Disparities in Perioperative Use of Patient Engagement Technologies - Not All Use is Equal.

OBJECTIVE: To determine the association of patient-level characteristics on the use of a patient engagement technology during the perioperative period. SUMMARY OF BACKGROUND DATA: As implementation of patient engagement technologies continues to grow, it remains unclear who uses, and not uses, these technologies. Existing literature suggests significant disparities in usage of other technologies by patient age, race, sex, and geographic location, however, have yet to characterize patient usage of patient engagement technologies. METHODS: This is a retrospective cohort study of patients undergoing elective surgery by a colorectal surgeon between January 2018 and March 2020 who enrolled in a patient engagement technology at a single institution. Patients enrolled received educational content, healthcare reminders, patient reported outcome (PRO) surveys, and health checks preoperatively, in-hospital, and for 30-days postdischarge. The primary outcome was patient activation of the patient engagement technology. Secondary outcomes were completion of at least 1 PRO survey, 1 in-hospital health check, and 1 postdischarge health check. RESULTS: Of 549 patients who enrolled in the patient engagement technology, 473 (86.2%) activated. On multivariable stepwise regression, female patients [odds ratio (OR) 2.4, confidence interval (CI) 1.4-4.0, P = 0.001] and privately insured patients (OR 2.0, CI 1.1-3.8, P = 0.03) were more likely to activate. Black patients were less likely to activate (OR 0.5, CI 0.3-0.9, P = 0.02). Once activated, privately insured patients were more likely to complete PRO surveys (OR 2.3, CI 1.2-4.3, P = 0.01), in-hospital health checks (OR 2.4, CI 1.4-4.1, P = 0.002), and postdischarge health checks (OR 1.9, CI 1.1 -3.3, P < 0.001) than uninsured patients. Black patients were less likely to complete PRO surveys (OR 0.4, CI 0.3-0.7, P = 0.001) and in-hospital health checks (OR 0.6, CI 0.4-0.9, P = 0.03) than White patients. CONCLUSIONS: Use of a patient engagement technology in the perioperative period differs significantly by sex, race/ethnicity, and insurance status. These technologies may not be used equally by all patients, which should be considered during implementation of interventions to improve surgical outcomes.

Disparities in Surgical Timing and Guideline-Adherent Staging Work-Up for Colon Cancer.

BACKGROUND: Expedited or delayed surgery for colon cancer without appropriate work-up increases mortality risk. We sought to identify what patient, social, and hospital factors were associated with timely, guideline-adherent work-up for colon cancer. METHODS: Retrospective analysis of 19,046 patients in the Surveillance, Epidemiology, and End Results (SEER) database linked with Medicare administrative claims who underwent elective surgery for colon cancer between 2010 and 2015 was performed. Primary outcome was receipt of complete preoperative work-up (colonoscopy, imaging, tumor marker evaluation) and timely surgery within 60 days of diagnosis. Patients were stratified into four groups: (1) adherent; (2) early surgery (< 30 days) with incomplete work-up; (3) surgery between 30 and 60 days with incomplete work-up; and (4) late surgery (> 60 days) with/without work-up. Characteristics were compared and multinomial logistic regression was performed. RESULTS: Overall, 46.2% of patients received adherent care, 33.1% had early surgery and inadequate work-up, 10.3% had appropriately timed surgery but incomplete work-up, and 10.4% underwent late surgery. Multivariable analysis demonstrated that older, female, Black, and unmarried patients as well as patients living in areas with higher rates of poverty were more likely to receive non-adherent care. A greater proportion of patients at teaching hospitals received complete work-up (57.6% vs. 49.5%) but also underwent late surgery (12.4% vs. 8.6%) compared with non-teaching hospitals. CONCLUSIONS: Patient, societal, and hospital factors impact whether patients receive guideline-adherent colon cancer care. Interventions are needed to improve access to timely and guideline-adherent cancer care as a possible mechanism to combat surgical disparities.

Characterizing the impact of verbal communication and health literacy in the patient-surgeon encounter.

BACKGROUND: Patients with limited health literacy (HL) have difficulty understanding written/verbal information. The quality of verbal communication is not well understood. Therefore, our aim was to characterize patient-surgeon conversations and identify opportunities for improvement. METHODS: New colorectal patient-surgeon encounters were audio-recorded and transcribed. HL was measured. Primary outcomes were rates-of-speech, understandability of words, patient-reported understanding, and usage of medical jargon/statistics. Secondary outcomes included length-of-visit (LOV), conversation possession time, patient-surgeon exchanges, and speech interruptions. RESULTS: Significant variations existed between surgeons in rates-of-speech and understandability of words (p < 0.05). Faster rates-of-speech were associated with significantly less understandable words (p < 0.05). Patient-reported understanding varied by HL and by surgeon. Conversation possession time and usage of medical jargon/statistics varied significantly by surgeon (p < 0.05) in addition to patient-surgeon exchanges and interruptions. Patients with limited HL had shorter LOV. CONCLUSIONS: Significant variations exist in how surgeons talk to patients. Opportunities to improve verbal communication include slowing speech and using more understandable words.

Current Barriers in Robotic Surgery Training for General Surgery Residents.

OBJECTIVE: To assess the current barriers in robotic surgery training for general surgery residents. DESIGN: Multi-institutional web-based survey. SETTING: 9 academic medical centers with a general surgery residency. PARTICIPANTS: General surgery residents of at least PGY-3 training level. RESULTS: 163 general surgery residents were contacted with 80 responses (49.1%). The most common responders were PGY-3s (38.8%) followed by PGY-5s (27.5%). The Northeast represented 42.5% of responses. Colorectal cases were the most common robotic case residents were involved in (51.3%). Residents' typical roles were assisting at the bedside (31.3%) and splitting time between assisting at the bedside and operating at the surgeon console (31.3%). 43% report to be either extremely or somewhat dissatisfied with their robotic surgery experience. 62.5% report they do not intend to integrate robotic surgery into their future practice. 93.8% of residents have a standardized robotic curriculum. 47.5% report using the simulator only during required didactic time with 52.5% having the robotic simulator conveniently located. The majority of residents report that the presence of dual consoles and first-assists in robotic cases enhance their robotic training (93% - 62%, respectively). 72.5% felt like they had more autonomy during laparoscopic cases and 96.8% of residents felt that an attendings' lack of experience impacted their time operating at the surgeon console. CONCLUSIONS: General surgery residents report lack of effective OR teaching, real clinical experience, and simulated experience as main barriers in their robotic surgery training. Dual consoles and first-assistants are favorably looked upon. Lack of attending experience and comfort were universally negatively associated with resident participation. For residents interested in robotic surgery, advocating for more robust investment in dual consoles, first-assistants, and faculty development would likely improve their robotic surgery training experience. However, residency programs should consider whether robotic surgery should be a core competency of an already time restricted training paradigm.

Ileostomy Patients Using Patient Engagement Technology Experience Decreased Length of Stay.

Patients who undergo colorectal surgery, particularly, construction of a new ileostomy, are known to have longer length of stay (LOS) and increased readmissions. With the increased availability of patient engagement technology (PET), we hypothesized that because PET facilitates education before and after surgery, ileostomy patients who used PET would have decreased LOS without increasing readmissions. Variables were obtained from the National Surgical Quality Improvement Program (NSQIP) database for patients undergoing ileostomy construction. Study patients were categorized into three groups: pre-PET (patients prior to PET), non-PET (patients who did not use PET), and PET users (patients who used PET). Univariate analysis of patient and surgical characteristics, LOS, ED visits, and readmissions and multivariable modeling of potential predictors of LOS were performed. There were 106 patients in the pre-PET, 51 in the PET, and 108 in the non-PET and cohorts were similar except pre-op diagnosis. Length of stay was lower for the PET cohort (p = 0.0001), with no significant difference in readmission or ED visits. On multivariable analysis, we identified the PET cohort as an independent predictor of shorter LOS relative to non-PET and pre-PET (p = 0.007 and p = 0.02, respectively). Similarly, patients had significantly shorter LOS who had a diagnosis of neoplasm as compared to IBD (p = 0.03). Hypertension requiring medication (p = 0.001) and Black race relative to White race (p = 0.002) were independent predictors of longer LOS. In this study of ileostomy patients, we have shown that use of PET is an independent predictor of decreased LOS without increased ED visits or readmissions.

Prevalence, Bias, and Rank List Impact of Illegal Questions in Surgical Specialty Residency Interviews.

OBJECTIVE: The purpose of this study is to characterize illegal questions as defined by federal law and to assess their impact on applicants' rank lists across four surgical specialties. DESIGN: A survey was developed and sent to surgical specialty residency applicants. The survey asked demographics, the frequency of questions about age, gender, religion, sexual orientation, family status and impact on final rank list. Applicants were asked to respond anonymously based on their experience at all institutions at which they interviewed during the interview cycle. Results were compared by applicant specialty and gender. SETTING: A large university-affiliated academic medical center PARTICIPANTS: Survey was administered to 3854 applicants (comprising between 28.9% and 41.2% of applicants nationwide) to general surgery, orthopaedic surgery, urology, and otolaryngology residency programs at a single institution during the 2018 and 2019 cycles. A total of 1066 applicants completed the survey. RESULTS: A total of 789 (74.0%) of applicants reported being asked at least one illegal question during the interview process at any institution. Applicants to orthopaedic surgery programs were most likely to be asked illegal question (n = 315, 81.6%), and general surgery applicants were least likely to be asked illegal questions (n = 324, 66.8%, p < 0.001). Females were more likely than males to be asked about gender (n = 99, 26.3% vs. n = 18, 2.6%, p < 0.001) and plans for pregnancy (n = 78, 20.8% vs. n = 78, 11.4%, p < 0.001). 152 (19.4%). Applicants reported that being asked an illegal question lowered a program on their rank list. Female applicants were more likely to lower a program on their rank list as a result of an illegal question (n = 102, 35.4% vs. n = 50, 10.1%, p < 0.001). CONCLUSIONS: Illegal questions in surgical specialty residency interviews are common, vary by specialty and applicant gender, and lower programs on applicants' rank lists. This data should serve to inform larger and more inclusive studies in the future. Programs should focus on educating interviewers on illegal topics in an effort to minimize illegal topics that may alienate applicants and contribute to workplace discrimination.

Understanding the surgical experience for Black and White patients with inflammatory bowel disease (IBD): The importance of health literacy.

BACKGROUND: Racial/ethnic disparities in outcomes exist for patients with inflammatory bowel disease (IBD) undergoing surgery. The underlying mechanism(s) remain unclear and patient perspectives are needed. We therefore aimed to characterize the surgical experience for Black and White IBD patients using qualitative methods. METHODS: Patients with IBD who had undergone surgery were recruited to same-race qualitative interviews. Semi-structured interviews explored barriers and facilitators to a positive or negative surgical experience. Transcripts were analyzed with NVivo 12 software. RESULTS: Six focus groups were conducted that included 10 Black and 17 White IBD participants. The mean age was 44.8 years (SD 13.2), 52% were male and 65% had Crohn's disease. Four themes emerged that most defined the surgical experience: the impact of the IBD diagnosis, the quality of provided information, disease management and the surgery itself. Within these themes, barriers to a positive surgical experience included inadequate personal knowledge of IBD, ineffective written and verbal communication, lack of a support system and complications after surgery. Both groups reported that information was provided inconsistently which led to unclear expectations of surgical outcomes. CONCLUSIONS: Black and White patients with IBD have varied surgical experiences but all stressed the importance of accurate, trustworthy and understandable health information. These findings highlight the value of providing health literacy-sensitive care in surgery.

The association of health literacy and postoperative complications after colorectal surgery: A cohort study.

BACKGROUND: Health literacy is a determinant of health. Few studies characterize its association with surgical outcomes. METHODS: Retrospective cohort study of patients undergoing elective colorectal surgery 2015-2020. Health literacy assessed using Brief Health Literacy Screening Tool. Outcomes were postoperative complications, LOS, readmissions, mortality. RESULTS: Of 552 patients, 46 (8.3%) had limited health literacy, 506 (91.7%) non-limited. Median age 57.7 years, 305 (55.1%) patients were female, 148 (26.8%) were Black. Limited patients had higher rates of overall complications (43.5% vs. 24.3%, p = 0.004), especially surgical site infections (21.7% vs. 11.3%, p = 0.04). Limited patients had longer LOS (5 vs 3.5 days, p = 0.006). Readmissions and mortality did not differ. On multivariable analysis, limited health literacy was independently associated with increased risk of complications (OR 2.03, p = 0.046), not LOS (IRR 1.05, p = 0.67). CONCLUSION: Limited health literacy is associated with increased likelihood of complications after colorectal surgery. Opportunities exist for health literate surgical care to improve outcomes for limited health literacy patients.

Racial disparities exist in surgical outcomes for patients with inflammatory bowel disease.

BACKGROUND: Racial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients. METHODS: This is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005-2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes. RESULTS: Of 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p < 0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1-1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1-2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4-1.9), and sepsis (OR: 1.7; 95% CI 1.4-2.02) compared to White patients. CONCLUSIONS: Racial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.

The impact of an enhanced recovery program (ERP) on the costs of colorectal surgery.

BACKGROUND: Enhanced Recovery Programs (ERPs) benefit patients but their effects on healthcare costs remain unclear. This study aimed to investigate the costs associated with a colorectal ERP in a large academic health system. METHODS: Patients who underwent colorectal surgery from 2012 to 2014 (pre-ERP) and 2015-2017 (ERP) were propensity score matched based on patient and operative-level characteristics. Primary outcomes were median variable, fixed, and total costs. Secondary outcomes included length-of-stay (LOS), readmissions, and postoperative complications (POCs). RESULTS: 616 surgical cases were included. Patient and operative-level characteristics were similar between the cohorts. Variable costs were $1028 less with ERP. ERP showed savings in nursing, surgery, anesthesiology, pharmacy, and laboratory costs, but had higher fixed costs. Total costs between the two groups were similar. ERP patients had significantly shorter LOS (-1 day, p < 0.01), but similar 30-day readmission rates and overall POCs. CONCLUSIONS: Implementation of an ERP for colorectal surgery was associated with lower variable costs compared to pre-ERP.

Understanding the Surgical Experience for African-Americans and Caucasians With Enhanced Recovery.

INTRODUCTION: Racial/ethnic disparities in surgical outcomes exist. Enhanced recovery programs (ERPs) have reduced some racial/ethnic disparities, but it remains unclear if disparities in experiences are also reduced. The purpose of this study was to use qualitative methods to better understand the surgical experience for African-American and Caucasian patients in the setting of an ERP. METHODS: Using purposeful sampling at a minority-serving institution, we recruited African-American and Caucasian patients who had undergone colorectal surgery under an ERP to six focus groups. Participants identified barriers and facilitators to a positive, or negative, surgical experience. Audio recordings were transcribed and analyzed using an indicative thematic approach with NVivo 10 software (QSR International). RESULTS: Forty-three patients (15 African-Americans and 28 Caucasians) participated in six focus groups. Six themes were identified by patients to be important in surgery: 1) knowledge about colorectal surgery, 2) obtaining information, 3) quality of information, 4) setting expectations about surgery, 5) following preoperative and postoperative instructions, and 6) confidence in surgery outcomes. For both racial/ethnic groups, patients felt that more information could have been provided, information should be given at their level of understanding, and trust in the physician made them feel confident in a positive outcome. African-American patients described experiences of having incorrect or no expectations on surgical outcomes, being provided inconsistent information, and feeling misled. African-Americans also described following instructions from family members and valued the importance of diet and exercise in recovery. CONCLUSIONS: African-American and Caucasian surgical patients have varied surgical experiences even under an ERP. All patients, however, valued the ability to obtain, process, and understand health information during the surgical process. These elements define "health literacy" and suggest the importance of providing health literacy-sensitive care in surgery.

Low Health Literacy Exists in the Inflammatory Bowel Disease (IBD) Population and Is Disproportionately Prevalent in Older African Americans.

BACKGROUND: Low health literacy is common in general populations, but its prevalence in the inflammatory bowel disease (IBD) population is unclear. The objective of this study was to assess the prevalence of low health literacy in a diverse IBD population and to identify risk factors for low health literacy. METHODS: Adult patients with IBD at a single institution from November 2017 to May 2018 were assessed for health literacy using the Newest Vital Sign (NVS). Demographic and socioeconomic data were also collected. Primary outcome was the prevalence of low health literacy. Secondary outcomes were length-of-stay (LOS) and 30-day readmissions after surgical encounters. Bivariate comparisons and multivariable regression were used for analyses. RESULTS: Of 175 IBD patients, 59% were women, 23% were African Americans, 91% had Crohn disease, and mean age was 46 years (SD = 16.7). The overall prevalence of low health literacy was 24%. Compared to white IBD patients, African Americans had significantly higher prevalence of low health literacy (47.5% vs 17.0%, P < 0.05). On multivariable analysis, low health literacy was associated with older age and African American race (P < 0.05). Of 83 IBD patients undergoing abdominal surgery, mean postoperative LOS was 5.5 days and readmission rate was 28.9%. There was no significant difference between LOS and readmissions rates by health literacy levels. CONCLUSIONS: Low health literacy is present in IBD populations and more common among older African Americans. Opportunities exist for providing more health literacy-sensitive care in IBD to address disparities and to benefit those with low health literacy.

Gastrointestinal Stromal Tumors of the Stomach and Esophagus.

Gastrointestinal stromal tumors (GISTs) arise anywhere along the gastrointestinal tract, most commonly as a result of c-kit or PDGFRA proto-oncogene mutations. Surgical resection is an important component of treatment. However, molecular profiling of GISTs has provided many insights into adjuvant and neoadjuvant therapy options. Imatinib, the most frequently studied medical therapy, has been shown in numerous studies to provide benefit to patients in both the neoadjuvant and adjuvant setting. Interval imaging is an important component of the treatment of GISTs and national surveillance recommendations should be followed.

Emotional intelligence in surgery is associated with resident job satisfaction.

BACKGROUND: Emotional intelligence (EI) has been associated with improved work performance and job satisfaction in several industries. We evaluated whether EI was associated with higher measures of work performance and job satisfaction in surgical residents. METHODS: We distributed the validated Trait EI Questionnaire and job satisfaction survey to all general surgery residents at a single institution in 2015. EI and job satisfaction scores were compared with resident performance using faculty evaluations of clinical competency-based surgical milestones and standardized test scores including the United States Medical Licensing Examination (USMLE) and American Board of Surgery In-Training Examination (ABSITE). Statistical comparison was made using Pearson correlation and simple linear regression adjusting for postgraduate year level. RESULTS: The survey response rate was 68.9% with 31 resident participants. Global EI was associated with scores on USMLE Step 2 (r = 0.46, P = 0.01) and Step 3 (r = 0.54, P = 0.01) but not ABSITE percentile scores (r = 0.06, P = 0.77). None of the 16 surgical milestone scores were significantly associated with global EI or EI factors before or after adjustment for postgraduate level. Global EI was associated with overall job satisfaction (r = 0.37, P = 0.04). Of the facets of job satisfaction, global EI was significantly associated with views of supervision (r = 0.42, P = 0.02) and nature of work (r = 0.41, P = 0.02). CONCLUSIONS: EI was associated with job satisfaction and USMLE performance but not ACGME competency-based milestones or ABSITE scores. EI may be an important factor for fulfillment in surgical training that is not currently captured with traditional in-training performance measures.

miR-335 and miR-363 regulation of neuroblastoma tumorigenesis and metastasis.

BACKGROUND: microRNA (miRNA) functions broadly as post-transcriptional regulators of gene expression, and disproportionate miRNAs can result in dysregulation of oncogenes in cancer cells. We have previously shown that gastrin-releasing peptide receptor (GRP-R) signaling regulates tumorigenicity of neuroblastoma cells. Herein, we sought to characterize miRNA profile in GRP-R silenced neuroblastoma cells, and to determine the role of miRNAs on tumorigenicity and metastatic potential. METHODS: Human neuroblastoma cell lines, BE(2)-C and SK-N-SH, were used for our study. Stably transfected GRP-R silenced cells were assessed for miRNA profiles. Cells were transfected with miR-335, miR-363, or miR-CON, a nontargeting control, and in vitro assays were performed. In vivo functions of miR-335 and miR-363 were also assessed in a spleen-liver metastasis murine model. RESULTS: GRP-R silencing significantly increased expression of miR-335 and miR-363 in BE(2)-C cells. Overexpression of miR-335 and miR-363 decreased tumorigenicity as measured by clonogenicity, anchorage-independent growth, and metastasis determined by cell invasion assay and liver metastasis in vivo. CONCLUSION: We report, for the first time, that GRP-R-mediated tumorigenicity and increased metastatic potential in neuroblastoma are regulated, in part, by miR-335 and miR-363. A better understanding of the anti-tumor functions of miRNAs could provide valuable insights to discerning molecular mechanisms responsible for neuroblastoma metastasis.