The impact of team familiarity and surgical experience on operative efficiency: a retrospective analysis

Abstract

Objectives: The independent impact of individual surgical experience and team familiarity on surgical performance has been widely studied; however, the interplay of these factors and their relative, quantified, contributions to performance is poorly understood. We determined the impact of team familiarity and surgeon, and cumulative team experience on operative efficiency in total knee replacement.

Design: Retrospective analysis of all total knee replacements conducted at the host institution in 1996-2009. Multivariate generalised-estimating-equation regression models were used to adjust for patient risk and clustering.

Setting: Tertiary care academic hospital.

Participants: All patients undergoing TKR at the host institution in 1996-2009.

Main outcome measure: Operative efficiency.

Results: A total of 4276 total knee replacements were completed by 1163 different surgical teams. The median experience level was 17.6 years for consultant surgeons and 3.7 years for trainee surgeons. After patient-risk adjustment, consultant surgical experience (p < 0.0001), trainee surgical experience (p < 0.05), cumulative team operative experience (p < 0.0001) and team familiarity (p < 0.0001) were associated with significant reductions in operative time. Surgical experience and team familiarity demonstrated concave and linear relationships with operative time, respectively. For a consultant surgeon, the expected reduction in operative time after 25 years in practice was 51 min, compared to a 21-min reduction over the span of 40 collaborations with the same team members.

Conclusions: Surgical experience and team familiarity display important and distinct relationships with operative time in total knee replacement. Appreciation of this interplay may serve to guide implementation and allocation of procedure-specific quality improvement strategies in surgery.

Keywords: Learning curve; collaboration; operative efficiency; performance curve; teamwork; total knee replacement.

Figure 1.

Total knee replacement consultant surgeon learning curve. Raw observed data are shown in grey. Adjustment for patient case-mix (dashed black line) reveals that consultant surgeons’ growing operative experience was associated with reductions in operative time over the course of the procedural learning curve, reaching a plateau at approximately 26 years.

Figure 2.

Reductions in expected operative time as a function of cumulative team experience. Raw observed data are shown in grey. After adjustment for patient case-mix, cumulative team experience versus operative time demonstrated similar improvements in operative efficiency through 31 years of combined consultant/trainee experience (dashed black line).

Figure 3.

(a) Expected operative time as a function of team familiarity. Increasing team familiarity between discrete consultant–trainee surgeon pairs was independently associated with a reduction in both operative time and operative time variance. (b) Risk-adjusted operative time as a function of team familiarity. Operative time displayed a linear relationship with team familiarity.