Getting better with age: Older surgeons have lower patient mortality rates

The older a surgeon gets, the lower the patient mortality rate, with female surgeons in their 50s having the lowest rates overall, according to research led by Yusuke Tsugawa, MD, MPH, PhD, assistant professor at the University of California, Los Angeles.

Published in the BMJ, Tsugawa and his coauthors examined record of more than 892,000 Medicare patients who had one of 20 common types of emergency surgery between 2011 and 2014. These included the most common non-cardiovascular surgeries, like hip and femur fracture and appendectomy, along with four cardiovascular procedures: carotid endarterectomy, heart valve procedures, coronary artery bypass grafting, and abdominal aortic aneurysm repair.

Using data only from non-elective surgeries performed within three days of hospital admission minimized the bias in the results caused by patients choosing their surgeons based on age or gender or by surgeons choosing patients based on severity of illness. More than 45,000 surgeons were included in the study.

The study found when broken down by age group and adjusted for various patient characterists, mortality rates were 6.6 percent for surgeons younger than 40, then fell for each older age group: 6.5 percent for those aged 40 to 49, 6.4 percent for those aged 50 to 59 and 6.3 percent for surgeons age 60 and older.

“The accumulation of skills and knowledge from experience may lead to better surgical performance,” Tsugawa and his coauthors wrote. “We found the strongest association between surgeons’ age and operative mortality among surgeons with high and medium operative volumes, suggesting that surgeons with sufficient operative volume accumulate the skills and experience needed to improve surgical performance over the course of their careers (on the contrary, surgical performance may deteriorate for older surgeons if they perform only a small number of procedures).”

Researchers found no significant difference in mortality rates based on whether the surgeon was male or female. The study did note the wide gender gap, however—only 10.1 percent of surgeons were female and within the same hospital, female surgeons were generally younger (43 years versus 43.9 years) and performed fewer procedures (39.9 versus 72.9).

The lowest mortality rate among all groups was achieved by female surgeons aged 50 to 59. Overall, the researchers found no gap in quality between male and female surgeons, yet noted women continue to be paid less than men in surgical specialties and are less likely to be full professors at U.S. medical schools.

Tsugawa and his coauthors said their results were evidence of a long “learning curve” in surgical practice. While the researchers acknowledged the possibility of self-selection by surgeons, with the lower skilled ones not performing procedures and moving towards administrative work, as one explanation for their findings, they also suggested more oversight and supervision in surgeons’ early post-residency career may be helpful in saving lives.

“Although the difference in operative mortality between younger and older surgeons was modest, a 5 percent difference in odds of mortality between surgeons aged under 40 years and those aged 60 years or over is a clinically meaningful difference,” Tsugawa and his coauthors wrote. “These results, if causal, suggest that for every 333 Medicare beneficiaries who undergo surgery in the US, one fewer death would occur if surgical quality of care was equivalent between younger and older surgeons.”