title: Influence of experience and the surgical learning curve on long-term patient outcomes in cardiac surgery.
abstract: OBJECTIVE
  We hypothesized that increased postgraduate surgical experience correlates with improved operative efficiency and long-term survival in standard cardiac surgery procedures.
  
  
  METHODS
  Utilizing a prospectively collected retrospective database, we identified patients who underwent isolated coronary artery bypass grafting (CABG) (n = 3726), aortic valve replacement (AVR) (n = 1626), mitral valve repair (n = 731), mitral valve replacement (MVR) (n = 324), and MVR + AVR (n = 184) from January 2002 through June 2012. After adjusting for patient risk and surgeon variability, we evaluated the influence of surgeon experience on cardiopulmonary bypass and crossclamp times, and long-term survival.
  
  
  RESULTS
  Mean surgeon experience after fellowship graduation was 16.0 ± 11.7 years (range, 1.0-35.2 years). After adjusting for patient risk and surgeon-level fixed effects, learning curve analyses demonstrated improvements in cardiopulmonary bypass and crossclamp times with increased surgeon experience. There was marginal improvement in the predictability (R(2) value) of cardiopulmonary bypass and crossclamp time for CABG with the addition of surgeon experience; however, all other procedures had marked increases in the R(2) following addition of surgeon experience. Cox proportional hazard models revealed that increased surgeon experience was associated with improved long-term survival in AVR (hazard ratio [HR], 0.85; P < .0001), mitral valve repair (HR, 0.73; P < .0001), and MVR + AVR (HR, 0.95; P = .006) but not in CABG (HR, 0.80; P = .15), and a trend toward significance in MVR (HR, 0.87; P = .09).
  
  
  CONCLUSIONS
  In cardiac surgery, not including CABG, surgeon experience is an important determinant of operative efficiency and of long-term survival.
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex.
authors.forename: Bryan M
authors.initials: BM
authors.lastname: Burt
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, The Brigham and Women's Hospital, Boston, Mass.
authors.forename: Andrew W
authors.initials: AW
authors.lastname: ElBardissi
authors.affiliation: Harvard Business School, Harvard University, Boston, Mass.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Huckman
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, The Brigham and Women's Hospital, Boston, Mass.
authors.forename: Lawrence H
authors.initials: LH
authors.lastname: Cohn
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, The Brigham and Women's Hospital, Boston, Mass.
authors.forename: Marisa W
authors.initials: MW
authors.lastname: Cevasco
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, The Brigham and Women's Hospital, Boston, Mass.
authors.forename: James D
authors.initials: JD
authors.lastname: Rawn
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, The Brigham and Women's Hospital, Boston, Mass.
authors.forename: Sary F
authors.initials: SF
authors.lastname: Aranki
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, The Brigham and Women's Hospital, Boston, Mass. Electronic address: jbyrne@partners.org.
authors.forename: John G
authors.initials: JG
authors.lastname: Byrne
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002315:Cardiopulmonary Bypass / Q000193:education; D002983:Clinical Competence; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000193:education* / Q000401:mortality; D016208:Databases, Factual; D004503:Education, Medical, Graduate / Q000379:methods*; D004526:Efficiency; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000193:education* / Q000401:mortality; D006801:Humans; D059032:Learning Curve; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: aortic valve; aortic valve replacement; cardiopulmonary bypass; coronary artery bypass grafting; learning curve; mitral valve; mitral valve replacement; surgeon experience