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Influence of Fellowship Programs and In-house On-Call Attending Surgeon

Saman Arbabi, MD, MPH; Gregory J. Jurkovich, MD; Frederick P. Rivara, MD, MPH; Avery B. Nathens, MD, PhD, MPH; Maria Moore, MPH; Gerald B. Demarest, MD; Ronald V. Maier, MD

Arch Surg. 2003;138:47-51.

Background  There are very few data on characteristics or policies that improve patient outcomes in academic medical institutions. We were interested in 2 such policies or characteristics that are commonly implemented in academic centers: an in-house on-call attending physician policy and the existence of postgraduate medical education.

Hypothesis  An in-house attending surgeon on-call policy and the presence of trauma and critical care fellowship programs improve outcomes of critically injured patients.

Design  Multicenter cohort study. Two cohorts were analyzed: blunt trauma (n = 601; mortality, 16.0%) and penetrating abdominal trauma (n = 503; mortality, 7.5%).

Setting  Thirty-one academic level I trauma centers, 10 (32.3%) with in-house on-call policy and 11 (35.5%) with fellowship programs.

Main Outcome Measures  Mortality, hospital length of stay, and intensive care unit length of stay.

Results  In-house on-call surgeon policy had no impact on mortality or length of hospital or intensive care unit stay for either the blunt or penetrating trauma cohort. However, the presence of fellowship programs was associated with a significant decrease in blunt trauma mortality (odds ratio, 0.4; 95% confidence interval [CI], 0.1-0.8) and a decrease in length of intensive care unit stay (mean difference, 4.7 days; 95% CI, 0.6-8.8 days) and hospital stay (mean difference, 3.2 days; 95% CI, 0.6-5.9 days). There were no significant effects of fellowship programs on penetrating trauma outcomes.

Conclusions  An in-house on-call attending surgeon policy is not associated with improved outcomes. In contrast, presence of a trauma and surgical critical care fellowship program, a potential surrogate marker for an institution that is committed to this specialty interest, is associated with improved outcomes for critically injured patients. An investment in advanced postgraduate medical education has potential benefits in patient care and outcomes.

From the Department of Surgery, University of Michigan Medical Center, Ann Arbor (Dr Arbabi); Department of Surgery, University of Washington School of Medicine, Harborview Medical Center (Drs Jurkovich, Nathens, and Maier), and Harborview Injury Prevention and Research Center (Dr Rivara) Seattle; University HealthSystem Consortium, Chicago, Ill (Ms Moore); and Department of Surgery, University of New Mexico School of Medicine, Albuquerque (Dr Demarest).

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