title: Late Operating Room Start Times Impact Mortality and Cost for Nonemergent Cardiac Surgery.
abstract: BACKGROUND
  There is growing concern over the effect of starting non-emergent cardiac surgery later in the day on clinical outcomes and resource utilization. Our objective was to determine the differences in patient outcomes for starting non-emergent cardiac surgery after 3 pm.
  
  
  METHODS
  All non-emergent cardiac operations performed at a single institution from July 2008 to 2013 were reviewed. Cases were stratified based on "early start" or "late start," defined by incision time before or after 3 pm. Rates of observed and risk-adjusted mortality, major complications, and costs were compared on a univariate basis for all patients and by multivariable linear and logistic regression for patients with a valid The Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM).
  
  
  RESULTS
  A total of 3,395 non-emergent cardiac operations were reviewed, including 368 late start cases. Compared with cases starting earlier, mortality was significantly higher for patients undergoing late operations (5.2% vs 3.5%, p = 0.046) despite similar preoperative risk (STS PROM 3.8% vs 3.3%) and major complication rates (18.2% vs 18.3%). Costs were 8% higher with late start cases ($51,576 vs $47,641, p < 0.001). After controlling for case type, surgeon, year, and risk, late cases resulted in higher mortality (odds ratio 2.04, p = 0.041) despite shorter operative duration (16 minutes, p < 0.001).
  
  
  CONCLUSIONS
  Starting non-emergent cardiac cases later in the day is associated with 2 times higher absolute and risk-adjusted mortality. These data should be carefully considered, not only by surgeons and patients but also in the context of the operating room system when scheduling non-emergent cardiac cases.
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia. Electronic address: kenan.w.yount@gmail.com.
authors.forename: Kenan W
authors.initials: KW
authors.lastname: Yount
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Christine L
authors.initials: CL
authors.lastname: Lau
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Leora T
authors.initials: LT
authors.lastname: Yarboro
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Ravi K
authors.initials: RK
authors.lastname: Ghanta
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Irving L
authors.initials: IL
authors.lastname: Kron
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: John A
authors.initials: JA
authors.lastname: Kern
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
mesh_terms: D000368:Aged; D006348:Cardiac Surgical Procedures / Q000191:economics* / Q000401:mortality*; D005260:Female; D017048:Health Care Costs / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D009873:Operating Rooms; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome; D014768:Virginia / Q000453:epidemiology