Our next paper is the winner of the Robert Florin Award. Dr. Florin was a long-time leader in neurosurgery in the world of socioeconomic issues, and as many of you are aware, he passed away this past February. The title of the paper is Change in Policy Allowing Overlapping Surgery Decreases Length of Stay in an Academic Safety Net Hospital. It will be presented by Dr. Anthony DiGiorgio, discussed by Dr. Barker in terms of statistics, and a general discussion by Dr. William Caldwell. All right, well, thank you. Thank you to AANS and the scientific section for allowing me to speak in this very generous award. I'm very honored and humbled to be here today. So my name is Anthony DiGiorgio. I'm a PGY-6 here at LSU in New Orleans, and this is a study that was largely undertaken at our interim LSU hospital, which is one of the iterations of Charity before the newest Charity Hospital there that you can see the picture of. This project was largely conceived during my research year where I was fortunate enough to spend some time at UCSF with Dr. Mumineti, so I wanna make sure and acknowledge and thank him for all his input on this project. But these patients were all from our hospital here down at LSU. And I'll be talking about our overlapping surgery policy. First of all, no financial disclosures. This is kind of a controversial subject. As I'm sure as many of us know, because of this article here in the Boston Globe that was out in 2015, it documents a case where a spine surgeon happened to be running overlapping rooms and had a few high-profile complications. This led to the dismissal of the surgeon, but the investigative team, the spotlight team, kind of did some digging, and they found some unfriendly emails and quotes from some of the administrators and staff. And you can see one of the quotes up there. So it was an article that really painted surgeons in sort of a bad light. And I'm sure rubbed many of us in the wrong way if we had the chance to read it. And the follow-up article was also a little bit inflammatory. This was the headline. And yes, the Senate did, in fact, meet and discuss overlapping surgeries, but no, they did not call for a ban. If you actually read the Senate Finance Committee report, they said there were additional measures that were warranted. And some of those measures, the first one was they wanted patients to be informed, which I think is very reasonable, and we would all agree with that. And if you look at the study from the American College of Surgeons, it looks that patients really aren't aware of this practice. Only about 4% knew that overlapping surgery occurs, and only about a third, less than a third, actually support it. So if this is something that we think as a profession is beneficial, maybe we have a little PR campaign that we need to wage. And then the other issue with the Senate was, is this a safe practice? And this is something that I think has actually been shown pretty robustly in the literature. There's been quite a few very large, well-put-together studies that span the breadth of general surgery, neurosurgery, and orthopedic surgery, where they have directly compared patients that are operated in overlapping rooms versus patients that are operated in non-overlapping rooms, and found that these patients have similar rates of adverse events and complications, really showing that the policy of overlapping rooms is pretty safe for our patients. There is one study I should mention that recently came out a couple months ago out of Canada, which showed that in an orthopedic group that did about 2% of their cases in an overlapping manner, that 2% had a slightly higher increase in complication rate. But you can draw your own conclusions about a 2% sample. I think this data overwhelmingly shows that this is a pretty safe practice. So what if it were banned? I'm sure many of us that benefit from utilizing overlapping surgeries had some concerns when the Senate's Finance Committee was talking about possibly banning this. And this is an article that was out of Forbes Magazine, written by Dr. Richard Menger up in Shreveport, a very well-put-together article where he kind of elucidates many of the points that were made, I'm sure that many of us are thinking about if we thought about banning the surgery. It's certainly worth a read, but a very good opinion piece. And of course, I started thinking about our hospital, what if this policy were banned in our hospital? How would it affect our patient population? And it so happens that our hospital kind of put together a reverse experiment in this, because at one point, we did not have any overlapping surgery, and then we slowly transitioned into having two first starts, two days a week. And it wasn't so much the fact that we got those two first starts two days a week, it was that this sort of represented a policy shift and an idea shift in our hospital, where the other days of the week, if OR time were to open up, the hospital really had no problem with us running overlapping rooms. And it kind of cemented an official policy of saying, yes, overlapping surgery is gonna be allowed by your service. The change was gradual, so I simply wanted to compare the patient cohorts before and after this policy change. I was sort of limited at this seven-month time period, because about nine months before the policy change, we transitioned from paper charts to electronic medical records, and the ORs were essentially shut down for that. So I didn't want those compounding variables in our study. So it sort of limited me, but I was able to get a decent-sized patient cohort on either time of this policy change. Now, I really just wanted to look at the cohort as a whole, because I think that that individual cases that are operated on in overlapping rooms, that's been shown to be safe. So I wanted to look at the effect of the patient population as a whole. Of note, despite being a level one trauma center, one of two in the state, we are somewhat understaffed, and usually the elective schedule, or the entire OR schedule for any given day, is covered by one staff neurosurgeon during this time period, one chief resident and one lower-level resident with no mid-level providers. There is, of course, a backup surgeon designated for the overlapping rooms, but generally, we weren't just able to add more staff to cover the second room. So here are our data, here are the patient numbers. You can see, obviously, our elective case volume went up. This is to be expected with more OR time, but I really wanted to hone in and focus on these urgent cases, because these are the cases that come in through the ER that you have to fit into an already-packed elective schedule. These are the cases that, really, you can't dispo these patients, you can't get them on the road to recovery until they receive surgical treatment. And these are the ones that kind of are tough to fit in. As you can see here, in panel A, if you're not allowed to run overlapping rooms, these urgent add-ons have to be put at the end of the day, and we all know, once you pass that witching hour, there's no telling if you're even gonna get OR time to get these cases done. So oftentimes, they end up waiting until late at night, or getting pushed off day after day until you can finally, by some fortuitous timing, find some OR time. However, if you're allowed to run overlapping rooms, as you can see in panel B, you can easily fit that urgent add-on, and you can even picture putting in another short elective case or two to really make sure you have good utilization of your operative resources. So what did our data show here? The patient demographics before and after the policy shift, referred to as one room and two room here. They're pretty well-matched in terms of gender and age and insurance breakdown. And I do wanna focus up a little bit more on the insurance breakdown because of that initial quote, sort of, I'm sure, rubbed many of us the wrong way. This is our patient population, and this is comparing it to Louisiana in general. So this is a patient population that really exemplifies our safety net status. This is a charity hospital. It's in our charter. We accept all comers, regardless of their ability to pay. And you can see that, largely, these patients are being funded by public funds. These are a vulnerable patient population. These are not patients that are here making the hospital and the physicians a whole lot of money. These are vulnerable, needy patients that have to have their surgical needs met one way or another. In terms of indications and case types between the two groups, we do a lot of trauma in a delayed fashion, sort of the spinal cord stabilizations, spinal cord injury stabilizations. We do a lot of tumors that come through the ER that are pretty advanced and require surgery. A lot of advanced degenerative spines, cervical myelopathy, what have you. And about three quarters spine versus a quarter cranial cases, and pretty well-matched between the two groups. The outcomes is where we really see the difference. And if you look at the wait time, it took patients about two days quicker to get surgery once we were allowed to have overlapping rooms. This was not statistically significant. It trended towards significance. But what was significant was this two-day reduction in wait time for surgery ballooned into a six-day reduction in length of stay. And why would that happen? Well, if you look at the medical complication rates, the patients that aren't sitting around for those extra two days waiting for surgery have a far lower rate of medical complications than the things you get when you're sitting around waiting for surgery. Hospital-acquired infections, dementia, or excuse me, delirium, DVTs, things like that dropped significantly when we were allowed to operate on patients in a more timely manner. And this also, of course, led to an increased discharge-to-home rate. Again, let me reiterate, these are patients that are funded by taxpayer dollars, by public funds. If they're not going home, that means they're going to someplace else that's gonna end up costing more money. The surgical complications and 30-day readmissions were equivalent, which tells me that the surgical quality that they're getting is equivalent to those in the two groups, and it trended towards $50,000 just inpatient hospital charges reduction in two rooms, although this did not meet statistical significance. We did regression modeling, a multivariate regression with a negative binomial modeling because it is a count variable with a significant skew, and it did show that being in a non-overlapping cohort showed a significant correlation with an increased length of stay, a few other variables there. And then in univariate, again, the patients that had a significantly high length of stay correlated with a high wait time and increased hospital charges. I'll admit there's very many limitations to this study. It's a retrospective cohort. It was done using chart reviews. It's a very heterogeneous population, trauma, tumor, aneurysms, what have you, and it is a relatively small sample size. Again, I was somewhat limited by the cohort that I could use in this, but I still think that in conclusion, it does show that operating in overlapping rooms, allowing this policy is really beneficial for our patients. I think this is a very, very vulnerable patient population. If some administrators were to step in and ban this from being able to occur, it would severely harm our patients. These are patients that come to us in need and don't have the option of just going to any hospital they choose. So I think it's not only been shown to be safe, but it's actually very beneficial for patients. Again, I have to acknowledge Dr. Mumineti, my program director, Dr. Wilson, my chairman, Dr. Klikia, for all their support. They've been great. And of course, my program in general. I work with some very talented, wonderful human beings, so I'm very fortunate, and I have to thank them and thank you all for your time. Thank you. This paper reports short-term outcomes in two groups of general neurosurgical patients. The first operated in an era without overlapping surgery, and the second in an era with potentially overlapping surgery, with a single attending surgeon operating in two rooms. The actual prevalence of overlap during the second era was not reported, but with 25% larger case volumes, we might guess that about half of cases or more overlapped. Let's focus on the safety outcomes because this has been the emphasis of news coverage and public concern. Surgical complications and 30-day readmissions showed no significant change, and medical complications decreased in the overlapping cohort. The lack of statistical significance, though, is not proof that there was no clinically significant change in these outcomes. Calculating confidence intervals, we can't exclude a doubling of surgical complications or, in risk difference terms, a 10% increase. We need confirmation from other studies to be completely sure there is no meaningful harm from overlapping surgery. Well, thank you, and I thank the Scientific Program Committee for the opportunity to comment on this paper. Could I get my slides up, please? So, I have no relevant disclosures. Overlapping surgery is defined as the practice of running more than one operating room simultaneously when the critical portions do not overlap. It's been a common practice in academic medical centers, largely to enhance access to care, training of residents, and allow efficient use of the operating room for the most part, especially in those training programs where the turnover times are so long. It's obviously become a very controversial issue. The current study examined the policy of a change in surgery scheduling that allowed overlapping rooms, and when they compared the patient's outcomes before and after the change, they noted that patients having surgery in the post-change period were found to have shorter length of stay, a lower instance of medical complications, and a higher rate of discharge to home. So, now there are numerous publications that have supported the safety profile of overlapping neurosurgical procedures. This is from our group and many other groups in the country. But this represents the first study demonstrating actually a positive effect on the outcomes for patient care. There's a preponderance of evidence suggesting overlapping neurosurgical operations may be undertaken safely if the operating framework is controlled. I want to note that in the Canadian study mentioned by Dr. DiGiorgio, the majority of the assistants in the operating room were non-orthopedic surgeons, and they were family doctors as well. So, as shown by Dr. DiGiorgio and colleagues, this allows for more expeditious management of urgent cases, improving outcomes. What hasn't been emphasized in any of these papers is that this experience provides enhanced number of cases for the operating surgeon, increasing their competency, and optimizing outcome in the well-established volume outcome relationship. So, the pushback is public perception. So, where do we go from here? Well, here's a suggestion. We should reframe the discussion into one of team neurosurgery with lifelong learning. This can be actually implemented using the established program we have in our residency already. We have milestones in our training programs, and we could credential each of our residents to be able to open and close independently at the appropriate level, much as we do with the placement of external ventricular drains. So, we have a mechanism to do this now. Thank you.

Robert Florin Award

overlapping surgery

Dr. Anthony DiGiorgio

Dr. Barker

Dr. William Caldwell