Key result
CABG performed by trainee surgeons was associated with similar adjusted 4-year freedom from death compared to Consultant-led cases (91.8% vs 90.8%; P=0.53).
Why the study?
Does CABG performed by trainee surgeons affect mortality and morbidity outcomes compared to Consultant surgeons in patients undergoing isolated CABG?
Cohort (n=5,678)
Does CABG performed by trainee surgeons affect mortality and morbidity outcomes compared to Consultant surgeons in patients undergoing isolated CABG?
Absolute Event Rate: 91.8% vs 90.8%
p-value: p=0.53
With careful case selection, CABG performed by trainee surgeons does not adversely affect early and mid-term mortality compared to Consultant surgeons.
Supports supervised trainee CABG in selected cases; leaves open generalizability and morbidity effects pending prospective data.
OBJECTIVE: We examined our coronary artery bypass surgery (CABG) experience to assess the effect of training on mortality and morbidity outcomes. METHODS: Between April 1997 and September 2002, 5678 consecutive patients underwent isolated CABG. Five hundred and fifty-five (9.9%) were performed by trainee surgeons. Multivariate logistic regression was used to assess the effect of training on adverse outcomes, while adjusting for patient and disease characteristics (treatment selection bias). Cox proportional hazards analysis was used to adjust Kaplan-Meier survival curves. Treatment selection bias was controlled for by constructing a propensity score from core patient characteristics including the additive EuroSCORE. The propensity score was the probability of CABG performed by trainee, with a C-statistic of 0.79, and was included along with the comparison variable (trainee vs Consultant) in a multivariable analysis of outcome. The propensity score is used as the sole variable for adjustment due to the low number of events, providing a more complete risk adjustment. RESULTS: CABG procedures performed by trainee surgeons were less likely to be female, hypertensive, obese, triple-vessel disease, redo and emergency cases. Also, trainee surgeons were less likely to operate on patients with cerebrovascular disease, renal dysfunction, and previous myocardial infarctions, prior gastrointestinal surgery, and poor left ventricular ejection fraction. The additive EuroSCORE was 2.9 in trainee cases compared to 3.5 in Consultant led cases (P<0.001) Crude outcomes were significantly better in trainee CABGs due to selection bias. In-hospital results were no longer significantly different between both groups after adjusting for the propensity score. The adjusted freedom from death in the trainee cases at 30 days, 1, 2, 3, and 4 years was 98.1, 96.2, 94.7, 93.2 and 91.8%, respectively, compared to 97.9, 95.7, 94.1, 92.3 and 90.8% for the Consultant led cases (P=0.53). CONCLUSIONS: After adjusting for case-mix, with careful case selection, training does not adversely affect the early and mid-term outcomes of CABG.
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OO et al. (2004) conducted a cohort in Coronary artery disease requiring CABG (n=5,678). CABG performed by trainee surgeons vs. CABG performed by Consultant surgeons was evaluated on Adjusted freedom from death at 4 years (p=0.53). CABG performed by trainee surgeons was associated with similar adjusted 4-year freedom from death compared to Consultant-led cases (91.8% vs 90.8%; P=0.53).
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