Although overlapping surgery is used to maximize efficiency, more empirical data are needed to guide patient safety. We conducted a retrospective cohort study to evaluate the safety of overlapping inpatient orthopedic surgery, as judged by the occurrence of perioperative complications.
Overlapping surgery refers to “operations performed by the same primary surgeon such that the start of one surgery overlaps with the end of another.”1 This longstanding practice has been used by surgeons and hospitals to maximize operating room efficiency, with the additional benefit of allowing graduated responsibility to surgical trainees.
This practice has been criticized, citing concerns about patient safety, informed consent, and strain to the doctor-patient relationship. Advocates for overlapping surgery mention its increased efficiency, its ability to increase the availability of specialist surgeons, and an anecdotal belief in safety. Critics of overlapping surgery point to a lack of empirical evidence demonstrating security and the threat that this practice creates public trust in hospitals and surgeons2 as well as concerns from bioethical, professionalism, and legal perspectives3.
Orthopedic Surgical Procedures
All inpatient orthopedic surgical procedures performed at five academic institutions from January 1, 2015, to December 31, 2015, were included. Overlapping surgery was defined as two skin incisions open simultaneously for one surgeon. In comparing patients who underwent overlapping surgery with those who underwent non-overlapping surgery, the primary outcome was the occurrence of a perioperative complication within 30 days of the surgical procedure.
To determine if there was an association between overlapping surgery and a perioperative complication, we tested for non-inferiority of overlapping medicine, assuming a null hypothesis of an increased risk of 50%. We used an inverse probability of treatment weighted regression model adjusted for the institution, procedure type, demographic characteristics (age, sex, race, comorbidities), admission type, admission severity of illness, and clustering by the surgeon. Among 14,135 cases, the frequency of overlapping surgery was 40%. The frequencies of perioperative complications were 1% in the overlapping surgery group and 2% in the non-overlapping surgery group.
The overlapping surgery group was non-inferior to the non-overlapping surgery group (odds ratio [OR], 0.61 [90% confidence interval (CI), 0.45 to 0.83]; p < 0.001), with reduced odds of perioperative complications (OR, 0.61 [95% CI, 0.43 to 0.88]; p = 0.009). For secondary outcomes, there was a significantly lower chance of all-cause 30-day readmission in the overlapping surgery group (OR, 0.67 [95% CI, 0.52 to 0.87]; p = 0.003) and shorter length of stay (eβ, 0.94 [95% CI, 0.89 to 0.99]; p = 0.012). There was no difference in mortality.
Researcher results suggest that overlapping inpatient orthopedic surgery does not introduce additional perioperative risk for the complications that we evaluated. Individual surgeons should determine the suitability of this practice on a case-by-case basis with appropriate informed consent.