Metro

More researchers weigh in on double-booked surgeries

The latest report on double-booked surgeries was based on a study of cases at Emory University Hospital in Atlanta.
REUTERS/File 2014
The latest report on double-booked surgeries was based on a study of cases at Emory University Hospital in Atlanta.

Neurosurgeons can safely run two operations at once without endangering patients, a study from Emory University in Atlanta concluded, part of a growing body of research in response to a Globe Spotlight Team report that found surgeons sometimes do simultaneous surgeries without telling patients.

The Emory researchers found no difference in complication rates between 1,303 cases that overlapped and 972 cases that didn’t at Emory University Hospital. However, the overlapping surgeries take longer, and patients may spend more time under anesthesia.

The researchers did not determine whether the patients had given consent to share their surgeon with another patient. During overlapping procedures, a junior surgeon fills in when the attending surgeon is operating on a second patient.

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“These data suggest that overlapping neurosurgery is safe and has the potential to benefit patients by maximizing efficiency and making highly sought-after specialists available to a greater number of patients,’’ said the article, whose lead author is Dr. Brian M. Howard, a neurosurgical fellow at Emory.

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The study, scheduled to be published Wednesday in JAMA Surgery, is at least the seventh peer-reviewed paper published by a medical journal about the safety of overlapping surgeries since October 2015, when a Spotlight Team story about a controversy over simultaneous operations at Massachusetts General Hospital drew national attention to the issue. None of the studies have found a significant difference in complication rates.

But an eighth study, as yet unpublished, found an increased risk for postoperative complications in concurrent surgery for hip fractures, and that the longer the surgeries overlap, the greater the rate of complications. An assistant professor of surgery at the University of Toronto used data from about 100 hospitals to compare about 1,000 concurrent hip surgeries with 1,000 that were not performed simultaneously from 2009 to 2014.

At MGH, a handful of top orthopedic surgeons sometimes scheduled two operations that overlapped for hours, prompting several colleagues to allege that patients were endangered and had not consented to share their surgeon. MGH leaders said they took the allegations seriously and imposed new limits on double-booking, but insisted that no patients were imperiled.

Concurrent surgery is now the focus of lawsuits against MGH by two doctors who left the hospital after complaining about it. In one, Dr. Dennis Burke, a prominent orthopedic surgeon, charged that he was illegally fired for opposing concurrent surgery, while an anesthesiologist filed a separate whistle-blower lawsuit alleging that double-booked surgeries at MGH put patients at risk. The hospital has denied doing anything improper.

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Double-booking also figured in a series of stories in the Seattle Times about high-volume neurosurgeons at Seattle’s Swedish Neuroscience Institute. And it’s the backdrop for investigations by federal and New York state authorities into how a urologist at Lenox Hill Hospital in Manhattan handled his enormous surgical volume and billed for procedures.

The JAMA Surgery study compared how Emory neurosurgery patients in 2014 and 2015 fared in overlapping and non-overlapping operations up to 90 days after their procedures.

Researchers found no significant difference in the outcomes and rate of complications, including surgical site infections and unexpected readmissions. Overlapping surgery “can be safely performed if appropriate precautions and patient selection are followed,” the study said.

The study did not knowingly include overlapping surgeries in which “critical parts” of the two surgeries happened at the same time. The federal Medicare program requires surgeons to be in the operating room for the most important parts of the operation and not delegate the work to a junior surgeon.

The one significant difference between cases that overlapped and those that didn’t is that patients who shared their surgeon were in the operating room about 30 minutes longer and had open incisions nearly 30 minutes longer. Two of the other recent studies also found that overlapping cases took longer.
Dr. Daniel L. Barrow, chairman of the neurosurgery department at the Emory School of Medicine, said researchers did not know whether overlapping surgery prolonged cases or whether surgeons picked two cases to overlap because they were more complex and would take more time.

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Michelle M. Mello, a health law scholar at Stanford’s schools of law and medicine who is working on a study of concurrent surgeries at multiple hospitals, generally praised the JAMA Surgery study. But she said it has shortcomings, including the fact that it dealt with only one hospital. And it doesn’t distinguish between cases that overlap for only a few minutes and those that overlap for far longer.

“Do patients who have more overlap do worse than patients who have only a bit of overlap?” she said. “We just don’t know.”

One thing that is clear, though, is that patients want to know if their surgeon will be tending to a second patient during their surgery.

Roughly 95 percent of the people surveyed for a recent study in the Journal of the American College of Surgeons said a surgeon should inform them beforehand that the doctor will be operating on two patients. And over 91 percent wanted the surgeon to document when he or she was present. Overall, fewer than 4 percent of those surveyed knew anything about overlapping surgery.

Defenders of doctors running two operating rooms have argued that it increases efficiency, gives patients greater access to coveted surgeons, and instills independence in surgical residents who help attending surgeons.

That is the position voiced in an opinion piece accompanying the study in JAMA Surgery by Dr. David B. Hoyt, executive director of the American College of Surgeons. Hoyt applauded the new study as “very important.”

But Dr. Michael Mulholland, chairman of surgery at the University of Michigan, has said double-booking benefits only the surgeons, who can increase their surgical volumes. It is inefficient for all other medical staff, he said, including other surgeons who lose operating room time.

He also doubted that patients want it.

“How would a reasonable patient react to a surgeon saying, ‘I plan to be in an adjacent operating room operating on a different patient during your proposed procedure — is that acceptable to you?’ ” said Mulholland, speaking at a panel discussion at MGH last year. “There are no data to answer that question, but I think that common sense says that virtually no patient would find this acceptable.’’

Jonathan Saltzman can be reached at jonathan.saltzman@globe.com.