Surgical learning curves and operative efficiency: a cross-specialty observational study

OBJECTIVES To evaluate the learning curves of three high-volume procedures, from distinct surgical specialties. SETTING Tertiary care academic hospital. PARTICIPANTS A prospectively collected database comprising all medical records of patients undergoing isolated coronary artery bypass grafting (CABG), total knee replacement (TKR) and bilateral reduction mammoplasty (BRM) at the Brigham and Women's Hospital, USA, 1996-2010. Multivariate generalised estimating equation (GEE) regression models were used to adjust for patient risk and clustering of procedures by surgeon. PRIMARY OUTCOME MEASURE Operative efficiency. RESULTS A total of 1052 BRMs, 3254 CABGs and 3325 TKRs performed by 30 surgeons were analysed. Median number of procedures per surgeon was 61 (range 11-502), 290 (52-973) and 99 (10-1871) for BRM, CABG and TKR, respectively. Mean operative times were 134.4 (SD 34.5), 180.9 (62.3) and 101.9 (30.3) minutes, respectively. For each procedure, attending surgeon experience was associated with significant reductions in operative time (p<0.05). After 15 years of experience, BRM operative time decreased by 69.8 min (38.3%), CABG operative time decreased by 17.5 min (7.8%) and TKR operative time decreased by 94.4 min (48.4%). CONCLUSIONS Common trends in surgical learning exist. Dependent on the procedure, experience can serve as a powerful driver of improvement or have clinically insignificant impacts on operative time.