May 2020

ASCRS NEWS

Eyeworld Journal Club
Review of “Effect of full time vs. volunteer faculty on resident cataract surgery complications”


by Rabia Karani, MD, Maryam Ghiassi, MD, Ives Valenzuela, MD, Royce W.S. Chen, MD, Leejee Suh, MD, and Noga Harizman, MD


Royce W.S. Chen, MD
Residency program director
Edward S. Harkness Eye Institute
Columbia University
Medical Center
New York, New York


From the Edward S. Harkness Eye Institute, Columbia University Medical Center, New York Presbyterian Hospital:
top from left: Noga Harizman, MD, Royce W.S. Chen, MD; middle from left: Rabia Karani, MD, MPH, Leejee Suh, MD; bottom from left: Maryam Ghiassi, MD, MHS, Ives A. Valenzuela, MD
Source: Columbia University Medical Center

Many of us attend resident cataract surgery. Whether having volunteer or full time faculty attendings makes a difference in complication rates is evaluated in a May JCRS paper. I asked the Columbia residents to review this paper during the COVID-19 lockdown.

—David F. Chang, MD EyeWorld Journal
Club Editor


In the study, “Effect of full time vs. volunteer faculty on resident cataract surgery complications,” the authors review resident cataract surgery cases performed under the supervision of full time vs. volunteer faculty with at least 10 years of post-residency surgical experience. Cases were stratified by level of risk to determine if teaching experience, as quantified by volunteer vs. full time faculty status, had an effect on intraoperative complication rates.
This study is important in a time with decreasing surgical reimbursement, as intraoperative time and material use are becoming increasingly relevant. Given these conditions, resident cases may become more limited especially on a per attending basis. By incorporating volunteer attendings into resident education, residents have increased opportunity to perform surgeries. This technique has proven to be beneficial in other specialties like OBGYN in increasing surgical volume.1 Studies have shown that attending experience is a risk factor for intraoperative complications,2 but this has not been separated into surgical vs. teaching experience. This study seeks to assess teaching experience as a risk factor for intraoperative complications by comparing volunteer and full time attending ophthalmologists; understanding its effect could both improve resident training and patient outcomes. 
The authors conducted a retrospective chart review of resident cases from 2010 to 2017 in which residents were supervised by an anterior segment attending with 10 or more years of experience. The authors of this study created a risk stratification score for cataract cases by looking at preoperative risk factors such as presence of pseudoexfoliation, proliferative diabetic retinopathy, prior vitrectomy, 4+ dense, white or brunescent cataract, current tamsulosin use, pre-existing zonular dialysis, intraoperative use of iris hooks, or other pupillary expansion device. This scale was similar to other grading rubrics for cataract surgery risk factors that have been published previously,2–6 including one study that validated a previously identified scale,7 and the authors did show that there was a statistically significant difference in complication rate between each category, with complication rates increasing with higher risk categories, providing validation for this scale. Complication rates between the two supervising attending groups were compared in each risk category using clustered logistic regression analysis.
The authors found a statistically significant difference in complication rates among simple, intermediate, and complex cases, with complex cases showing the highest complication rates. The authors did not find a statistically significant difference in any risk category among low-, intermediate-, and high-risk cases in terms of intraoperative complications between full time and volunteer faculty. Although there was no statistical significance in either category, the study suggests that there did seem to be a higher non-statistically significant rate of intraoperative complication in the high-risk category for volunteer attendings. In terms of secondary endpoints, the authors did find a difference between the types of complications seen between full time and volunteer attendings. The authors did not note any statistically significant difference in terms of complication rates for individual attendings during this study.
The results show that complication rates increased with increasing complexity between cases, as expected, thus adding to the known literature on the fact that increased preoperative risk leads to increased intraoperative complications.5,8,9 The fact that there was no statistically significant difference in complication rates supports the idea that there was no significant bias in this way between attendings. 
There was no statistically significant difference in complication rates between volunteer and full time attendings in the three case complexity categories. The authors conclude that volunteer faculty can be safely integrated into residency training programs and would benefit programs by helping increase resident case volume and by exposing residents to diverse surgical techniques. The authors point out that while this can be concluded for lower-risk cases, further exploration is needed for intermediate- and high-risk cases as the numbers in both of these categories were small and may not have had adequate power to make any conclusions. 
This paper has several strengths. The first is that it included 1,377 cases, thereby providing adequate statistical power in lower-risk cases.10 The second is that it incorporated a grading scale for presumed patient risk prior to cataract surgery. This scale was developed based on prior studies looking at high-risk factors for cataract surgery complications. The scale’s accuracy was verified by the fact that the complication rates increased with increased risk category. The third strength is that this study only included experienced attendings that were 10 years or more post-residency. Having extensive surgical experience helped decrease bias regarding surgeon skill and allowed the study to focus on teaching ability. Finally, this study used a clustered logistic regression model to decrease biases between individual surgeons.
The limitations of this paper are as follows. First, this study was limited to data from only one residency program. Different factors within that program such as internal bias toward attending selection, attending availability, and attending preference for second- vs. third-year ophthalmology residents could have played a role in the rates of intraoperative complications. Additionally, clarification of when residents were allowed to perform more complex cases based on their level of training would be valuable as this could directly affect complication rates as well. The study would have benefited from including additional residency programs if the diverse role of volunteer vs. full time attending faculty were being evaluated. Second, the study noted mostly intraoperative complications; however, many significant complications of cataract surgery such as endophthalmitis, postoperative inflammation, and postoperative elevated pressure occur days after the surgery. These complications would be helpful in comparing full time vs. volunteer faculty as they could provide details on differences in supervision in the postoperative period. Finally, an increased number of intermediate- and high-complexity cases would have allowed for more robust analysis of the differences in complication rates between full time and volunteer faculty in more complex cases. 
Ultimately, the goal of this study was to determine whether attending teaching experience plays a role in intraoperative complication rates in resident cataract cases, assuming that full time faculty spend more time in their careers working and operating with the residents. Volunteer vs. full time faculty status does not necessarily reflect years of teaching experience, as it is possible that current full time attendings were previously in private practice and vice versa. We therefore think it will be beneficial to evaluate years of teaching experience in order to answer this question. It would additionally have been beneficial to include surgical case volume with the residents for each attending, as this is not necessarily reflected in full time vs. voluntary faculty status. Specifically, a multi-institution retrospective comparison of resident intraoperative and postoperative outcomes based on attending teaching experience and surgical case volume with residents is needed to more definitively answer the question of whether teaching experience has an effect on complication rates. Moreover, ultimate surgical outcomes for patients, such as vision and IOP after surgery,11 should be included in any future studies to determine true outcomes after surgery.

Contact

Chen: rc2631@cumc.columbia.edu

References

1. Kim DS, et al. Implementing a teaching service for voluntary faculty in obstetrics and gynecology: long-term results. J Reprod Med. 2013;58:371–376.
2. Najjar DM, Awwad ST. Cataract surgery risk score for residents and beginning surgeons. J Cataract Refract Surg. 2003;29:2036–2037.
3. Gupta A, et al. Cataract classification system for risk stratification in surgery. J Cataract Refract Surg. 2011;37:1363–1364.
4. Puri S, et al. Comparing resident cataract surgery outcomes under novice versus experienced attending supervision. Clin Ophthalmol. 2015;9:1675–1681.
5. Rutar T, et al. Risk factors for intraoperative complications in resident-performed phacoemulsification surgery. Ophthalmology. 2009;116:431–436.
6. Woodfield AS, et al. Intraoperative phacoemulsification complication rates of second- and third-year ophthalmology residents a 5-year comparison. Ophthalmology. 2011;118:954–958.
7. Blomquist PH, et al. Validation of Najjar-Awwad cataract surgery risk score for resident phacoemulsification surgery. J Cataract Refract Surg. 2010;36:1753–1757.
8. Briszi A, et al. Complication rate and risk factors for intraoperative complications in resident-performed phacoemulsification surgery. Graefes Arch Clin Exp Ophthalmol. 2012;250:1315–1320.
9. Biró Z, Kovacs B. Results of cataract surgery in previously vitrectomized eyes. J Cataract Refract Surg. 2002;28:1003–1006
10. Ellis EM, et al. Complication rates of resident-performed cataract surgery: Impact of early introduction of cataract surgery training. J Cataract Refract Surg. 2018;44:1109–1115.
11. Zafar S, et al. Outcomes of resident-performed small incision cataract surgery in a university- based practice in the USA. Clin Ophthalmol. 2019;13:529–534.

Review of “Effect of full time vs. volunteer faculty on resident cataract surgery complications” Review of “Effect of full time vs. volunteer faculty on resident cataract surgery complications”
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