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Association of Cataract Surgical Outcomes With Late Surgeon Career StagesA Population-Based Cohort Study

Educational Objective
To investigate whether an increase in cataract surgical adverse events occurs during later surgeon career stages.
1 Credit CME
Key Points

Question  Are advancing surgeon career stages associated with cataract surgical outcomes?

Findings  In this population-based study of 499 650 cataract operations, a late surgeon career stage was not associated with an increased overall risk of cataract surgical adverse events.

Meaning  These results suggest that cataract surgery can be performed by surgeons at later career stages without increasing the risk of surgical adverse events.

Abstract

Importance  Evidence suggests that the quality of some aspects of care provided by physicians may decrease during their late career stage. However, to our knowledge, data regarding the association of advancing surgeon career phase with cataract surgical outcomes have been lacking.

Objective  To investigate whether an increase in cataract surgical adverse events occurs during later surgeon career stages.

Design, Setting, and Participants  This population-based study of 499 650 cataract operations performed in Ontario, Canada, between January 1, 2009, and December 31, 2013, investigated the association between late surgeon career stage and the risk of surgical adverse events. Linked health care databases were used to study cataract surgical complications while controlling for patient-, surgeon-, and institution-level covariates. All ophthalmologists who performed cataract surgery in Ontario within the study period were included in the analysis.

Exposures  Isolated cataract surgery performed by surgeons at early, mid, and late career stages.

Main Outcomes and Measures  Four serious adverse events were evaluated: dropped lens fragments, posterior capsule rupture, suspected endophthalmitis, and retinal detachment.

Results  Of 416 502 participants, 244 670 (58.7%) were women, 90 429 (21.7%) were age 66 to 70 years, 111 530 (26.8%) were age 71 to 75 years, 90 809 (21.8%) were age 76 to 80 years, and 123 734 (29.7%) were 81 years or older. Late-career surgeons performed 143 108 of 499 650 cataract operations (28.6%) during the study period. Late surgeon career stage was not associated with an increased overall risk of surgical adverse events (odds ratio [OR] vs midcareer, 1.06; 95% CI, 0.85-1.32). In a sensitivity analysis with surgeon volume removed from the model, late career stage was still not associated with overall adverse surgical events (OR, 1.10; 95% CI, 0.88-1.38). Among individual complications, late surgeon career stage was associated with an increased risk of dropped lens fragment (OR, 2.30; 95% CI, 1.50-3.54) and suspected endophthalmitis (OR, 1.41; 95% CI, 1.01-1.98). These corresponded with small absolute risk differences of 0.11% (95% CI, 0.085%-0.130%) and 0.045% (95% CI, 0.028%-0.063%) for dropped lens fragment and suspected endophthalmitis, respectively.

Conclusions and Relevance  These findings suggest that later-career surgeons are performing a substantial proportion of cataract operations with overall low surgical adverse event rates. Future studies might extend evaluations to the frequency of secondary surgical interventions as additional measures of surgical care quality.

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Article Information

Accepted for Publication: August 24, 2018.

Corresponding Author: Robert J. Campbell, MD, MSc, Department of Ophthalmology, Queen’s University and Kingston Health Sciences Centre, Hotel Dieu Hospital site, 166 Brock St, Kingston, ON K7L 5G2, Canada (rob.campbell@queensu.ca).

Published Online: October 11, 2018. doi:10.1001/jamaophthalmol.2018.4886

Author Contributions: Dr R. Campbell had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: R. Campbell, El-Defrawy, Whitehead, Bell.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: R. Campbell.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: R. Campbell, Whitehead.

Obtained funding: R. Campbell.

Administrative, technical, or material support: El-Defrawy, Gill, Whitehead, E. Campbell, Hooper.

Supervision: R. Campbell, El-Defrawy, Bell.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Bell receives consulting fees for the Ontario Ministry of Health and Long-Term Care. No other disclosures are reported.

Funding/Support: Dr R. Campbell is supported by the David Barsky chair in Ophthalmology and Visual Sciences. Dr Bell is supported by a Canadian Institutes of Health Research and Canadian Patient Safety Institute chair in Patient Safety and Continuity of Care. This study was supported by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care.

Role of the Funder/Sponsors: The funding organizations of this study had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit for publication.

Disclaimer: The opinions, results and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by the Institute for Clinical Evaluative Sciences or the Ontario Ministry of Health and Long-Term Care is intended or should be inferred.

References
1.
Makary  MA, Daniel  M.  Medical error—the third leading cause of death in the US.  BMJ. 2016;353:i2139. doi:10.1136/bmj.i2139PubMedGoogle ScholarCrossref
2.
Chassin  MR.  Improving the quality of health care: what’s taking so long?  Health Aff (Millwood). 2013;32(10):1761-1765. doi:10.1377/hlthaff.2013.0809PubMedGoogle ScholarCrossref
3.
Bardach  NS, Wang  JJ, De Leon  SF,  et al.  Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial.  JAMA. 2013;310(10):1051-1059. doi:10.1001/jama.2013.277353PubMedGoogle ScholarCrossref
4.
Choudhry  NK, Fletcher  RH, Soumerai  SB.  Systematic review: the relationship between clinical experience and quality of health care.  Ann Intern Med. 2005;142(4):260-273. doi:10.7326/0003-4819-142-4-200502150-00008PubMedGoogle ScholarCrossref
5.
Blasier  RB.  The problem of the aging surgeon: when surgeon age becomes a surgical risk factor.  Clin Orthop Relat Res. 2009;467(2):402-411. doi:10.1007/s11999-008-0587-7PubMedGoogle ScholarCrossref
6.
Tsugawa  Y, Newhouse  JP, Zaslavsky  AM, Blumenthal  DM, Jena  AB.  Physician age and outcomes in elderly patients in hospital in the US: observational study.  BMJ. 2017;357:j1797. doi:10.1136/bmj.j1797PubMedGoogle ScholarCrossref
7.
Norcini  JJ, Kimball  HR, Lipner  RS.  Certification and specialization: do they matter in the outcome of acute myocardial infarction?  Acad Med. 2000;75(12):1193-1198. doi:10.1097/00001888-200012000-00016PubMedGoogle ScholarCrossref
8.
O’Neill  L, Lanska  DJ, Hartz  A.  Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy.  Neurology. 2000;55(6):773-781. doi:10.1212/WNL.55.6.773PubMedGoogle ScholarCrossref
9.
Hartz  AJ, Kuhn  EM, Pulido  J.  Prestige of training programs and experience of bypass surgeons as factors in adjusted patient mortality rates.  Med Care. 1999;37(1):93-103. doi:10.1097/00005650-199901000-00013PubMedGoogle ScholarCrossref
10.
Waljee  JF, Greenfield  LJ, Dimick  JB, Birkmeyer  JD.  Surgeon age and operative mortality in the United States.  Ann Surg. 2006;244(3):353-362.PubMedGoogle Scholar
11.
Boom-Saad  Z, Langenecker  SA, Bieliauskas  LA,  et al.  Surgeons outperform normative controls on neuropsychologic tests, but age-related decay of skills persists.  Am J Surg. 2008;195(2):205-209. doi:10.1016/j.amjsurg.2007.11.002PubMedGoogle ScholarCrossref
12.
Chao  LL, Knight  RT.  Prefrontal deficits in attention and inhibitory control with aging.  Cereb Cortex. 1997;7(1):63-69. doi:10.1093/cercor/7.1.63PubMedGoogle ScholarCrossref
13.
Mani  TM, Bedwell  JS, Miller  LS.  Age-related decrements in performance on a brief continuous performance test.  Arch Clin Neuropsychol. 2005;20(5):575-586. doi:10.1016/j.acn.2004.12.008PubMedGoogle ScholarCrossref
14.
Chai  CY, Chen  CH, Lin  HW, Lin  HC.  Association of increasing surgeon age with decreasing in-hospital mortality after coronary artery bypass graft surgery.  World J Surg. 2010;34(1):3-9. doi:10.1007/s00268-009-0291-0PubMedGoogle ScholarCrossref
15.
Prystowsky  JB.  Are young surgeons competent to perform alimentary tract surgery?  Arch Surg. 2005;140(5):495-500. doi:10.1001/archsurg.140.5.495PubMedGoogle ScholarCrossref
16.
Prystowsky  JB, Bordage  G, Feinglass  JM.  Patient outcomes for segmental colon resection according to surgeon’s training, certification, and experience.  Surgery. 2002;132(4):663-670. doi:10.1067/msy.2002.127550PubMedGoogle ScholarCrossref
17.
Cullen  KA, Hall  MJ, Golosinskiy  A.  Ambulatory surgery in the United States, 2006.  Natl Health Stat Report. 2009;(11):1-25.PubMedGoogle Scholar
18.
OECD Publishing. Cataract surgeries. https://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf. Accessed March 27, 2018.
19.
Bell  CM, Hatch  WV, Fischer  HD,  et al.  Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery.  JAMA. 2009;301(19):1991-1996. doi:10.1001/jama.2009.683PubMedGoogle ScholarCrossref
20.
Ontario Ministry of Health and Long-Term Care Cataract Surgery Quality-Based Procedure Expert Group. Quality-based procedures clinical handbook for cataract day surgery. http://www.health.gov.on.ca/en/pro/programs/ecfa/docs/qbp_cataract.pdf. Accessed March 27, 2018.
21.
Campbell  RJ, El-Defrawy  SR, Gill  SS,  et al.  New surgeon outcomes and the effectiveness of surgical training: a population-based cohort study.  Ophthalmology. 2017;124(4):532-538. doi:10.1016/j.ophtha.2016.12.012PubMedGoogle ScholarCrossref
22.
Campbell  RJ, Bell  CM, Gill  SS,  et al.  Subspecialization in glaucoma surgery.  Ophthalmology. 2012;119(11):2270-2273. doi:10.1016/j.ophtha.2012.05.043PubMedGoogle ScholarCrossref
23.
Campbell  RJ, Bell  CM, Paterson  JM,  et al.  Stroke rates after introduction of vascular endothelial growth factor inhibitors for macular degeneration: a time series analysis.  Ophthalmology. 2012;119(8):1604-1608. doi:10.1016/j.ophtha.2012.05.028PubMedGoogle ScholarCrossref
24.
Campbell  RJ, Gill  SS, Bronskill  SE, Paterson  JM, Whitehead  M, Bell  CM.  Adverse events with intravitreal injection of vascular endothelial growth factor inhibitors: nested case-control study.  BMJ. 2012;345:e4203. doi:10.1136/bmj.e4203PubMedGoogle ScholarCrossref
25.
Bell  CM, Hatch  WV, Cernat  G, Urbach  DR.  Surgeon volumes and selected patient outcomes in cataract surgery: a population-based analysis.  Ophthalmology. 2007;114(3):405-410. doi:10.1016/j.ophtha.2006.08.036PubMedGoogle ScholarCrossref
26.
Williams  JI, Young  W. A summary of studies on the quality of health care administration databases in Canada. In: Goel  V, Williams  JI, Anderson  GM, Blackstien-Hirsch  P, Fooks  C, Naylor  D, eds.  Patterns of Health Care in Ontario: The ICES Practice Atlas. 2nd ed. Ottawa, Ontario, Canada: Canadian Medical Association; 1996:339-345.
27.
Levy  AR, O’Brien  BJ, Sellors  C, Grootendorst  P, Willison  D.  Coding accuracy of administrative drug claims in the Ontario Drug Benefit database.  Can J Clin Pharmacol. 2003;10(2):67-71.PubMedGoogle Scholar
28.
Juurlink  DN, Preyra  C, Croxford  R,  et al.  Canadian Institute for Health Information Discharge Abstract Database: A Validation Study. Toronto, Ontario, Canada: Institute for Clinical Evaluative Sciences; 2006.
29.
Hux  JE, Ivis  F, Flintoft  V, Bica  A.  Diabetes in Ontario: determination of prevalence and incidence using a validated administrative data algorithm.  Diabetes Care. 2002;25(3):512-516. doi:10.2337/diacare.25.3.512PubMedGoogle ScholarCrossref
30.
Jain  AK, McLeod  I, Huo  C,  et al.  When laboratories report estimated glomerular filtration rates in addition to serum creatinines, nephrology consults increase.  Kidney Int. 2009;76(3):318-323. doi:10.1038/ki.2009.158PubMedGoogle ScholarCrossref
31.
Grunfeld  E, Hodgson  DC, Del Giudice  ME, Moineddin  R.  Population-based longitudinal study of follow-up care for breast cancer survivors.  J Oncol Pract. 2010;6(4):174-181. doi:10.1200/JOP.200009PubMedGoogle ScholarCrossref
32.
Campbell  RJ, Bell  CM, Gill  SS,  et al.  Clinic-based glaucoma care in the era of surgical subspecialization.  Am J Ophthalmol. 2014;157(3):631-9.e1, 2. doi:10.1016/j.ajo.2013.11.019PubMedGoogle ScholarCrossref
33.
Stein  JD, Grossman  DS, Mundy  KM, Sugar  A, Sloan  FA.  Severe adverse events after cataract surgery among Medicare beneficiaries.  Ophthalmology. 2011;118(9):1716-1723. doi:10.1016/j.ophtha.2011.02.024PubMedGoogle ScholarCrossref
34.
Hahn  P, Yashkin  AP, Sloan  FA.  Effect of prior anti-VEGF injections on the risk of retained lens fragments and endophthalmitis after cataract surgery in the elderly.  Ophthalmology. 2016;123(2):309-315. doi:10.1016/j.ophtha.2015.06.040PubMedGoogle ScholarCrossref
35.
Hahn  P, Jiramongkolchai  K, Stinnett  S, Daluvoy  M, Kim  T.  Rate of intraoperative complications during cataract surgery following intravitreal injections.  Eye (Lond). 2016;30(8):1101-1109. doi:10.1038/eye.2016.109PubMedGoogle ScholarCrossref
36.
Lee  AY, Day  AC, Egan  C,  et al; United Kingdom Age-related Macular Degeneration and Diabetic Retinopathy Electronic Medical Records Users Group.  Previous intravitreal therapy is associated with increased risk of posterior capsule rupture during cataract surgery.  Ophthalmology. 2016;123(6):1252-1256. doi:10.1016/j.ophtha.2016.02.014PubMedGoogle ScholarCrossref
37.
Stein  JD.  Serious adverse events after cataract surgery.  Curr Opin Ophthalmol. 2012;23(3):219-225. doi:10.1097/ICU.0b013e3283524068PubMedGoogle ScholarCrossref
38.
Freeman  EE, Roy-Gagnon  MH, Fortin  E, Gauthier  D, Popescu  M, Boisjoly  H.  Rate of endophthalmitis after cataract surgery in Quebec, Canada, 1996-2005.  Arch Ophthalmol. 2010;128(2):230-234. doi:10.1001/archophthalmol.2009.380PubMedGoogle ScholarCrossref
39.
Sparrow  JM, Taylor  H, Qureshi  K, Smith  R, Birnie  K, Johnston  RL; UK EPR user group.  The Cataract National Dataset electronic multi-centre audit of 55,567 operations: risk indicators for monocular visual acuity outcomes.  Eye (Lond). 2012;26(6):821-826. doi:10.1038/eye.2012.51PubMedGoogle ScholarCrossref
40.
Urbach  DR, Austin  PC.  Conventional models overestimate the statistical significance of volume-outcome associations, compared with multilevel models.  J Clin Epidemiol. 2005;58(4):391-400. doi:10.1016/j.jclinepi.2004.12.001PubMedGoogle ScholarCrossref
41.
Greenberg  PB, Tseng  VL, Wu  WC,  et al.  Prevalence and predictors of ocular complications associated with cataract surgery in United States veterans.  Ophthalmology. 2011;118(3):507-514. doi:10.1016/j.ophtha.2010.07.023PubMedGoogle ScholarCrossref
42.
Peisah  C, Wijeratne  C, Waxman  B, Vonau  M.  Adaptive ageing surgeons.  ANZ J Surg. 2014;84(5):311-315. doi:10.1111/ans.12506PubMedGoogle ScholarCrossref
43.
Drag  LL, Bieliauskas  LA, Langenecker  SA, Greenfield  LJ.  Cognitive functioning, retirement status, and age: results from the Cognitive Changes and Retirement among Senior Surgeons study.  J Am Coll Surg. 2010;211(3):303-307. doi:10.1016/j.jamcollsurg.2010.05.022PubMedGoogle ScholarCrossref
44.
Zhou  AW, Noble  J, Lam  WC.  Canadian ophthalmology residency training: an evaluation of resident satisfaction and comparison with international standards.  Can J Ophthalmol. 2009;44(5):540-547. doi:10.3129/i09-155PubMedGoogle ScholarCrossref
45.
Rowden  A, Krishna  R.  Resident cataract surgical training in United States residency programs.  J Cataract Refract Surg. 2002;28(12):2202-2205. doi:10.1016/S0886-3350(02)01380-9PubMedGoogle ScholarCrossref
46.
Chan  WH, Saedon  H, Falcon  MG.  Postgraduate ophthalmic training: how do we compare?  Eye (Lond). 2011;25(8):965-967. doi:10.1038/eye.2011.120PubMedGoogle ScholarCrossref
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