. 7% unadjusted 30-day mortality rate was found among patients operated on the surgeon’s birthday (145 on 2064) while in any other day it was a rate of 5.6 % (54,824 / 978.812). Patient mortality was also found higher when the same surgeon performed many procedures on their birthday versus another surgeon performing a smaller number of procedures on their birthday. No difference between surgeons were found whenever a birthday was on a Friday.
In conclusion, a national sample of Medicare beneficiaries who underwent common emergency surgical procedures was studied on their postoperative 30-day-mortality and it was concluded that the mortality rate was found higher in patients who underwent surgical procedure on an operating surgeon’s birthdate compared to any patient who received a procedure on another day of the year. These analyses suggest that a surgeon’s performance might be affected by life events that are not directly related to work activities.
The study is not perfect and has its limitations and other factors may enter in cause, all independent of the component studied like distracting factors in the Operating room team, medical error, fatigue, presence of surgical trainees etc. I found it a good paper to report upon and if one has a choice to do accepting or refusing surgery when it coincides with the surgeon’s birthday, perhaps it may be wise to remember reading on the topic.
Maxime J-m Coles MD
Boca Raton FL
1- BMJ 2020; 371 doi : https://doi.org/10.1136/bmj.m4381 (Published 10 December 2020) Cite this as: BMJ 2020;371:m4381.