title: Association of operative time of day with outcomes after thoracic organ transplant.
abstract: BACKGROUND
  Recent emphasis on systems-based approaches to patient safety has led to several studies demonstrating worse outcomes associated with surgery at night.
  
  
  OBJECTIVE
  To evaluate whether operative time of day was associated with thoracic organ transplant outcomes, hypothesizing that it would not be associated with increased morbidity or mortality.
  
  
  METHODS
  We conducted a retrospective cohort study of adult heart and lung transplant recipients in the United Network for Organ Sharing database from January 2000 through June 2010. Primary stratification was by operative time of day (night, 7 PM-7 AM; day, 7 AM-7 PM).
  
  
  METHODS
  Primary end points were short-term survival, assessed by the Kaplan-Meier method at 30, 90, and 365 days. Secondary end points encompassed common postoperative complications. Risk-adjusted multivariable Cox proportional hazards regression examined mortality.
  
  
  RESULTS
  A total of 27,118 patients were included in the study population. Of the 16,573 who underwent a heart transplant, 8346 (50.36%) did so during the day and 8227 (49.64%) during the night. Of the 10,545 who underwent a lung transplant, 5179 (49.11%) did so during the day and 5366 (50.89%) during the night. During a median follow-up of 32.2 months (interquartile range, 11.2-61.1 months), 8061 patients (28.99%) died. Survival was similar for organ transplants performed during the day and night. Survival rates at 30 days for heart transplants during the day were 95.0% vs 95.2% during the night (hazard ratio [HR], 1.05; 95% confidence interval, 0.83-1.32; P = .67) and for lung transplants during the day were 96.0% vs 95.5% during the night (HR, 1.22; 95% CI, 0.97-1.55; P = .09). At 90 days, survival rates for heart transplants were 92.6% during the day vs 92.7% during the night (HR, 1.05; 95% CI, 0.88-1.26; P = .59) and for lung transplants during the day were 92.7% vs 91.7% during the night (HR, 1.23; 95% CI, 1.04-1.47; P = .02). At 1 year, survival rates for heart transplants during the day were 88.0% vs 87.7% during the night (HR, 1.05; 95% CI, 0.91-1.21; P = .47) and for lung transplants during the day were 83.8% vs 82.6% during the night (HR, 1.08; 95% CI, 0.96-1.22; P = .19). Among lung transplant recipients, there was a slightly higher rate of airway dehiscence associated with nighttime transplants (57 of 5022 [1.1%] vs 87 of 5224 [1.7%], P = .02).
  
  
  CONCLUSIONS
  Among patients who underwent thoracic organ transplants, there was no significant association between operative time of day and survival up to 1 year after organ transplant.
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: George
authors.forename: George J
authors.initials: GJ
authors.lastname: Arnaoutakis
authors.forename: Christian A
authors.initials: CA
authors.lastname: Merlo
authors.forename: Clinton D
authors.initials: CD
authors.lastname: Kemp
authors.forename: William A
authors.initials: WA
authors.lastname: Baumgartner
authors.forename: John V
authors.initials: JV
authors.lastname: Conte
authors.forename: Ashish S
authors.initials: AS
authors.lastname: Shah
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D016027:Heart Transplantation / Q000401:mortality*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016040:Lung Transplantation / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology