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PubMed2003

The surgeon and human immunodeficiency virus.

The moral dilemmas faced by surgeons worldwide who treat patients infected with the human immunodeficiency virus (HIV) can be viewed against the background of experience in sub-Saharan countries, where the community prevalence is in excess of 25% (90% of hospital inpatients). When seeking consent for an HIV test before surgery, frank communication regarding the surgeons' perspective of risks to themselves and the patient is helpful. When consent for a test must be obtained from a substitute decision-maker, the surgeon should consider if the patient would want the decision-maker to know the result. Understanding the natural history of HIV in the surgical setting can help deal with the uncertainties encountered and should be a research priority for developing countries. International professional organizations are useful platforms for the exchange of ideas when surgeons encounter uncertainty by increasing access to journals and creating opportunities for discussion. Although supervisory bodies in some parts of the world prevent HIV-infected surgeons from putting patients at risk by offering surgery, the withdrawal of their services in developing countries can cause more harm than good. Surgeons in that position may be entitled to offer surgery but only with full disclosure of the risk of HIV infection to the patient. The decision-making process known as "accountability for reasonableness" allows surgeons to determine fairness, legitimacy, and acceptability when making resource allocation decisions involving patients with HIV.

Decision Making↗
PubMed2006

The effect of surgeon volume and hospital characteristics on in-hospital outcome after ureteral reimplantation in children.

The aim of this study was to examine the association between surgeon and hospital characteristics on in-hospital outcome after ureteral reimplantation in children. Patients<18 years undergoing vesicoureteral reimplantation (n=3,109) were identified in Kids' Inpatient Database, an administrative database containing discharge records from 27 states during 2000 in the US. Based on patient volume in 2000, surgeons were designated as low volume (<11 procedures), medium volume (11-20 procedures) and high volume (>20 procedures) surgeons. Length of stay and hospital charges were analyzed using multivariate linear regression analysis. A significant association between shorter length of stay and higher surgeon volume (p=0.02) was observed that was independent of children's hospital status, hospital volume and other hospital characteristics. Length of stay was 20% shorter when the procedure was performed by the highest volume surgeons compared to when performed by the lowest. No significant effect of surgeon volume on hospital charges, however, was observed. Higher surgeon volume was associated with shorter length of stay but no difference in hospital charges among children undergoing vesicoureteral reimplantation.

Child↗
PubMed2005

Perception of Garden's classification for femoral neck fractures: an international survey of 298 orthopaedic trauma surgeons.

The Garden classification is the most popular femoral neck fracture classification system. We surveyed orthopaedic surgeons about their preferences for femoral neck fracture classification systems and their belief about their ability to discriminate between the four different Garden fracture types. A questionnaire was developed to examine surgeons' training and experience and their preferences for classification of femoral neck fractures by consulting five orthopaedic surgeons in Canada and the United States, and the previous literature. The Garden classification was the preferred femoral neck fracture classification for 72% of all the surveyed surgeons (n=298). Only 39% of all the surveyed surgeons believed they were able to distinguish all four Garden fracture types. However, 96% of the surgeons felt they could differentiate between undisplaced (Garden I/II) and displaced (Garden III/IV) fractures. High variability in the surgeons' perceptions of the Garden classification system provides a rationale for discontinuing the use of this system in daily practice.

Adult↗
PubMed2001

The effect of laparoscopic instrument working angle on surgeons' upper extremity workload.

BACKGROUND: Laparoscopic surgery may be kinder to the patient, but it is more demanding on the surgeon. Fixed trocar positions often require the surgeon to work with instruments at awkward angles to their body. We studied the effect of horizontal and vertical laparoscopic instrument working angle on the surgeon's thumb, forearm, and shoulder muscle work. METHODS: Electronyographic (EMG) signals were collected from the thenar compartment (TH), flexor digitorum superficialis (FDS), and deltoid (DEL) muscles of the dominant arm of eighth surgeons while they were closing a standard pistol-grip disposable laparoscopic grasper against a fixed resistance of 3 N. With the aid of a special testing bench, the instruments' position was randomly changed among 15 degrees, 45 degrees, and 75 degrees of horizontal angulation relative to the surgeons' sagital plane, and 15 degrees, 45 degrees, and 75 degrees degrees of vertical angulation relative to a horizontal plane. EMG signals were rectified and smoothed using analogue circuitry and digitally sampled at l0 Hz using a National Instruments DAQCard-700 connected to a Macintosh PowerBook 5300c running LabVIEW software. Statistical analysis was carried out by analysis of variance (ANOVA). RESULTS: The effects of vertical and horizontal working angles on the muscle effort were as follows: TH (horizontal, N.S.; vertical, N.S.), FDS (horizontal, p 45 degrees to the surgeon's sagital plane significantly increases the workload of the flexor digitorium superficialis and deltoid muscles. The deltoid muscle is also adversely affected by vertical angulation of the instrument. The instrument working angle has no effect on the thenar muscles. Whenever possible, laparoscopic surgeons should strive to place their instruments and trocars so as to minimize extreme horizontal or vertical displacement of their hands away from a resting position of comfort.

Arm↗
PubMed2006

Effect of surgeon on outcome of antireflux surgery.

BACKGROUND: We sought to determine whether subjective outcomes one or more years after antireflux surgery are affected by the operating surgeon. METHODS: We reviewed records of patients who had antireflux surgery from June 2000 to June 2002 and mailed the patients a 19-item survey that focused on current medication use, postoperative symptom improvement, and satisfaction with surgery. We tested the significance of predictor variables using chi-squared and Fisher exact tests for categorical variables and analysis of variance for continuous variables. RESULTS: We mailed the survey to 74 patients. Ninety-one percent of the operations were initially laparoscopic, with 5 (7%) subsequently converting to open. Ninety-five percent of patients were taking protein pump inhibitors (PPIs) preoperatively. Surgeons (n = 7) were divided into four groups, with the four surgeons who did two or fewer procedures in one group. Fifty-two of 74 patients (70%) responded to the survey (mean age, [SD] 44 [21] years, 37% male). The mean duration of followup was 2.1 [0.46] years. Thirty-eight percent of patients were taking medications for gastroesophageal reflux disease at the time of survey completion. It was found that the surgeon had an influence on patients' perceptions of the success of the surgery and whether having surgery was a good idea. We did not identify a statistically significant effect of the surgeon on preoperative symptom severity, postoperative ability to belch, dysphagia, medication use, and lifestyle. CONCLUSION: A patient's surgeon has an effect on satisfaction with antireflux surgery. Further research should clarify specific practices of the surgeon (patient selection, operative technique, followup) associated with best outcome.

Adult↗
PubMed1997

A comparison of surgeons' posture during laparoscopic and open surgical procedures.

BACKGROUND: There is increasing recognition of surgeons' physical fatigue in the new ergonomic environment of laparoscopic surgery. The purpose of this study was to determine what the differences are in the movement of the surgeon's axial skeleton between laparoscopic and open operations. METHODS: Surgeons' body positions were recorded on videotape during four laparoscopic (LAP) and six open (OP) operations. The percent of time the head and back were in a normal, bent, or twisted position as well as the number of changes in head and back position were tabulated using a computer program. A separate laboratory study was performed on four surgeons "walking" a 0.5-inch polyethylene tubing forward and backward using laparoscopic and open techniques. The movements of the surgeons' head, trunk, and pelvis were measured using a three-camera kinematic system (Kin). The center of pressure was recorded using a floor-mounted forceplate (Fp). RESULTS: In the operating room surgeons' head and back positions were more often straight in laparoscopic procedures and more often bent in open operations. The number of changes in back position per minute were significantly decreased when the laparoscopic-only part of surgery was analyzed. In the laboratory the subjects' head position was significantly (p = 0.02) more upright and the anteroposterior (AP) and rotational range of motion of the head was significantly reduced during laparoscopy. Subjects' CP was more anterior and there was a significant reduction in the AP range of motion of the CP during laparoscopy. CONCLUSIONS: Our study suggests that surgeons exhibit decreased mobility of the head and back and less anteroposterior weight shifting during laparoscopic manipulations despite a more upright posture. This more restricted posture during laparoscopic surgery may induce fatigue by limiting the natural changes in body posture that occur during open surgery.

Ergonomics↗
PubMed2005

Surgeons' economic profiles: can we get the "right" answers?

Hospitals and payers use economic profiling to evaluate physician and surgeon performance. However, there is significant variation in the data sources and analytic methods that are used. We used information from a hospital's cardiac surgery and cost accounting information systems to create surgeon economic profiles. Three scenarios were examined: (1) surgeon modeled as fixed effect with no patient-mix adjustment; (2) surgeon modeled as fixed effect with patient-mix adjustment; (3) and surgeon modeled as random effect with patient-mix adjustment. We included 574 patients undergoing coronary artery bypass surgery at Baptist Medical Center, Oklahoma City, OK between July 1, 1995 and April 30, 1996. We found that profiles reporting unadjusted average surgeon costs may incorrectly identify high- and low-cost outliers. Adjusting for patient-mix differences and treating surgeons as random effects was the preferred approach. These results demonstrate the need for hospitals to reexamine their economic profiling methods.

Aged↗
PubMed1992

Asymptomatic mandibular third molars: oral surgeons' judgment of the need for extraction.

Ten oral surgeons were asked to judge the need for extraction of asymptomatic mandibular third molars. Thirty-six mandibular third molars with equal distribution of angular position, impaction status, and patient's sex and age were selected. To estimate the consistency of judgment, the 36 cases were duplicated so that, in all, 72 cases were judged. The judgment of the oral surgeons was compared with that of 30 general dental practitioners (GDPs). The number of mandibular third molars the oral surgeons proposed to extract varied from 3 to 21 of 36 teeth. The mean number of molars proposed for extraction was 12 for the oral surgeons and 13 for the GDPs. There was no third molar that all the observers in the two groups agreed should be extracted. About three times as many observers in both groups proposed extraction of molars partially covered by soft tissue. The oral surgeons were unanimous in their judgment not to extract 11 molars, and the GDPs were also unanimous in judgment not to extract two of these. The mean intraobserver agreement within the two groups was comparable, 94% for the oral surgeons and 92% for the GDPs. We conclude that there is a great variation among oral surgeons in their judgment on the need for removal of asymptomatic mandibular third molars. A similar variation in judgment also was observed among GDPs.

Adolescent↗
PubMed2006

Is there evidence to support the need for routine surgeon presence on trauma patient arrival?

The trauma center certification requirements of the American College of Surgeons include the expectation that, whenever possible, general surgeons be routinely present at the emergency department arrival of seriously injured patients. The 2 historical factors that originally prompted this requirement, frequent exploratory laparotomies and emergency physicians without trauma training, no longer exist in most modern trauma centers. Research from multiple centers and in multiple varying formats has not identified improvement in patient-oriented outcomes from early surgeon involvement. Surgeons are not routinely present during the resuscitative phase of Canadian and European trauma care, with no demonstrated or perceived decrease in the quality of care. American trauma surgeons themselves do not consistently believe that their use in this capacity is either necessary or an efficient distribution of resources. There is not compelling evidence to support the assumption that trauma outcomes are improved by the routine presence of surgeons on patient arrival. Research is necessary to clarify which trauma patients require either emergency or urgent unique expertise of a general surgeon during the initial phase of trauma management. Individual trauma centers should be permitted the flexibility necessary to perform such research and to use such findings to refine and focus their secondary triage criteria.

Child↗
PubMed2004

Explaining disparities in access to high-quality cardiac surgeons.

BACKGROUND: Racial disparities in access to coronary artery bypass graft (CABG) surgery are well documented. Recent evidence shows that even when patients receive CABG surgery, racial minorities are more likely to be treated by lower quality providers. METHODS: New York State (NYS) hospital discharge data for 1996 and 1997 for patients undergoing CABG surgery were combined with risk-adjusted mortality rates for cardiac surgeons calculated by the NYS Department of Health. Statistical analysis was performed to determine the relationship between patients' race and the quality of the surgeon performing the CABG, as measured by the surgeon's risk-adjusted mortality rate, after controlling for patient characteristics such as comorbidities and socioeconomic status; the hospital where the surgery was performed; and the number of surgeries the surgeon performed over a 3-year period. RESULTS: African Americans and Asian/Pacific Islanders are treated by surgeons with higher risk-adjusted mortality rates compared with whites. This association does not appear to be a result of inadequate risk adjustment. It is explained to some degree by the hospital to which these patients are admitted, and to a lesser degree by (1) the education and income level in the patient's zipcode of residence and (2) being treated by a low-volume surgeon. After controlling for these factors, race continues to be associated with treatment by a surgeon with a higher risk-adjusted mortality rate. CONCLUSIONS: Efforts to achieve the "Healthy People 2010" goals of eliminating health disparities should address not only access to care, but also access to high-quality care.

Black or African American↗
PubMed2005

An analysis of the Research Fellowship Scheme of the Royal College of Surgeons of England.

BACKGROUND: The Research Fellowship Scheme of the Royal College of Surgeons of England commenced in 1993 with the aim of exposing selected surgical trainees to research techniques and methodology, with the hope of having an impact on surgical research and increasing the cadre of young surgeons who might decide to pursue an academic career in surgery. Over 11 million pounds sterling (approximately US 20 million dollars) has been invested in 264 fellowships. The College wished to evaluate the impact of the Scheme on the careers of research fellows, surgical research, and patient care. As the 10th anniversary of the Scheme approached. STUDY DESIGN: Two-hundred and sixty research fellows whose current addresses were available were sent a questionnaire. Two-hundred and thirty-eight (91.5%) responded. RESULTS: Three-quarters of the research fellows conducted laboratory-based research, with most of the remainder conducting patient-based clinical research. One-third of the fellows who have reached consultant status have an academic component to their post. The total number of publications based on fellowship projects was 531, with a median impact factor of 3.5. Almost all fellows had been awarded a higher degree or were working toward this. Half of the fellows received subsequent funding for research, mostly awarded by national or international funding bodies. CONCLUSIONS: The Research Fellowship Scheme of the Royal College of Surgeons of England has successfully supported many trainee surgeons in the initial phase of their research career. It has helped surgical research by increasing the pool of surgeons willing to embark on an academic career. Indirectly, patient care has benefited by promoting an evidence-based culture among young surgeons. Such schemes are relevant to surgical training programs elsewhere if more young surgeons are to be attracted into academic surgery.

Biomedical Research↗
PubMed2006

Association of race and gender with general surgeons' annual incomes.

BACKGROUND: Specialty, work effort, and gender have been shown to be associated with physicians' annual incomes. Although female plastic, oral, and cardiothoracic surgeons have been shown to have lower incomes than their male counterparts, differences in incomes attributable to gender or race among general surgeons have not been evaluated. STUDY DESIGN: We used survey responses collected during the 1990s from 771 actively practicing general surgeons and linear regression modeling to determine the association of race and gender with general surgeons' annual incomes after controlling for work effort, provider characteristics, and practice characteristics. RESULTS: Compared with Caucasian men, both African-American male and Caucasian female general surgeons reported having fewer patient visits (10% fewer and 17% fewer, respectively), but working more annual hours (14% more and 6.7% more, respectively). Caucasian women were more likely than the other groups to be nonpractice-owner employees. African-American men and Caucasian women were less likely than their Caucasian male counterparts to be board certified. After adjustment for work effort, provider characteristics, and practice characteristics, African-American men's mean annual income was $248,048, or $49,205 (17%) lower than that for Caucasian men (95% CI: $129,645 lower to $31,236 higher, p=0.2); Caucasian women's was $233,397, or $63,856 (21%) lower (95% CI: $120,367 to $7,345 lower, p=0.03). CONCLUSIONS: During the 1990s, among Caucasian general surgeons, female gender was associated with considerably lower annual incomes; among male general surgeons, African-American race was associated with lower annual incomes, but not substantially so. These findings warrant additional exploration to ensure that income differences among physicians are not unjustly determined by race or gender.

Black or African American↗
PubMed2006

Impact of surgeon-specific feedback on surgical site infection rates in Thailand.

Data on surgeon-specific feedback on surgical site infection (SSI) rates are not currently available in Thailand. The authors conducted a before and after study among patients undergoing surgery in seven Thai hospitals to examine whether a feedback system to surgeons could reduce SSI rates. After a six-month surveillance period, surgeons were provided with their own SSI rates and standardized infection ratios (SIRs). The criteria of the National Nosocomial Infection Surveillance (NNIS) system were used to determine SSI rates, and the SSI rates were compared with the NNIS report in terms of the SIR. To compare the SIR before and after intervention, the SIR ratio was calculated and logistic regression analysis was used to estimate the relative impact of surgeon-specific feedback, adjusting for patient sex, patient age, degree of wound contamination, American Society of Anesthesiologists' score, duration of operation, type of operation, use and duration of antibiotic prophylaxis, and length of pre-operative stay. After confidential feedback to surgeons for six months, SSI rates and the SIR remained unchanged. The SSI rate in the pre-intervention period was 1.7 infections/100 operations and the corresponding SIR was 0.8 [95% confidence intervals (CI)=0.6-0.9]. In the post-intervention period, the SSI rate was 1.8 infections/100 operations, with a corresponding SIR of 0.8 (95%CI=0.7-0.9). The SIR ratio was 1.0. The relative risk of SSI after surgeon-specific feedback suggested that this intervention had no effect (adjusted relative risk=1.02, 95%CI=0.77-1.35). Feedback to surgeons on their SSI rates did not reduce the rates of such infections in Thailand.

Adolescent↗
PubMed2005

Pediatric trauma patients with isolated airway compromise or Glasgow Coma Scale less than 8: does immediate attending surgeon's presence upon arrival make a difference?

BACKGROUND/PURPOSE: Optimal trauma care requires an attending pediatric surgeon to head a trauma team for the most severely injured patients. Recently, the American College of Surgeons-Committee on Trauma has added "Glasgow Coma Scale (GCS) <8" and "airway compromise" to the existing anatomical and physiological criteria for immediate attending presence. This report analyzes the outcome of children who met these isolated criteria and were treated before the change in guidelines was made. METHODS: The trauma registry of this level I trauma center was queried for all pediatric patients with GCS <8 or airway compromise. Age, sex, initial GCS, Revised Trauma Score, Injury Severity Score, outcome, and probability of survival (TRISS methodology) were recorded. The subgroup of patients for whom an attending surgeon was not immediately present was further analyzed. RESULTS: Over a 5-year period, 2895 trauma patients (aged 0-16 years) were admitted. One hundred fifteen patients had a GCS <8 and/or airway compromise. In 61 cases, an attending surgeon was not present upon patient arrival. Of these patients, 24 died (group D), 15 were discharged to a rehabilitation facility (group R), and 22 were discharged home (group H). Ten patients with a probability of survival of lower than 0.5 survived. Only 4 of the 24 patients who died had a probability of survival of >0.5 (mean, 0.697). All 4 had an Injury Severity Score >25 and a GCS < or =4. All deaths were reviewed through a quality improvement program and were deemed nonpreventable by objective reviewers. Patient outcome was not affected by the presence or absence of an attending surgeon upon patient arrival. CONCLUSIONS: Outcome of severely injured children with GCS <8 or airway compromise met and, in some cases, exceeded expectations of survival according to the TRISS methodology. The lack of immediate attending surgeon's presence does not appear to have negatively influenced the outcome in these children. Based on this series, there is no evidence to justify mandatory immediate presence of an attending surgeon for these 2 criteria alone.

Adolescent↗
PubMed2004

Bypass versus angioplasty to treat severe limb ischemia: factors that affect treatment preferences of UK surgeons and interventional radiologists.

OBJECTIVE: There is continuing controversy as to whether surgical bypass or angioplasty should be first-line treatment of severe limb ischemia. We undertook this study to examine angiographic and clinical factors that influence the treatment of severe limb ischemia by vascular surgeons and interventional radiologists. METHODS: Twenty consultant vascular surgeons and 17 consultant vascular interventional radiologists evaluated 596 hypothetical clinical or angiographic scenarios, and recorded whether, in their opinion, the most appropriate first-line treatment was surgical bypass, angioplasty, or primary amputation. Stepwise multiple linear regression was used to identify the factors that significantly affected responses from the entire group and from surgeons and radiologists separately. RESULTS: There were significant differences between surgeons and radiologists with regard to how clinical and angiographic variables determined treatment preferences. Increasing disease severity, absence of runoff into the foot, presence of a suitable vein, and tissue loss as opposed to rest pain only (the latter only significant to surgeons) all increased the response score toward surgery. However, surgeons and radiologists weighted each of these factors quite differently. Even in the most complex statistical model, 19% of surgical and 13% of radiologic response variations remained unexplained. CONCLUSIONS: Individual surgeons and radiologists vary considerably in their views of the relative merits of surgery and angioplasty in patients with severe limb ischemia. This broad gray area mandates the need for randomized controlled trial data to inform joint decision-making and to optimize patient outcome.

Amputation, Surgical↗
PubMed2006

Non-technical skills for surgeons in the operating room: a review of the literature.

BACKGROUND: This review examines the surgical and psychological literature on surgeons' intraoperative non-technical skills. These are the critical cognitive and interpersonal skills that complement surgeons' technical abilities. The objectives of this paper are (1) to identify the non-technical skills required by surgeons in the operating room and (2) assess the behavioral marker systems that have been developed for rating surgeons' non-technical skills. METHODS: A literature search was conducted against a set of inclusion criteria. Databases searched included BioMed Central, Medline, EDINA BIOSIS, Web-of-Knowledge, PsychLit, and ScienceDirect. RESULTS: A number of "core" categories of non-technical skills were identified from 4 sources of data: questionnaire and interview studies, observational studies, adverse event analyses, and the surgical education/competence assessment literature. The main skill categories were communication, teamwork, leadership, and decision making. The existing frameworks used to measure surgeons' non-technical skills were found to be deficient in terms of either their psychometric properties or suitability for rating the full range of skills in individual surgeons. CONCLUSIONS: Further work is required to develop a valid taxonomy of individual surgeons' non-technical skills for training and feedback.

Cognition↗
PubMed2004

Patient, surgeon, and treatment characteristics associated with homologous blood transfusion requirement during radical retropubic prostatectomy: multivariate nomogram to assist patient counseling.

OBJECTIVES: To identify the preoperative patient, treatment, and surgeon factors associated with the administration of homologous blood transfusion during or after radical retropubic prostatectomy (RRP) to be able to better inform patients regarding the probability of transfusion. Homologous blood transfusion is sometimes required during or after RRP, but predictive models for estimating transfusion probability using patient and surgical characteristics are lacking. METHODS: Data were prospectively collected regarding patient characteristics, cancer severity, surgeon experience, anesthetic used, operative blood loss, and transfusion among 1123 consecutive RRP cases. Multivariate regression analysis identified baseline factors associated with a homologous transfusion requirement and generated a model for predicting the likelihood of perioperative homologous transfusion. RESULTS: Homologous transfusion was administered in 3.8% of subjects; the mean estimated blood loss was 953 mL. Multivariable regression analysis identified prostate size (P <0.0001, odds ratio [OR] 1.74), use of general anesthesia (P = 0.01, OR 2.22), use of neoadjuvant hormonal therapy (P = 0.006, OR 3.35), and surgeon expertise (P <0.0001, OR 8.63) as independent risk factors associated with a need for perioperative homologous transfusion. The most influential factor, surgical expertise, clustered among surgeons who performed more than 15 RRPs annually, because these surgeons had lower transfusion rates and lower estimated blood loss more consistently than did surgeons who performed fewer RRPs annually. CONCLUSIONS: Larger prostate size, use of general anesthesia, use of neoadjuvant hormonal therapy, and annual surgeon case volume were independently associated with an increased probability that an individual patient would receive homologous transfusion during or after RRP. A nomogram indicating the probability of homologous transfusion based on these factors provides a benchmark of expected homologous transfusion rates according to individual patient and treatment parameters.

Adenocarcinoma↗
PubMed1995

Institution and per-surgeon volume versus survival outcome in Pennsylvania's trauma centers.

BACKGROUND: The American College of Surgeons recommends minimum patient volumes for trauma centers and surgeons. Those numbers, however, are largely based on results from studies of surgical (but not trauma) relationships between volume and outcome. METHODS: Using stepwise regression, relationships were sought between measures of patient volume per trauma center and per surgeon and ana severity-controlled measure of survival outcome (W). For significant z values, W is the number of additional (or fewer) survivors, per 100 patients treated, than expected from ASCOT norms. W = 0 when z is nonsignificant. Data are from patients admitted in 1988 and 1989 to accredited Pennsylvania trauma centers. RESULTS: The relationships found for all patients and for adult blunt-injured patients are W = 0.3312 + 0.0200 (NSER/SURG) and W = 0.3638 + 0.0248 (NBSER/SURG), respectively, where NSER/SURG is the number of seriously, injured patients treated annually per surgeon and NBSER/SURG is the number of adult patients with serious blunt injuries treated annually per surgeon. Serious injury was defined, using the Injury Severity Scale, as > = 13 or, using the Abbreviated Injury Scale, as a head injury of > = 3. The relationships explained 36% and 61% of the variance in W (R2 for all patients and adult blunt-injured patients, respectively. To achieve normative survival (W =0), 95% confidence intervals suggest that a trauma surgeon should treat at least 35 seriously injured patients per year and at least 28 adult patients with serious blunt injury annually. No volume-related variable was a significant contributor to predictions of W for adult patients with penetrating injuries or for pediatric patients. CONCLUSIONS: These results support the regionalization of trauma care by affirming that increased per-surgeon experience in the treatment of seriously injured patients is associated with improved outcomes and help define the minimum experience needed to achieve normative survival. Prospective study of the relationship between volume and survival and other outcomes is required.

Adult↗