Journal of the American College of Surgeons
Volume 209, Issue 4 , Pages 434-445.e2, October 2009

Time-of-Day Effects on Surgical Outcomes in the Private Sector: A Retrospective Cohort Study

  • Rachel R. Kelz, MD, MSCE, FACS

      Affiliations

    • Department of Surgery, Philadelphia VA Medical Center, Philadelphia, PA
    • Department of Surgery, School of Medicine, University of Pennsylvania, Philadelphia, PA
    • Corresponding Author InformationCorrespondence address: Rachel R Kelz, MD, MSCE, FACS, Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce St, 4 Silverstein, Philadelphia, PA 19104
    • ,
  • Timothy T. Tran, BA

      Affiliations

    • Department of Surgery, School of Medicine, Washington University in St Louis, St Louis, MO
    • ,
  • Patrick Hosokawa, MS

      Affiliations

    • Health Outcomes Program, University of Colorado, Denver, CO
    • ,
  • William Henderson, PhD

      Affiliations

    • Health Outcomes Program, University of Colorado, Denver, CO
    • ,
  • E. Carter Paulson, MD

      Affiliations

    • Department of Surgery, School of Medicine, University of Pennsylvania, Philadelphia, PA
    • ,
  • Francis Spitz, MD

      Affiliations

    • Department of Surgery, Philadelphia VA Medical Center, Philadelphia, PA
    • Department of Surgery, School of Medicine, University of Pennsylvania, Philadelphia, PA
    • ,
  • Barton H. Hamilton, PhD

      Affiliations

    • Olin Business School, Washington University in St Louis, St Louis, MO
    • ,
  • Bruce L. Hall, MD, PhD, MBA, FACS

      Affiliations

    • Department of Surgery, School of Medicine, Washington University in St Louis, St Louis, MO
    • Olin Business School, Washington University in St Louis, St Louis, MO
    • Department of Surgery, John Cochran Veterans Affairs Medical Center, St Louis, MO
    • Center for Health Policy, Washington University in St Louis, St Louis, MO

Received 8 April 2009; received in revised form 11 May 2009; accepted 12 May 2009. published online 24 July 2009.

Background

Surgical care is delivered around the clock. Elective cases within the Veterans Affairs health system starting after 4 pm appear to have an elevated risk of morbidity, but not mortality, compared with earlier cases. The relationship between operation start time and patient outcomes is not described in private-sector patients or for emergency cases.

Study Design

We performed a retrospective cohort study of 56,920 general and vascular surgical procedures performed from October 2001 through September 2004, and entered into the National Surgical Quality Improvement Program database. Operation start time was the independent variable of interest. Random effects, hierarchical logistic regression models adjusted for patient, operative, and facility characteristics. Two independent models determined associations between start time and morbidity or mortality. Subset analysis was performed for emergency and nonemergency cases.

Results

After adjustment for patient and procedure characteristics, mortality had a moderately strong association with start time, but only for nonemergency cases starting 9:30 pm to 7:30 am (odds ratio = 1.752; p = 0.028; reference 7:30 am to 9:30 am). As for morbidity, after adjustment, operations starting 9:30 am to 1:30 pm and 5:30 pm to 9:30 pm were associated with a weakly elevated risk of morbidity, but those starting 9:30 pm to 7:30 am demonstrated a strong effect on morbidity (odds ratio = 1.32; p < 0.0001). Subgroup analysis showed this effect was largely a result of elevated risk of morbidity in emergency cases from this overnight time period (odds ratio = 1.48; p = 0.001).

Conclusions

Surgical start times are associated with risk-adjusted patient outcomes. In terms of facility operations management and resource allocation, consideration should be given to the capacity to accommodate cases with differences in risk during different time periods.

Abbreviations and Acronyms: NSQIP, National Surgical Quality Improvement Program, OR, odds ratio, PSS, Private Sector Study, RVU, relative value unit, SST, surgical start time, VA, Veterans Affairs

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 Disclosure Information: Nothing to disclose.

 This study does not represent the views of the ACS or the ACS NSQIP.

 This material is based upon work supported by the Office of Research and Development, competitive pilot project fund, Department of Veterans Affairs 693/11. Dr Hall was supported by the Center for Health Policy under the direction of Dr William Peck, Washington University in St Louis, St Louis, MO. This article is partially derived from the Patient Safety in Surgery Study, and partially supported by the Agency for Healthcare Research and Quality, grant number 5U18HS011913, entitled “Reporting System to Improve Patient Safety in Surgery.”

PII: S1072-7515(09)00507-9

doi:10.1016/j.jamcollsurg.2009.05.022

Journal of the American College of Surgeons
Volume 209, Issue 4 , Pages 434-445.e2, October 2009

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