Importance:Sleep timing regularity is increasingly recognized as a determinant of cognitive performance, yet its influence on surgeons' well-being and patient safety remains unexplored. Objective:To evaluate the association between surgeons' sleep timing regularity and major adverse events in their patients. Design, Setting, and Participants:This multicenter prospective cohort study was conducted from November 1, 2020, to December 31, 2021, across 14 surgical departments in 7 specialties at 4 university hospitals in France. Patients were excluded if they were younger than 18 years, underwent palliative surgery, had incomplete operative time stamps, or were operated on by surgeons with invalid sleep data. Study data were analyzed from January to June 2025. Exposures:Surgeons' sleep was continuously monitored using actigraphy. Sleep timing regularity in the 30 days preceding surgery was quantified using midsleep time (midpoint between bedtime and get-up time). Social jet lag (SJL) was defined as the absolute difference between midsleep times on free days and workdays, and midsleep time variability was the SD of daily midsleep times. Main Outcomes and Measures:Outcomes included major adverse events within 30 days postoperatively, including inpatient death, prolonged intensive care unit stay, reoperation, or severe complications. Mixed-effects multivariable models were adjusted for surgeon sleep duration, midsleep time, age, sex, professional status, working hours, night shifts, patient case mix (ie, a composite risk score incorporating patient comorbidities and surgery characteristics), and time of incision, with a random effect for surgeons. Surgeon burnout was assessed using the Maslach Burnout Inventory. Results:Among 7117 operations (7117 patients; mean [SD] age, 55.9 [17.5] years; 3877 female [54.5%]) performed by 38 attending surgeons (mean [SD] age at study start, 46.1 [8.5] years; 30 male [79%]), 1410 (19.8%) resulted in a major adverse event. SJL of 2 or more hours (342 operations [4.8%]; 7 surgeons) was associated with increased risk of major adverse events compared with less than 1 hour (adjusted relative risk [RR], 1.36; 95% CI, 1.04-1.69) and 1 to 2 hours (RR, 1.45; 95% CI, 1.12-1.81). Midsleep time variability of 60 minutes or longer (864 operations [12.1%]; 20 surgeons) was not associated with adverse outcomes. Surgeons with burnout had higher median [IQR] social jet lag (75 [47-94] vs 52 [38-61] minutes; P = .04) and midsleep time variability (54 [44-68] vs 43 [36-48] minutes; P = .01) than those without burnout. Conclusions and Relevance:Patients operated on by surgeons experiencing substantial social jet lag had a higher associated risk of major adverse events. Interventions promoting regular sleep timing and reducing circadian misalignment may improve surgeon burnout and patient safety.

Wearable sensors enable objective, non-invasive and accurate measurement of surgeons’ physiological parameters that potentially impact surgeon performance and patient outcomes. This scoping review aimed to explore studies measuring surgeons’ sleep, stress or physical activity using wearable sensors and to identify research gaps. A systematic search of PubMed and Scopus was conducted following PRISMA-ScR guidelines, for English-language articles published from January 1, 1950 to June 1, 2025. We included original quantitative studies measuring sleep, stress or physical activity in practicing or training surgeons, either as a parameter to investigate, or a determinant of performance. Data on physiological parameters, surgeon and surgical procedure, operating room (OR) setting, performance, study design, objectives, and findings were extracted using a predefined form. Among 100 included studies, 88 measured stress, 9 sleep, and 5 physical activity. Stress was primarily assessed intraoperatively while sleep and physical activity during extended period inside/outside the OR. Most studies investigated the relationship between physiological parameters and surgeon attributes or within team role (43

OBJECTIVE:To quantify the association between surgeon age and intraoperative hemodynamic instability (IHI) occurrence during pheochromocytoma surgery. BACKGROUND:Surgeons must master technical and nontechnical skills to limit IHI occurrence during pheochromocytoma resection, a rare, complex surgery. METHODS:This retrospective cohort study included data from adult patients who underwent pheochromocytoma surgery undertaken by surgeons aged 30 to 65 in 8 high-referral university hospitals in France from 01/01/2000 to 12/31/2016. Surgeon experience was quantified using surgeon's age at the time of surgery, and performance was evaluated using IHI occurrence. GEE logistic regression models, adjusted for potential confounders related to the patient and surgical procedure, were used to determine the probability of IHI according to surgeon age, independently of the surgeon-anesthesiologist duo and each surgeon's annual surgical volume. RESULTS:Nine hundred ninety pheochromocytoma surgeries performed by 44 surgeons were analyzed. There was a concave relationship between surgeon age and IHI (P=0.012). Standardized rates of IHI were 71.7% (95% CI: 60.9%-82.6%) at 30 years, reached a minimum of 50.4% (45.9%-54.7%) at 48 years, and were 70.2% (55.7%-80.2%) at 65 years. Among low-volume surgeons, IHI occurrence was more likely in those aged 55 to 65 compared with those aged 45 to 55 [adjusted odds ratios=1.71 (1.04 to 2.80)]. Among high-volume surgeons, IHI was more likely to occur in surgeons aged 30 to 44 compared with those aged 45-55 [2.05 (1.10 to 3.83)]. CONCLUSIONS:Our results suggest that in pheochromocytoma surgery surgeon performance could peak at mid-career, and then plateau and decline. Solutions that help surgeons maintain performance throughout their careers might be beneficial.

Background: Exercise training improves heart rate variability, and evidence suggests it can mitigate the detrimental effects of stress. This study aims to evaluate the relationship between surgeons’ physical activity habits and their stress, assessed as heart rate variability, at the start of surgery. Materials and methods: This multispecialty prospective cohort study included surgeons from fourteen cardiac, endocrine, digestive, gynecologic, orthopedic, thoracic, and urologic surgical departments of four university hospitals. Surgeons wore accelerometers 24/7 from 1 November 2020 to 31 December 2021 to quantify the mean daily step counts and daily sedentary time for 7 days prior to each operation. RMSSD, the root mean square of successive differences between normal heart beats, is a heart rate variability (HRV) metric that reflects cardiac vagal tone. We evaluated RMSSD during the first 5 minutes of surgeries performed over five 15-day periods. Data were analyzed using a multivariable linear mixed model with a random effect for surgeons. Results: We analyzed 722 surgeries performed by 37 surgeons (median age = 47 (IQR 42–55); 29 (78.4%) male). On average (SD), surgeons walked 9762 (2447) steps and were sedentary 391 (102) minutes daily. The model showed a positive relationship between steps and cardiac vagal tone, with an increase in lnRMSSD (0.028, 95% CI 0.003 to 0.053, P = 0.026) for every 1000 more steps per day, but not for sedentary behavior. Senior surgeons presented lower lnRMSSD (−0.437, −0.749 to −0.126, P = 0.006), as did surgeons who spent less total time operating over the study period (−0.337, −0.646 to −0.027, P = 0.033), compared to their counterparts. Conclusions: Higher daily step counts the week before surgery were associated with increased cardiac vagal tone, indicating lower stress levels at the beginning of surgery. This relationship highlights the influence of physical activity on surgeons’ stress in the operating room.

ImportanceSurgical complications represent a considerable proportion of hospital expenses. Therefore, interventions that improve surgical outcomes could reduce healthcare costs.ObjectiveEvaluate the effects of implementing surgical outcome monitoring using control charts to reduce hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer.DesignNational, parallel, cluster-randomised SHEWHART trial using a difference-in-difference approach.Setting40 surgical departments from distinct hospitals across France.Participants155 362 patients over the age of 18 years, who underwent hernia repair, cholecystectomy, appendectomy, bariatric, colorectal, hepatopancreatic or oesophageal and gastric surgery were included in analyses.InterventionAfter the baseline assessment period (2014–2015), hospitals were randomly allocated to the intervention or control groups. In 2017–2018, the 20 hospitals assigned to the intervention were provided quarterly with control charts for monitoring their surgical outcomes (inpatient death, intensive care stay, reoperation and severe complications). At each site, pairs, consisting of one surgeon and a collaborator (surgeon, anaesthesiologist or nurse), were trained to conduct control chart team meetings, display posters in operating rooms, maintain logbooks and design improvement plans.Main outcomesNumber of hospital bed-days per patient within 30 days following surgery, including the index stay and any acute care readmissions related to the occurrence of major adverse events, and hospital costs reimbursed for this care per patient by the insurer.ResultsPostintervention, hospital bed-days per patient within 30 days following surgery decreased at an adjusted ratio of rate ratio (RRR) of 0.97 (95% CI 0.95 to 0.98; p<0.001), corresponding to a 3.3% reduction (95% CI 2.1% to 4.6%) for intervention hospitals versus control hospitals. Hospital costs reimbursed for this care per patient by the insurer significantly decreased at an adjusted ratio of cost ratio (RCR) of 0.99 (95% CI 0.98 to 1.00; p=0.01), corresponding to a 1.3% decrease (95% CI 0.0% to 2.6%). The consumption of a total of 8910 hospital bed-days (95% CI 5611 to 12 634 bed-days) and €2 615 524 (95% CI €32 366 to €5 405 528) was avoided in the intervention hospitals postintervention.ConclusionsUsing control charts paired with indicator feedback to surgical teams was associated with significant reductions in hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer.Trial registration numberNCT02569450.

Objective: To determine the influence of operating room familiarity on surgeon stress. Background: Regulating surgeon stress may improve patient safety. This study evaluated how assisting surgeons and operating room familiarity influence intraoperative heart rate variability among surgeons. Methods: Attending surgeons from 7 specialties within 4 university hospitals in France were enrolled from November 1, 2020 to December 31, 2021. Vagal tone, an indicator of stress derived from heart rate variability, was assessed during the first 5 minutes after incision using the root mean square of successive differences (RMSSD). Higher RMSSD values indicate greater vagal tone. Team familiarity was quantified as the cumulative time the attending and assisting surgeons had operated together in the past, while operating rooms in which the surgeon conducted >10% of their operations were termed familiar. The effect of each on the RMSSD was assessed via a linear mixed-effect model adjusting for the random effect of the surgeon and possible confounders. Results: Overall, 643 surgeries performed by 37 surgeons were included. The median surgeon age was 49 years; 299 (78.4%) were male, and 22 (59.5%) were professors. Surgeons spent an average of 21.2 hours with the assisting surgeon before surgery and conducted 585 (91.0%) of their operations in a familiar operating room. For every 10 additional hours spent operating together, ln(RMSSD) significantly increased by 0.018 (95% CI: 0.003 to 0.033, P=0.016). Familiar operating rooms also tended to increase surgeon ln(RMSSD) [0.098 (95%CI: -0.007 to 0.203, P=0.068)]. Conclusion: Familiar with assisting surgeons and potentially operating rooms, increased surgeon vagal tone. Maintaining a stable operating room environment may improve surgeon stress and patient care.

Objective: To determine the influence of hospital bed turnover rate (BTR) on the occurrence of complications following minor or major digestive surgery. Background: Performance improvement in surgery aims at increasing productivity while preventing complications. It is unknown whether this relationship can be influenced by the complexity of surgery. Methods: A nationwide retrospective cohort study was conducted, based on generalized estimating equation modeling to determine the effect of hospital BTR on surgical outcomes, adjusting for patient mix and clustering within 631 public and private French hospitals. All patients who underwent minor or major digestive surgery between January 1, 2013 and December 31, 2018 were included. Hospital BTR was defined as the annual number of stays per bed for digestive surgery and categorized into tertiles. The primary endpoint was a composite measurement of events occurring within 30 days after surgery: inpatient death, extended intensive care unit (ICU) admission, and reoperation. Results: Rate of adverse events was 2.51% in low BTR hospitals versus 2.25% in high BTR hospitals for minor surgery, and 16.79% versus 16.83% for major surgery. Patients who underwent minor surgery in high BTR hospitals experienced lower complications (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.81–0.97; P = 0.009), mortality (OR, 0.87; 95% CI, 0.78–0.98, P = 0.02), ICU admission (OR, 0.83; 95% CI, 0.70–0.99; P = 0.03), and reoperation (OR, 0.91; 95% CI, 0.85–0.97; P = 0.002) compared to those in low BTR hospitals. Such differences were not consistently observed among patients admitted for major surgery. Conclusions: High turnover of patients in beds is beneficial for minor procedures, but questionable for major surgeries.

Background: Guidelines recommend using fine-needle aspiration cytology (FNAC) to guide thyroid nodule surgical indication. However, the extent to which these guidelines are followed remains unclear. This study aimed to analyze the quality of the preoperative care pathway and to evaluate whether compliance with the recommended care pathway influenced the relevance of surgical indications. Methods: Nationwide historical cohort study based on data from a sample (1/97th) of French health insurance beneficiaries. Evaluation of the care pathway of adult patients operated on between 2012 and 2015 during the year preceding thyroid nodule surgery. The pathway containing only FNAC was called “FNAC”, the pathway including an endocrinology consultation (ENDO) with FNAC was called “FNAC+ENDO”, whereas the no FNAC pathway was called “NO FNAC”. The main outcome was the malignant nature of the nodule. Results: Among the 1080 patients included in the study, “FNAC+ENDO” was found in 197 (18.2%), “FNAC” in 207 (19.2%), and “NO FNAC” in 676 (62.6%) patients. Cancer diagnosis was recorded in 72 (36.5%) “FNAC+ENDO” patients and 66 (31.9%) “FNAC” patients, against 119 (17.6%) “NO FNAC” patients. As compared to “NO FNAC”, the “FNAC+ENDO” care pathway was associated with thyroid cancer diagnosis (OR 2.67, 1.88–3.81), as was “FNAC” (OR 2.09, 1.46–2.98). Surgeries performed in university hospitals were also associated with thyroid cancer diagnosis (OR 1.61, 1.19–2.17). Increasing the year for surgery was associated with optimal care pathway (2015 vs. 2012, OR 1.52, 1.06–2.18). Conclusions: The recommended care pathway was associated with more relevant surgical indications. While clinical guidelines were insufficiently followed, compliance improved over the years.

OBJECTIVE To determine the effect of introducing prospective monitoring of outcomes using control charts and regular feedback on indicators to surgical teams on major adverse events in patients. DESIGN National, parallel, cluster randomised trial embedding a difference-in-differences analysis. SETTING 40 surgical departments of hospitals across France. PARTICIPANTS 155 362 adults who underwent digestive tract surgery. 20 of the surgical departments were randomised to prospective monitoring of outcomes using control charts with regular feedback on indicators (intervention group) and 20 to usual care only (control group). INTERVENTIONS Prospective monitoring of outcomes using control charts, provided in sets quarterly, with regular feedback on indicators (intervention hospitals). To facilitate implementation of the programme, study champion partnerships were established at each site, comprising a surgeon and another member of the surgical team (surgeon, anaesthetist, or nurse), and were trained to conduct team meetings, display posters in operating rooms, maintain a logbook, and devise an improvement plan. MAIN OUTCOME MEASURES The primary outcome was a composite of major adverse events (inpatient death, intensive care stay, reoperation, and severe complications) within 30 days after surgery. Changes in surgical outcomes were compared before and after implementation of the programme between intervention and control hospitals, with adjustment for patient mix and clustering. RESULTS 75047 patients were analysed in the intervention hospitals (37 579 before and 37 468 after programme implementation) versus 80 315 in the control hospitals (41 548 and 38 767). After introduction of the control chart, the absolute risk of a major adverse event was reduced by 0.9% (95% confidence interval 0.4% to 1.4%) in intervention compared with control hospitals, corresponding to 114 patients (70 to 280) who needed to receive the intervention to prevent one major adverse event. A significant decrease in major adverse events (adjusted ratio of odds ratios 0.89, 95% confidence interval 0.83 to 0.96), patient death (0.84, 0.71 to 0.99), and intensive care stay (0.85, 0.76 to 0.94) was found in intervention compared with control hospitals. The same trend was observed for reoperation (0.91, 0.82 to 1.00), whereas severe complications remained unchanged (0.96, 0.87 to 1.07). Among the intervention hospitals, the effect size was proportional to the degree of control chart implementation witnessed. Highly compliant hospitals experienced a more important reduction in major adverse events (0.84, 0.77 to 0.92), patient death (0.78, 0.63 to 0.97), intensive care stay (0.76, 0.67 to 0.87), and reoperation (0.84, 0.74 to 0.96). CONCLUSIONS The implementation of control charts with feedback on indicators to surgical teams was associated with concomitant reductions in major adverse events in patients. Understanding variations in surgical outcomes and how to provide safe surgery is imperative for improvements.

OBJECTIVEThe aim of the study was to investigate whether patients who undergo surgery in hospitals experiencing significant length of stay (LOS) reductions over time are exposed to a higher risk of severe adverse events in the postoperative period.SUMMARY BACKGROUND DATASurgical care innovation has encouraged hospitals to shorten LOS under financial pressures with uncertain impact on patient outcomes.METHODSWe selected all patients who underwent elective colectomy or urgent hip fracture repair in French hospitals between 2013 and 2016. For each procedure, hospitals were categorized into 3 groups according to variations in their median LOS as follows: major decrease, moderate decrease, and no decrease. These groups were matched using propensity scores based on patients' and hospitals' potential confounders. Potentially avoidable readmission for severe adverse events and death at 6 months were compared between groups using Cox regressions.RESULTSWe considered 98,713 patients in 540 hospitals for colectomy and 206,812 patients in 414 hospitals for hip fracture repair before matching. After colectomy, patient outcomes were not negatively impacted when hospitals reduced their LOS [hazard ratio (95% confidence interval): 0.93 (0.78-1.10)]. After hip fracture repair, patients in hospitals with major decreases in LOS had a higher risk of severe adverse events [1.22 (1.11-1.34)] and death [1.17 (1.04-1.32)].CONCLUSIONSPatients who underwent surgical procedures in hospitals experiencing major decreases in LOS were demonstrated worse postoperative outcomes after urgent hip fracture repair and not after elective colectomy. Development of care bundles to enhance recovery after emergency surgeries may allow better control of LOS reduction and patient outcomes.

Objective: To compare the clinical outcomes and direct costs at 5 years between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) using real-world evidence. Methods: We performed a nationwide longitudinal study using data from the French Hospital Information System from 2009 to 2015. We matched, inside hospitals, 2 cohorts of adults who underwent TAVI or SAVR during 2010 on propensity score based on patient characteristics. Outcomes analysis included mortality, morbidity, and total costs and with a maximum 60-month follow-up. Clinical outcomes were compared between cohorts using hazard ratios (HRs) estimated from a Cox proportional hazards model for all-cause death, and from Fine and Gray's competing risk model for morbidity. Results: Based on a cohort of 1598 patients (799 in each group) from 27 centers, a higher risk of death was observed after 1 year with TAVI compared with SAVR (16.8% vs 12.8%, respectively; HR, 1.33; 95% confidence interval [CI], 1.02-1.72) and was sustained up to 5 years (52.4% vs 37.2%; HR, 1.56; 95% CI, 1.33-1.84). At 5 years, the risk of stroke was increased (HR, 1.64; 95% CI, 1.07-2.54) as was myocardial infarction (HR, 2.30; 95% CI, 1.12-4.69) and pacemaker implantation (HR, 2.40; 95% CI, 1.81-3.17) after TAVI. The hospitalization costs per patient at 5 years were (sic)69,083 after TAVI and (sic)55,687 after SAVR (P<.001). Conclusions: In our study, high-risk patients harbored a greater risk of mortality and morbidity at 5 years after TAVI compared with those who underwent SAVR and higher hospitalizations costs. Those results should encourage caution before expanding the indications of TAVI.

ObjectiveTo identify the determinants of operative time for thyroidectomy and quantify the relative influence of preoperative and intra-operative factors.BackgroundAnticipation of operative time is key to avoid both waste of hospital resources and dissatisfaction of the surgical staff. Having an accurate and anticipated planning would allow a rationalized operating room use and may improve patient flow and staffing level.MethodsWe conducted a prospective, cross-sectional study between April 2008 and December 2009. The operative time of 3454 patients who underwent thyroidectomy performed by 28 surgeons in five academic hospitals was monitored. We used multilevel linear regression to model determinants of operative time while accounting for the interplay of characteristics specific to surgeons, patients, and surgical procedures. The relative impact of each variable on operative time was estimated.ResultsOverall, 86% (99% CI 83 to 89) of operative time variation was related to preoperative variables. Surgeon characteristics accounted for 32% (99% CI 29 to 35) of variation, center location for 29% (99% CI 25 to 33), and surgical procedure or patient variables for 24% (99% CI 20 to 27). Operative time was significantly lower among experienced surgeons having practiced from 5-19 years (-21.8 min, P<0.05), performing at least 300 thyroidectomies per year (-28.8 min, P<0.05), and with increasing number of thyroidectomies performed the same day (-11.7min, P<0.001). Conversely, operative time increased in cases of procedure supervision by a more experienced surgeon (+20.0 min, P<0.001). The remaining 13.0% of variability was attributable to unanticipated technical difficulties at the time of surgery.ConclusionsVariation in thyroidectomy duration is largely explained by preoperative factors, suggesting that it can be accurately anticipated. Prediction tools allowing better regulation of patient flow in operating rooms appears feasible for both working conditions and cost management.

The volume of bariatric surgery has significantly increased over the past decade with concomitant postoperative outcomes improvement. The goal of this nationwide study was to estimate the volume-outcome relationship in bariatric surgery at the hospital level.