Operative Autonomy: Assessing resident impact on surgical outcomes in arteriovenous fistula creation in the VA Health Care System
Diana Otoya, Alexander Simmonds, Kedar Lavingia, Michael Amendola
VA Medical Center/VCU, Richmond, VA
INTRODUCTION: It is thoughts that the implementation of work-hour restrictions in 2003 significantly impacted resident education. An essential procedure in vascular surgery is. For over 75 years, the VA Healthcare System has helped provide an environment for training surgical residents with affiliated academic programs documenting their involvement in operative care as part of its Veterans Affairs Surgical Quality Improvement Program (VASQIP). We set forth to examine VASQIP to determine the nature of resident operative independence during arteriovenous fistula (AVF) creation for hemodialysis access.
METHODS: All VASQIP entries for direct arteriovenous autogenous access (CPT Code 36818,36819 and 36821) five years before and after work hour restrictions implementation (January 1998 to January 2008) were examined. All cases were categorized based on if the attending was noted to being scrubbed (attending scrubbed) or not (attending not scrubbed) during the case. Case matching was performed between the groups based on the following variables: gender, diabetes, CHF, COPD and smoking status. Pre-operative patient comorbidities were collected. Intra-operative variables included the post-graduate year of the resident involved and operative time. 30-day postoperative outcomes including wound infection, return to the operating room, mortality and any complication were collected. ANOVA* and Fisher’s Exact Test** were utilized.
RESULTS: A total of 11,837 VASQIP records were obtained, with 864 remaining after case-control matching. Cases were identified with the attending scrubbed (n=429) and the attending not scrubbed (n=435). 30-day mortality, any complication rate, length of stay, return to the operating room, and superficial wound infection were not statistically significantly different between the two groups. The proportion of resident independent cases fell significantly after 2003 (15.3% vs 2.5%; p<0.001**). Resident autonomy resulted in a significant increased if the attending was not scrubbed (151 ± 58.2 vs. 120.1 ± 52; p<0.001*).
CONCLUSION: Resident autonomy has significantly decreased since the implementation of work-hour restrictions. Increased resident independence during arteriovenous access creation at VA hospitals is associated with an average increase of half an hour in operating times with no impact on patient outcomes. These data add to the ongoing understand of the cost of safe training of surgical residents in the VA Healthcare System. 
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