title: Surgical resident supervision in the operating room and outcomes of care in Veterans Affairs hospitals.
abstract: BACKGROUND
  There has been concern that a reduced level of surgical resident supervision in the operating room (OR) is correlated with worse patient outcomes. Until September 2004, Veterans' Affairs (VA) hospitals entered in the surgical record level 3 supervision on every surgical case when the attending physician was available but not physically present in the OR or the OR suite. In this study, we assessed the impact of level 3 on risk-adjusted morbidity and mortality in the VA system.
  
  
  METHODS
  Surgical cases entered into the National Surgical Quality Improvement Program database between 1998 and 2004, from 99 VA teaching facilities, were included in a logistic regression analysis for each year. Level 3 versus all other levels of supervision were forced into the model, and patient characteristics then were selected stepwise to arrive at a final model. Confidence limits for the odds ratios were calculated by profile likelihood.
  
  
  RESULTS
  A total of 610,660 cases were available for analysis. Thirty-day mortality and morbidity rates were reported in 14,441 (2.36%) and 63,079 (10.33%) cases, respectively. Level 3 supervision decreased from 8.72% in 1998 to 2.69% in 2004. In the logistic regression analysis, the odds ratios for mortality for level 3 ranged from .72 to 1.03. Only in the year 2000 were the odds ratio for mortality statistically significant at the .05 level (odds ratio, .72; 95% confidence interval, .594-.858). For morbidity, the odds ratios for level 3 supervision ranged from .66 to 1.01, and all odds ratios except for the year 2004 were statistically significant.
  
  
  CONCLUSIONS
  Between 1998 and 2004, the level of resident supervision in the OR did not affect clinical outcomes adversely for surgical patients in the VA teaching hospitals.
authors.affiliation: VA Boston Health Care System (112A), Boston and Harvard Universities, 1400 VFW Pkwy., West Roxbury, MA 02132, USA. kitani@med.va.gov
authors.forename: Kamal M F
authors.initials: KM
authors.lastname: Itani
authors.forename: Ralph G
authors.initials: RG
authors.lastname: DePalma
authors.forename: Tracy
authors.initials: T
authors.lastname: Schifftner
authors.forename: Karen M
authors.initials: KM
authors.lastname: Sanders
authors.forename: Barbara K
authors.initials: BK
authors.lastname: Chang
authors.forename: William G
authors.initials: WG
authors.lastname: Henderson
authors.forename: Shukri F
authors.initials: SF
authors.lastname: Khuri
mesh_terms: D005260:Female; D013502:General Surgery / Q000193:education*; D006787:Hospitals, Veterans; D006801:Humans; D015994:Incidence; D007396:Internship and Residency / Q000458:organization & administration*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D009873:Operating Rooms; D017063:Outcome Assessment, Health Care / Q000458:organization & administration*; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000401:mortality / Q000592:standards*; D015996:Survival Rate; D014481:United States; D014493:United States Department of Veterans Affairs