Journal of Clinical & Experimental Orthopaedics

Commentary

Since the publication of the Boston Globe article “Clash in the Name of Care” [1] was published in October of 2015, there has been a significant increase in attention surrounding the topics of overlapping and concurrent surgery. The dilemma that has been brought forth questions patient wellbeing versus efficient use of medical resources. This mainstream media attention has led to a subsequent sharp increase in publications on the topics of overlapping and concurrent surgery. While often used synonymously, overlapping and concurrent surgery differ based on what portions of the operations overlap. Concurrent surgery involves the overlap of two “critical portions”. Overlapping surgery involves the overlap of one “noncritical portion” with either a critical portion or another noncritical portion. The United States Senate deemed concurrent surgery “not appropriate” in elective operations [2]. These federal guidelines and publications serve as initial empirical data for physicians and medical staff to determine whether overlapping surgery is safe, ethical, and efficient.

Recent literature on safety of overlapping procedures demonstrates that this phenomenon is generally felt to be safe. One of the first studies published looking at outcomes in the ambulatory setting following overlapping and nonoverlapping surgeries showed no statically significant differences in operating room time, procedure time, and 30-day complication rates [3]. The neurosurgical literature similarly supports the practice with a recent study showing no association between overlapping surgery and serious complications [4]. A large study at a high-volume academic referral center supported the safety of overlapping procedures at their institutions showing no differences on mortality or length of stay [5]. A look at patients who underwent neurosurgical procedures at another major academic medical center showed that patients who undergo overlapping surgeries failed to have a correlation with mortality, morbidity, or worsened functional status as compared to patients who underwent non-overlapping procedures [6]. These studies support the safety of overlapping surgery and echo the general sentiment of many surgeons who feel in the appropriate setting the practice is safe.

Given this evidence based support of the practice it’s reasonable to assume overlapping surgery will continue to exist in years to come. The next step is to improve quality of care becomes understanding what patients know and feel about overlapping surgery. Two recent studies have shown that a small minority of the general public is aware of the practice of overlapping surgery and the majority of responders were not supportive of the practice [7]. Generally, patients and family members were neutral to uncomfortable with concurrent and overlapping surgery procedures. Furthermore, many patients believed that surgeons are operating two rooms for the primary purpose of increasing hospital revenue [2].

Given this, it is imperative that providers further recognize patient understanding of attending versus resident role in the operating room and the safety of overlapping surgeries. Additionally, educating the patient and their families on what to expect before, during and after surgery, can go a long way in assuaging fear and anxiety, and creating a more pleasant experience for the patient. Correcting common misconceptions is also an important aspect of this education. Finally, as transparency in surgery increases, physicians must continue to work together with patients to provide the safest most efficient and highly evidence-based care to ensure good outcomes.

References

1. Abelson J, Saltzman J, Kowalczyk L, Allen S (2015) Clash in the name of care. Boston Globe 25.
2. Edgington JP, Petravick ME, Idowu OA, Lee MJ, Shi LL (2017) Preferably Not My Surgery: A Survey of Patient and Family Member Comfort with Concurrent and Overlapping Surgeries. J Bone Joint Surg Am 99: 1883-1887.
3. Zhang AL, Sing DC, Dang DY, Ma CB, Black D, et al. (2016) Overlapping surgery in the ambulatory orthopaedic setting. J Bone Joint Surg Am 98: 1859-1867.
4. Guan J, Karsy M, Brock AA, Couldwell WT, Kestle JRW, et al. (2017) Impact of a more restrictive overlapping surgery policy: An analysis of pre- and postimplementation complication rates, resident involvement, and surgical wait times at a high-volume neurosurgical department. J Neurosurg 3: 1-9.
5. Hyder JA, Hanson KT, Storlie CB, Glasgow A, Madde NR, et al. (2017) Safety of overlapping surgery at a high-volume referral center. Ann Surg 265: 639-644.
6. Howard BM, Holland CM, Mehta CC, Tian G, Bray DP, et al. (2017) Association of overlapping surgery with patient outcomes in a large series of neurosurgical cases. JAMA surg.
7. Kent M, Whyte R, Fleishman A, Tomich D, Forrow L, et al. (2017) Public perceptions of overlapping surgery." J Am Coll Surg 224: 771-778.