A. Yaghoubian et al. Appendicitis outcomes better at teaching hospitals 811 Some surgeons and patients believe that educating and Table 1 Morbidity and LOH outcomes in patients withtraining future surgeons conﬂicts with providing the best appendicitis managed at teaching and nonteachingpossible care to patients. Yet few data are available as to institutionswhether resident involvement in common surgical proce-dures adversely affects patient outcomes. In the current era Outcome Teaching Nonteaching Pof a heightened emphasis on patient outcomes, it is impor- Nonperforated appendicitis 2,289 10,385tant to document the effect of residents as primary surgeons. Wound infection 2.7% 2.3% .30Thus, the purpose of this study was to determine the out- Abscess drainage .4% 1% .02 Readmission within 30comes of appendicitis between teaching and nonteaching days 1.7% 3.5% Ͻ.0001institutions. LOH (days) 1.7 Ϯ 1.5 1.8 Ϯ 1.6 .002 Laparoscopic appendectomy 48% 68% Ͻ.0001 Perforated appendicitis:Methods operative 953 4098 Wound infection 4.8% 7% .03 After obtaining institutional review board approval, a Abscess drainage 4.9% 10% Ͻ.0001retrospective review of all appendicitis patients aged Ͼ 18 Readmission within 30years between 1998 and 2007 at 12 hospitals was per- days 4.2% 8.4% Ͻ.0001 LOH (days) 5.0 Ϯ 4.2 5.2 Ϯ 3.1 .30formed. Two were teaching hospitals (Harbor-UCLA Med- Laparoscopicical Center and Kaiser Permanente Los Angeles Medical appendectomy 23% 42% Ͻ.0001Center), and 11 were nonteaching Kaiser Permanente hos- Perforated appendicitis:pitals. At the teaching institutions, the surgical residents nonoperative 10% 6% Ͻ.0001are actively involved in all aspects of patient care. They are Data are expressed as numbers, percentages, or mean Ϯ SD.the ﬁrst to see consultations in the emergency room, serve asthe primary surgeons, direct the postoperative care, and seepatients back in clinic after discharge. Senior resident sur-geons at the teaching institutions typically serve as teaching perforated appendicitis rates were 29% at the teaching in-assistants for the appendectomy cases under attending su- stitutions and 28% at the nonteaching institutions (P ϭ .20).pervision. In contrast, there are no residents at the nonteach- Outcomes data are summarized in the Table 1. For non-ing institutions, and the attending surgeons perform all perforated appendicitis, there was no difference in theaspects of patient care. wound infection rate between teaching and nonteaching Patient factors collected included age, gender, and the institutions. However, there were lower rates of abscesspresence of perforation. Outcome variables were 30-day drainage (.4% vs 1.0%, P ϭ .02) and readmission (1.7% vsmorbidity and length of hospitalization (LOH). Thirty-day 3.5%, P Ͻ .0001) at teaching than at nonteaching institu-morbidity included wound infection, postoperative abscess tions, respectively. LOH was shorter at the teaching insti-drainage, and readmission. Outcomes of patients with ap- tutions. The use of laparoscopy for nonperforated appendi-pendicitis were compared between teaching and nonteach- citis was lower at the teaching institutions.ing hospitals. For perforated appendicitis, there were also lower rates All patient data were collected in an Excel spreadsheet of wound infection (4.8% vs 7.0%, P ϭ .03), abscess drain-(Microsoft Corporation, Redmond, WA) and translated into age (4.9% vs 10.0%, P ϭ .02), and readmission (4.2% vsnative SAS format using DBMS/Copy (Dataﬂux Corpora- 8.4%, P Ͻ .0001) at teaching than at nonteaching institu-tion, Cary, NC). Descriptive statistics were calculated for all tions, respectively. The LOH was similar. The use of lapa-variables. Numerical variables were compared using the roscopy for perforated appendicitis was lower at the teach-nonparametric Wilcoxon rank-sum test and are reported as ing institutions. However, nonoperative management ofmedians with interquartile ranges. Categorical or nominal perforated appendicitis was higher at the teaching institu-variables were compared using the 2 test or Fisher’s exact tions.test, as appropriate.Results Comments Overall, 3,242 patients with appendicitis were treated at There has always been controversy regarding the qualitythe teaching institutions and 14,483 at the nonteaching in- of care delivered at teaching hospitals. Academic surgeonsstitutions. The mean ages were 41 years at the teaching have the dual responsibility of ensuring the best possibleinstitutions and 38 years at the nonteaching institutions. care to patients while simultaneously training and educatingSixty-one percent of patients were male at the teaching future generations of surgeons. Thus, the ability to ade-institutions and 54% at the nonteaching institutions. The quately train surgical residents without compromising the
812 The American Journal of Surgery, Vol 200, No 6, December 2010quality of care is a concern for all faculty members involved appendicitis and a similar LOH for perforated appendicitis.in surgical education. The LOH at teaching hospitals may have been even shorter Previous studies examining other procedures have shown than stated because the rate of laparoscopic appendectomythat the quality of care at teaching and nonteaching institu- was also lower at teaching hospitals. We have recentlytions is similar.1–5 A prior pilot study by our institution, shown that LOH was shorter in patients undergoing lapa-which compared 1 teaching and 1 nonteaching hospital, roscopic appendectomy versus open appendectomy.9 Al-found comparable quality of care when outcomes for pedi- though we did not perform a formal cost analysis, weatric appendicitis were analyzed.6 Unlike our previous believe that cost at the teaching institutions was lowerstudy, this multi-institutional study demonstrated lower because both morbidity was lower and LOH was shortermorbidity for both adult perforated and nonperforated ap- compared with nonteaching institutions.pendicitis at teaching hospitals with respect to readmission In the present study, we also found that patients withrate, wound infection, and postoperative abscess drainage. perforated appendicitis were more likely to be managedMeguid et al,7 in a retrospective study of outcomes of lung nonoperatively at the teaching institutions. A potentialcancer resections, demonstrated a lower mortality rate at explanation for this ﬁnding is that teaching institutionsteaching hospitals. Similarly, a study by the same group were more willing to implement a fairly novel techniquefound a lower mortality rate for abdominal aortic aneurysm of nonoperative management on the basis of researchrepair at teaching hospitals although the length of stay was studies.10 –12 By contrast, the nonteaching institutionslonger.8 They attributed their improved outcomes to the performed a much higher rate of laparoscopic appendec-presence of specialty training and increased volume. The tomies compared with the nonteaching institutions. Theauthors hypothesized that the increase in length of stay was reason behind this observation was because one of thedue to sicker patients at the teaching hospitals. The limita- teaching institutions transitioned into performing laparo-tion of the prior mentioned studies is that they evaluated the scopic appendectomy at a much later date. This was dueoutcomes of complex procedures in which residents typi- mainly to resistance from the attending surgeons tocally play the role of assistants rather than primary sur- change in techniques, and it was the residents’ inﬂuence that ultimately led to the change in practice. Currently,geons. Looking at more routine operations, Hwang et al1 nearly all patients with appendicitis will undergo laparo-performed an analysis of outcomes of bowel resection, lapa- scopic appendectomy at both institutions.roscopic cholecystectomy, hernia, mastectomy, and appen- There were several limitations of this study. First, this isdectomy of 4 attending surgeons who worked with residents a retrospective analysis and by nature had its limitations.versus 4 who did not. Comparing all procedures together, We did not evaluate the length of the operation, which maythere were no differences in complications between the understandably take longer at the academic institutions andgroups, although there was greater mortality, a greater du- contribute to increased costs of the operating room, asration of stay, and higher costs in the resident group. When demonstrated by other studies. Furthermore, the overall lowcomparing the 5 most common procedures individually, morbidity and mortality of appendicitis may offset the in-there was no difference in complications or mortality, al- creased risk for resident-related errors in patient manage-though a greater length of stay and higher costs were seen in ment. We also did not review the number of cases thatthe teaching group. began laparoscopically and required conversion to open In general, similar or improved outcomes at teaching appendectomy between the 2 types of institutions. Last,institutions have come at the expense of increase LOH and teaching hospitals may be inherently different from non-thus higher cost. A study by Hutter et al2 in the evaluation teaching hospitals independent of the presence of residentsof pancreatic resections also demonstrated improved out- or students.comes at the teaching hospitals, but they found a longer Our data demonstrate that teaching hospital care oflength of stay and attributed this to their care of uninsured patients with appendicitis is associated with improvedpatients. In a subset analysis, the uninsured patients had the outcomes. In addition, patients at teaching institutionslongest length of stay (27 vs 20 days). Unlike previous with perforated appendicitis were more likely to be man-studies, in our pilot study comparing outcomes of pediatric aged nonoperatively at teaching institutions comparedappendicitis, we found a decrease in the LOH for children with nonteaching institutions. In general, our data refutewith nonperforated appendicitis.6 Because the decrease in the notion that there is a conﬂict between training futureLOH was only .4 days, one can argue that this may not be surgeons and simultaneously providing the best possibleclinically signiﬁcant. One possible explanation for this ﬁnd- patient care.ing is that more patients at the teaching institution may havebeen discharged in the evening rather than the next morninggiven the availability of the resident team. If this were Referencesindeed the case, then this would have led to substantial costsavings in this group of patients, making this ﬁnding clini- 1. Hwang C, Pagano CR, Wichterman KA. Resident versus no resident:cally signiﬁcant. In this current multi-institutional study, we a single institutional study on operative complications, mortality, andalso found a slight decrease in LOH for nonperforated cost. Surgery 2008;144:339 – 44.