title: Resident involvement is associated with worse outcomes after major lower extremity amputation.
abstract: BACKGROUND
  Despite the recent major changes in vascular and general surgery training, there has been a paucity of literature examining the effect of these changes on training and surgical outcomes. Amputations represent a common cross-section in core competencies for general surgery and vascular surgery trainees. This study evaluates the effect of trainee participation on outcomes after above-knee and below-knee amputations.
  
  
  METHODS
  The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database (2005 to 2010) was queried using Current Procedural Terminology codes (American Medical Association, Chicago, Ill) for below-knee amputation (27880, 27882) and above knee-amputation (27590, 27592). Resident involvement was defined using the NSQIP variable and was narrowed to postgraduate year 1 to 5. Variables associated with resident involvement were identified, and mortality, morbidity, intraoperative transfusion, and operative time (75th percentile vs the bottom three quartiles) were evaluated as distinct categoric end points in logistic regression. Included in the model were variables with a P value <.1 on χ(2) or independent t-test, as appropriate. Significance was defined at P < .05.
  
  
  RESULTS
  Residents were involved in 6587 of 11,038 amputations (62%). After adjustment for preoperative and intraoperative factors on logistic regression, there was a significant increase in major morbidity (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.14-1.42; P < .001), intraoperative transfusion (OR, 1.78; 95% CI, 1.50-2.11; P < .001), and operative time (OR, 1.64 95% CI, 1.46-1.84; P < .001) in resident cases.
  
  
  CONCLUSIONS
  Resident involvement was associated with increased odds of major morbidity after amputation and also with increased operative time and risk for intraoperative transfusions.
authors.affiliation: Surgical Health Outcomes & Research Enterprise, University of Rochester Medical Center, Rochester, NY 14642, USA. james_iannuzzi@urmc.rochester.edu
authors.forename: James C
authors.initials: JC
authors.lastname: Iannuzzi
authors.forename: Ankur
authors.initials: A
authors.lastname: Chandra
authors.forename: Aaron S
authors.initials: AS
authors.lastname: Rickles
authors.forename: Neil G
authors.initials: NG
authors.lastname: Kumar
authors.forename: Kristin N
authors.initials: KN
authors.lastname: Kelly
authors.forename: David L
authors.initials: DL
authors.lastname: Gillespie
authors.forename: John R T
authors.initials: JR
authors.lastname: Monson
authors.forename: Fergal J
authors.initials: FJ
authors.lastname: Fleming
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000009:adverse effects* / Q000193:education* / Q000401:mortality; D016063:Blood Loss, Surgical / Q000401:mortality / Q000517:prevention & control; D001803:Blood Transfusion / Q000401:mortality; D016009:Chi-Square Distribution; D002983:Clinical Competence; D004503:Education, Medical, Graduate; D005260:Female; D006801:Humans; D007396:Internship and Residency; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D065227:Transfusion Reaction; D016896:Treatment Outcome; D014481:United States