title: Surgeon length of service and risk-adjusted outcomes: linked observational analysis of the UK National Adult Cardiac Surgery Audit Registry and General Medical Council Register.
abstract: OBJECTIVE
  To explore the relationship between in-hospital mortality following adult cardiac surgery and the time since primary clinical qualification for the responsible consultant cardiac surgeon (a proxy for experience).
  
  
  METHODS
  Retrospective analysis of prospectively collected national registry data over a 10-year period using mixed-effects multiple logistic regression modelling. Surgeon experience was defined as the time between the date of surgery and award of primary clinical qualification.
  
  
  METHODS
  UK National Health Service hospitals performing cardiac surgery between January 2003 and December 2012.
  
  
  METHODS
  All patients undergoing coronary artery bypass grafts and/or valve surgery under the care of a consultant cardiac surgeon.
  
  
  METHODS
  All-cause in-hospital mortality.
  
  
  RESULTS
  A total of 292,973 operations performed by 273 consultant surgeons (with lengths of service from 11.2 to 42.0 years) were included. Crude mortality increased approximately linearly until 33 years service, before decreasing. After adjusting for case-mix and year of surgery, there remained a statistically significant (p=0.002) association between length of service and in-hospital mortality (odds ratio 1.013; 95% CI 1.005-1.021 for each year of 'experience').
  
  
  CONCLUSIONS
  Consultant cardiac surgeons take on increasingly complex surgery as they gain experience. With this progression, the incidence of adverse outcomes is expected to increase, as is demonstrated in this study. After adjusting for case-mix using the EuroSCORE, we observed an increased risk of mortality in patients operated on by longer serving surgeons. This finding may reflect under-adjustment for risk, unmeasured confounding or a real association. Further research into outcomes over the time course of surgeon's careers is required.
authors.affiliation: Centre for Health Informatics, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London W1T 7HA, UK.
authors.forename: Graeme L
authors.initials: GL
authors.lastname: Hickey
authors.affiliation: National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London W1T 7HA, UK Department of Cardiothoracic Surgery, Manchester Academic Health Science Centre, University of Manchester, University Hospital of South Manchester, Manchester M23 9LT, UK.
authors.forename: Stuart W
authors.initials: SW
authors.lastname: Grant
authors.affiliation: Department of Primary Care and Population Health, University College London, London NW3 2PF, UK.
authors.forename: Nick
authors.initials: N
authors.lastname: Freemantle
authors.affiliation: National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London W1T 7HA, UK.
authors.forename: David
authors.initials: D
authors.lastname: Cunningham
authors.affiliation: Department of Cardiothoracic Surgery, Leeds General Infirmary, Leeds LS1 3EX, UK.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Munsch
authors.affiliation: Department of Cardiac Surgery, University Hospital Southampton, Southampton SO16 6YD, UK.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Livesey
authors.affiliation: Department of Cardiothoracic Surgery, St Thomas' Hospital, London SE1 7EH, UK.
authors.forename: James
authors.initials: J
authors.lastname: Roxburgh
authors.affiliation: Centre for Health Informatics, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK.
authors.forename: Iain
authors.initials: I
authors.lastname: Buchan
authors.affiliation: Centre for Health Informatics, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London W1T 7HA, UK Department of Primary Care and Population Health, University College London, London NW3 2PF, UK ben.bridgewater@uhsm.nhs.uk.
authors.forename: Ben
authors.initials: B
authors.lastname: Bridgewater
mesh_terms: D000328:Adult; D000368:Aged; D006348:Cardiac Surgical Procedures / Q000401:mortality*; D002983:Clinical Competence; D003253:Consultants; D001026:Coronary Artery Bypass; D005260:Female; D006351:Heart Valves / Q000601:surgery; D017052:Hospital Mortality; D006801:Humans; D016015:Logistic Models; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D016017:Odds Ratio; D010820:Physicians / Q000145:classification; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D013903:Thoracic Surgery; D013997:Time Factors; D006113:United Kingdom
keywords: General Medical Council register; audit; cardiac surgery; clinical experience; clinical performance; length of service