Maryland's Global Budget Revenue Program and Equitable Access to Esophagectomy for Esophageal Cancer.

INTRODUCTION: We evaluated equity in access to esophagectomy after Maryland's 2014 "Global Budget Revenue" (GBR) implementation, which equalizes reimbursement rates irrespective of patient insurance and employs an annual hospital revenue ceiling to incentivize reductions in unnecessary resource utilization. We hypothesized that more traditionally underserved patients would undergo surgical treatment for esophageal cancers after GBR. METHODS: Using Maryland's Health Services Cost Review Commission database, we retrospectively analyzed patient demographics, insurance statuses, inflation-adjusted hospital charges, postoperative outcomes, and discharge dispositions for esophagectomies for neoplasms between 2012 and 2018. RESULTS: Four hundred eighty six patients were included: 22.0% (107) pre-GBR and 78.0% (379) post-GBR. The proportion of African-American patients increased post-GBR (5.6% versus 12.9%, P = 0.035) and subsequently exhibited year-over-year increases. While not statistically significant, the proportion of Medicaid patients increased from 4.7% to 10.0% (P = 0.085). The post-GBR era also saw patients from 10 new counties, six of which were in Maryland's bottom half of counties ranked by median household income, receive operative esophageal cancer treatment without losing representation from pre-GBR counties. Patient age and sex were comparable between the two groups, and there were no significant differences in mortality or 30-day readmissions. Inflation-adjusted hospital charges and length of hospital stay did not appreciably change post-GBR, including after adjusting for age, comorbidities, and surgical approach. CONCLUSIONS: GBR increased access to esophagectomy for African-Americans, those insured by Medicaid, and those from lower socioeconomic status counties. Contrary to prior studies of outpatient and emergency room settings, we found the GBR program's goal of reduction of resource utilization and cost were not apparent in this complex surgical population.

Pragmatic Emergency Department Intervention Reducing Default Quantity of Opioid Tablets Prescribed.

Introduction: The opioid epidemic is a major cause of morbidity and mortality in the United States. Prior work has shown that emergency department (ED) opioid prescribing can increase the incidence of opioid use disorder in a dose-dependent manner, and systemic changes that decrease default quantity of discharge opioid tablets in the electronic health record (EHR) can impact prescribing practices. However, ED leadership may be interested in the impact of communication around the intervention as well as whether the intervention may differentially impact different types of clinicians (physicians, physician assistants [PA], and nurse practitioners). We implemented and evaluated a quality improvement intervention of an announced decrease in EHR default quantities of commonly prescribed opioids at a large, academic, urban, tertiary-care ED. Methods: We gathered EHR data on all ED discharges with opioid prescriptions from January 1, 2019-December 6, 2021, including chief complaint, clinician, and opioid prescription details. Data was captured and analyzed on a monthly basis throughout this time period. On March 29, 2021, we implemented an announced decrease in EHR default dispense quantities from 20 tablets to 12 tablets for commonly prescribed opioids. We measured pre- and post-intervention quantities of opioid tablets prescribed per discharge receiving opioids, distribution by patient demographics, and inter-clinician variability in prescribing behavior. Results: The EHR change was associated with a 14% decrease in quantity of opioid tablets per discharge receiving opioids, from 14 to 12 tablets (P = <.001). We found no statistically significant disparities in prescriptions based on self-reported patient race (P = 0.68) or gender (P = 0.65). Nurse practitioners and PAs prescribed more opioids per encounter than physicians on average and had a statistically significant decrease in opioid prescriptions associated with the EHR change. Physicians had a lesser but still significant drop in opioid prescribing in the post-intervention period. Conclusion: Decreasing EHR defaults is a robust, simple tool for decreasing opioid prescriptions, with potential for implementation in the 42% of EDs nationwide that have defaults exceeding the recommended 12-tablet supply. Considering significant inter-clinician variability, future interventions to decrease opioid prescriptions should examine the effects of combining EHR default changes with targeted interventions for clinician groups or individual clinicians.

Surgery and Surgical Training Prior to Graduate Medical Education: A Blue Ribbon Committee II, Medical Student Education Subcommittee Report.

OBJECTIVE: To update and add to the first report commissioned by the Blue Ribbon Committee about 20 years prior. SUMMARY OF BACKGROUND DATA: Following a summit in late 2022 commissioned by the American Board of Surgery regarding competency-based reforms in surgical education and via a partnership with the American College of Surgeons (ACS) and other stakeholders, a Blue Ribbon Committee (BRC-II) on surgical education was formed. The BRC-II would have seven subcommittees. This paper details the work of the Medical Student Subcommittee within the BRC- II. METHODS: The subcommittee's work, supported by staff from the ACS, entailed a thorough literature review, which involved collating and aggregating the findings, identifying key challenges and opportunities, and committing to draft recommendations. These recommendations were then presented and refined via discussions with the Blue Ribbon Committee at large in multiple virtual and in-person settings. RESULTS: The subcommittee's work is detailed below and further summarized in table format. The section below elucidates the medical student education continuum and discusses the pertinent topics of recruitment, surgical engagement in medical student training and the surgical image, training for the current surgical practice model, trainee selection for graduate medical education (GME), and optimizing the transition from undergraduate medical education (UME) to GME. CONCLUSIONS: The last two decades have shown significant changes and shifts in medical education and surgical practice. The findings of BRC-II in this manuscript help to structure the current and future necessary improvements, focusing on different aspects of medical student education.

Multi-institutional beta testing of a novel cervical esophagogastric anastomosis simulator.

Objective: A novel simulator developed to offer hands-on practice for the stapled side-to-side cervical esophagogastric anastomosis was tested previously in a single-center study that supported its value in surgical education. This multi-institutional trial was undertaken to evaluate validity evidence from 6 independent thoracic surgery residency programs. Methods: After a virtual session for simulation leaders, learners viewed a narrated video of the procedure and then alternated as surgeon or first assistant. Using an online survey, perceived value was measured across fidelity domains: physical attributes, realism of materials, realism of experience, value, and relevance. Objective assessment included time, number of sutures tearing, bubble test, and direct inspection. Comparison across programs was performed using the Kruskal-Wallis test. Results: Surveys were completed by 63 participants as surgeons (17 junior and 20 senior residents, 18 fellows, and 8 faculty). For 3 of 5 tasks, mean ratings of 4.35 to 4.44 correlated with "somewhat easy" to "very easy" to perform. The interrupted outer layer of the anastomosis rated lowest, suggesting this task was the most difficult. The simulator was rated as a highly valuable training tool. For the objective measurements of performance, "direct inspection" rated highest followed by "time." A total of 90.5% of participants rated the simulator as ready for use with only minor improvements. Conclusions: Results from this multi-institutional study suggest the cervical esophagogastric anastomosis simulator is a useful adjunct for training and assessment. Further research is needed to determine its value in assessing competence for independent operating and associations between improved measured performance and clinical outcomes.

Non-Small Cell Lung Cancer, Version 4.2024, NCCN Clinical Practice Guidelines in Oncology

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Non-Small Cell Lung Cancer (NSCLC) provide recommendations for the treatment of patients with NSCLC, including diagnosis, primary disease management, surveillance for relapse, and subsequent treatment. The panel has updated the list of recommended targeted therapies based on recent FDA approvals and clinical data. This selection from the NCCN Guidelines for NSCLC focuses on treatment recommendations for advanced or metastatic NSCLC with actionable molecular biomarkers.

NCCN Guidelines® Insights: Mesothelioma: Pleural, Version 1.2024.

Mesothelioma is a rare cancer that originates from the mesothelial surfaces of the pleura and other sites, and is estimated to occur in approximately 3,500 people in the United States annually. Pleural mesothelioma is the most common type and represents approximately 85% of these cases. The NCCN Guidelines for Mesothelioma: Pleural provide recommendations for the diagnosis, evaluation, treatment, and follow-up for patients with pleural mesothelioma. These NCCN Guidelines Insights highlight significant updates to the NCCN Guidelines for Mesothelioma: Pleural, including revised guidance on disease classification and systemic therapy options.

Neoadjuvant nivolumab or nivolumab plus LAG-3 inhibitor relatlimab in resectable esophageal/gastroesophageal junction cancer: a phase Ib trial and ctDNA analyses.

Gastroesophageal cancer dynamics and drivers of clinical responses with immune checkpoint inhibitors (ICI) remain poorly understood. Potential synergistic activity of dual programmed cell death protein 1 (PD-1) and lymphocyte-activation gene 3 (LAG-3) inhibition may help improve immunotherapy responses for these tumors. We report a phase Ib trial that evaluated neoadjuvant nivolumab (Arm A, n = 16) or nivolumab-relatlimab (Arm B, n = 16) in combination with chemoradiotherapy in 32 patients with resectable stage II/stage III gastroesophageal cancer together with an in-depth evaluation of pathological, molecular and functional immune responses. Primary endpoint was safety; the secondary endpoint was feasibility; exploratory endpoints included pathological complete (pCR) and major pathological response (MPR), recurrence-free survival (RFS) and overall survival (OS). The study met its primary safety endpoint in Arm A, although Arm B required modification to mitigate toxicity. pCR and MPR rates were 40% and 53.5% for Arm A and 21.4% and 57.1% for Arm B. Most common adverse events were fatigue, nausea, thrombocytopenia and dermatitis. Overall, 2-year RFS and OS rates were 72.5% and 82.6%, respectively. Higher baseline programmed cell death ligand 1 (PD-L1) and LAG-3 expression were associated with deeper pathological responses. Exploratory analyses of circulating tumor DNA (ctDNA) showed that patients with undetectable ctDNA post-ICI induction, preoperatively and postoperatively had a significantly longer RFS and OS; ctDNA clearance was reflective of neoantigen-specific T cell responses. Our findings provide insights into the safety profile of combined PD-1 and LAG-3 blockade in gastroesophageal cancer and highlight the potential of ctDNA analysis to dynamically assess systemic tumor burden during neoadjuvant ICI that may open a therapeutic window for future intervention. ClinicalTrials.gov registration: NCT03044613 .

The Society of Thoracic Surgeons Looking to the Future Scholarship Program: A 15-Year Review.

BACKGROUND: It has been postulated that a possible barrier to pursuing cardiothoracic surgery is a lack of exposure and mentorship during training. In 2006, The Society of Thoracic Surgeons began the Looking to the Future Scholarship to expand interest in the field. Undecided trainees with limited exposure were prioritized in the selection process. This report summarizes the career outcomes of general surgery resident and medical student recipients. METHODS: Scholarship recipients and nonrecipients (control) were queried in a Google search. The percentage of those who were cardiothoracic surgeons or in cardiothoracic training (%CTS) was calculated, as well as the percentage of female surgeons in cardiothoracic surgery. RESULTS: From 2006 to 2021, there were 669 awardees. The %CTS was 63.7% for resident recipients and 31.4% for students, respectively. There was no significant difference in %CTS between resident and student recipients compared to nonrecipients. Notably, the percentage of female cardiothoracic surgeons was significantly greater for both resident and student recipients. CONCLUSIONS: The majority of resident recipients are now in cardiothoracic surgery, comparable to nonrecipients. While there was no significant difference between the percentage of recipients and non-recipients in cardiothoracic surgery, these groups differed substantially as nonrecipients had greater exposure and commitment to the field at the time of application.

Mesothelioma: Peritoneal, Version 2.2023, NCCN Clinical Practice Guidelines in Oncology.

Mesothelioma is a rare cancer originating in mesothelial surfaces of the peritoneum, pleura, and other sites. These NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) focus on peritoneal mesothelioma (PeM). The NCCN Guidelines for PeM provide recommendations for workup, diagnosis, and treatment of primary as well as previously treated PeM. The diagnosis of PeM may be delayed because PeM mimics other diseases and conditions and because the disease is so rare. The pathology section was recently updated to include new information about markers used to identify mesothelioma, which is difficult to diagnose. The term "malignant" is no longer used to classify mesotheliomas, because all mesotheliomas are now defined as malignant.

ACR Appropriateness Criteria® Routine Chest Imaging.

Routine chest imaging has been used to identify unknown or subclinical cardiothoracic abnormalities in the absence of symptoms. Various imaging modalities have been suggested for routine chest imaging. We review the evidence for or against the use of routine chest imaging in different clinical scenarios. This document aims to determine guidelines for the use of routine chest imaging as initial imaging for hospital admission, initial imaging prior to noncardiothoracic surgery, and surveillance imaging for chronic cardiopulmonary disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

NCCN Guidelines® Insights: Non-Small Cell Lung Cancer, Version 2.2023.

The NCCN Guidelines for Non-Small Cell Lung Cancer (NSCLC) provide recommendations for management of disease in patients with NSCLC. These NCCN Guidelines Insights focus on neoadjuvant and adjuvant (also known as perioperative) systemic therapy options for eligible patients with resectable NSCLC.

Is Female Representation Increasing in Society and Journal Editorial Boards in Oral and Maxillofacial Surgery?

PURPOSE: Surgical specialties, including oral and maxillofacial surgery (OMS), are traditionally male-dominated fields. This study aimed to analyze the proportions of female surgeons on specialty society boards and journal editorial boards in OMS in the United States and to assess whether they were proportionate with female representation in OMS academic faculty between 2011 and 2020. METHODS: A retrospective cohort study was performed using information obtained from the websites of two major OMS journals and information obtained directly from six American specialty societies for OMS. The predictor variable was time. The outcome variable was gender. Temporal changes in the proportion of women on society and journal editorial boards were compared with those amongst full-time board-certified faculty. Chi-squared test and simple linear regression were used for statistical analyses. RESULTS: Between 2011 and 2020, the proportion of women on editorial and society boards was 6.7% (31 women among 463 editorial board members) and 7.8% (43 women among 553 society board members), respectively. The proportion of women on editorial boards increased from 4.5% in 2011 to 10.6% in 2020 (ß = 0.656 [95% confidence interval, 0.336-0.975], P = .001) and that of women on society boards increased from 4.3% in 2011 to 10.3% in 2020 (ß = 0.645 [95% confidence interval, 0.252-1.037], P = .005). The proportion of women on editorial boards in 2011-2012 was significantly lower than that in full-time board-certified faculty positions (4.3% vs 11.0%, P = .045), whereas by 2019-2020, there was no difference between the 2 groups (9.8% vs 12.5%, P = .454). Similarly, the proportion of women on society boards in 2011-2012 tended to be lower than that in full-time board-certified faculty positions (5.6% vs 11.0%, P = .111), while in 2019-2020, no difference was observed between the 2 groups (10.4% vs 12.5%, P = .531). CONCLUSION: The proportion of women on society and journal editorial boards in OMS remains low but has progressively increased from 2011 to 2020, resulting in proportionate female representation in these positions compared with the gender composition of academic faculty in recent years. The current upward trend of female representation in leadership positions will hopefully present more diverse opportunities and mentorship/role models for trainees.

Disparities in Timing of Alveolar Bone Grafting and Dental Reconstruction in Patients With Clefts.

This study sought to identify disparities in the timing of alveolar bone grafting (ABG) surgery and the replacement strategy for missing maxillary lateral incisors for patients with clefts.A retrospective record review identified patients who underwent ABG. Multivariable regression analyzed the independent contribution of each variable.This institutional study was performed at the University of California, San Francisco.Patients who presented under age 12 and underwent secondary ABG between 2012 and 2020 (n = 160).The age at secondary ABG and the recommended dental replacement treatment for each patient, either dental implantation or canine substitution.The average age at ABG was 10.8 ± 2.1 years, 106 (66.3%) patients were not White, and 80 (50.0%) had private insurance. Independent predictors of older age at ABG included an income below $ 50 000 as estimated from ZIP code (ß = 15.0 months, 95% CI, 5.7-24.3, P = .002) and identifying as a race other than White (ß = 10.1 months, 95% CI, 2.1-18.0, P = .01). After ABG, patients were more likely to undergo dental implantation over canine substitution if they were female (odds ratio [OR] = 4.3, 95% CI, 1.3-17.1, P = .02) or had private insurance (OR = 12.5, 95% CI, 2.2-143.2, P = .01).Patients who were low-income or not White experienced delays in ABG, whereas dental implantation was more likely to be recommended for patients with private insurance. Understanding the sources of disparities in dental reconstruction of cleft deformities may reveal opportunities to improve equity.

Impact of the Southern Thoracic Surgical Association James W. Brooks Scholarship.

BACKGROUND: Medical students and general surgery residents often do not get exposure to cardiothoracic surgery (CTS) because of a decreased emphasis on CTS rotations during their training. The Southern Thoracic Surgical Association (STSA) began offering the Brooks Scholarship to medical students in 2010 and general surgery residents in 2014 to promote CTS. This study examines the impact of the scholarship. METHODS: We examined the history of the award and how STSA administers the award. Next we examined the impact of the award by evaluating the number of medical students and residents who are tracked to complete a CTS program. Finally we performed an analysis of the academic output of the awardees who have completed or were tracked to complete a CTS program. RESULTS: The scholarship was developed to honor the memory of past STSA President Dr James W. Brooks. The award is administered through the STSA scholarship committee and provides medical students and residents funds to attend the STSA annual meeting and the opportunity to spend time with a mentor during the meeting. Eighty-eight percent of medical student recipients (21/24) and 100% of general surgery resident recipients (15/15) have completed or are on track to complete a CTS program. The 36 recipients going into CTS have published a total of 823 papers and 9240 articles have cited those papers. CONCLUSIONS: The STSA medical student and general surgery Brooks scholarship awards were associated with completing or pursuing a career in CTS. STSA should continue the Brooks scholarship to attract talented medical students and residents to CTS.

A dedicated robotic bedside physician assistant significantly enhances trainee console operating time in general thoracic surgery.

Objective: As trainees rotate through thoracic subspecialties within their curricula, a crucial portion of their robotic training consists of actual console operating time. The more time spent on the surgeon console, the greater the development will be through the course of their training. Implementing a physician assistant at the bedside may increase the operative console time for the trainee and develop robotic skills in a more expeditious rate. The objective was to evaluate the impact a designated robotic physician assistant can have on trainee console learning opportunity. Methods: Operating room data collected consisted of all robotic general thoracic surgical cases that trainees participated in with and without a physician assistant present. Metrics regarding case efficiency included anesthesia ready-to-incision, incision-to-console, and raw resident console times. By using PRISM software, a nonparametric t test was used to analyze each averaged data group compared between when a physician assistant was present and not present. Results: The mean resident console time without and with a physician assistant assist was 45.8 minutes and 80.9 minutes, respectively (P < .0001). The average portion of a case performed by a trainee similarly without and with a physician assistant present was 28.0% and 77.1%, respectively (P < .0001). Case efficiency metrics between physician assistant presence cohorts showed no difference. Conclusions: Thoracic surgical trainees have increased opportunity for robotic skill development within a fellowship or resident program curriculum when a designated robotic physician assistant is present in the operating room. These findings are significant for the improvement of residency and fellowship robotic training models moving forward by incorporating robotic-specialized physician assistants in academic institutions.

Racial and Socioeconomic Disparities in Prompt Craniosynostosis Workup and Treatment.

The purpose of this study was to identify racial and socioeconomic disparities in craniosynostosis evaluation and treatment, from referral to surgery. Patients diagnosed with craniosynostosis between 2012 and 2020 at a single center were identified. Chart review was used to collect demographic variables, age at referral to craniofacial care, age at diagnosis, age at surgery, and surgical technique (open versus limited incision). Multivariable linear and logistic regression models with lasso regularization assessed the independent effect of each variable. A total of 298 patients were included. Medicaid insurance was independently associated with a delay in referral of 83 days [95% confidence interval (CI) 4-161, P=0.04]. After referral, patients were diagnosed a median of 21 days later (interquartile range 7-40), though this was significantly prolonged in patients who were not White (ß 23 d, 95% CI 9-38, P=0.002), had coronal synostosis (ß 24 d, 95% CI 2-46, P=0.03), and had multiple suture synostosis (ß 47 d, 95% CI 27-67, P<0.001). Medicaid insurance was also independently associated with diagnosis over 3 months of age (risk ratio 1.3, 95% CI 1.1-1.4, P=0.002) and undergoing surgery over 1 year of age (risk ratio 3.9, 95% CI 1.1-9.4, P=0.04). In conclusion, Medicaid insurance was associated with a 3-month delay in referral to craniofacial specialists and increased risk of diagnosis over 3 months of age, limiting surgical treatment options in this group. Patients with Medicaid also faced a 4-fold greater risk of delayed surgery, which could result in neurodevelopmental sequelae.