ASSESSING THE IMPACT OF RECENCY EFFECT IN SURGERY

Purpose: Recency effect suggests that people disproportionately value events from the immediate past when making decisions. The extent to which recency effect impacts decisions made by doctors has not been well characterized. We evaluated for recency effect in surgeons by examining their use of a preventative test (leak testing of a colorectal anastomosis during an operation) before and after a case with an anastomotic leak, a rare but potentially life-threating complication. While leak testing can prevent up to 50% of leaks, not all surgeons routinely leak test, suggesting this test is not equally valued and therefore may be an opportunity to evaluate recency effect.

Methods: Using a prospective cohort from the Surgical Care and Outcome Assessment Program in Washington State, we describe leak events and sequential leak testing patterns for elective colorectal procedures. We hypothesized that surgeons might display recency effect by increasing the use of leak testing in operations subsequent to an anastomotic leak. To test the hypothesis, we explored a difference-in-difference non-parametric model to compare a surgeon's use of leak testing in the 6 months before and after a leak compared to changes in leak testing when no leak occurred.

Results: From 2006 to 2013, 282 surgeons performed 4,854 elective colorectal operations across 44 hospitals with a leak rate of 2.6%(n=124). The 40 leaks(32%) in which the anastomosis was not tested occurred across 25 surgeons. Leak testing across all cases increased during this time from 60.0% to 79.6%, p-trend<0.001, but this rise was not different in surgeons who did and did not have leaks(p=0.87). The difference-in-difference analytic model was limited by small sample size, however, 36% of surgeons(9 of 25) increased their leak testing by 5 percent points or more after having a leak in a case in which the anastomosis was not tested(Figure 1). The patient characteristics, case-mix, and surgical outcomes of surgeons who did and did not display recency effect were similar.

Conclusions: Recency effect occurred in only one-third of surgeons. Leak testing may be resistant to recency effect because of individual practice preferences, training or external factors. Understanding which clinical decisions may be influenced by recency effect and the extent of that influence may be important in crafting quality improvement initiatives that require clinician behavior change.