Resident involvement is associated with worse outcomes after major lower extremity amputation.

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.

Prediction of postdischarge venous thromboembolism using a risk assessment model.

OBJECTIVE: The risk of postdischarge venous thromboembolism (VTE) (either deep vein or pulmonary embolism) is increasingly recognized yet the prescription of postdischarge thromboprophylaxis is inconsistent. There is a paucity of information to aid clinicians in identifying surgical patients who are at increased risk for postdischarge VTE. This study aimed to determine the incidence and risk factors associated with symptomatic postdischarge VTE and develop a risk score to identify patients who may benefit from extended duration thromboprophylaxis. METHODS: This was a retrospective study. All nonorthopedic cases in which the patient was discharged alive without inpatient VTE were selected from the 2005-2009 National Surgical Quality Improvement Program database. A multivariate logistic regression was used to create a risk score for postdischarge VTE prediction. The dataset was split into two-thirds for risk score development and validated in the remaining one-third. RESULTS: The overall incidence of early postdischarge VTE for 2005-2009 National Surgical Quality Improvement Program was 0.3%. The risk score stratified patients into low, moderate, and high risk for postdischarge VTE with the incidence based on the risk score ranging from 0.07% to 2.2%. The risk score had good predictive ability with c-statistic = 0.72 for model development and c-statistic = 0.71 in the validation dataset. Factors associated with postdischarge VTE on multivariate analysis included race, increasing age, steroid use, body mass index ≥30, malignancy, higher American Society of Anesthesiologists class, increasing operative time, length of postsurgical stay, and major postoperative complication. CONCLUSIONS: This novel postdischarge VTE prediction score utilizes patient, operative, and early outcome factors to accurately identify patients at increased risk of a postdischarge thromboembolic event. The development of a patient- specific postdischarge VTE risk profile may help address the challenge of determining postdischarge prophylaxis requirements.