Consolidation trends in vascular surgery.

BACKGROUND: Practice consolidation by vertical and horizontal integration is a growing trend in surgery. Practice consolidation has not been previously examined in vascular surgery. METHODS: The Medicare Provider Enrollment, Chain, and Ownership System data were used to identify vascular providers and vascular surgery practices in the United States in 2015 and 2020. Practices were categorized as solo (1 surgeon), small (2), medium (3-5), and large (≥6). The number of providers and the number of practices in each size group were determined. The Hirfendahl-Hirshman index (HHI), a measure of market consolidation, was calculated. Provider count, practice size, and HHI were additionally analyzed by urban and rural regions. All values were calculated for each time point and compared. RESULTS: Vascular providers increased in number from 2929 to 3154 (7.7%) from 2015 to 2020. The number of practices decreased from 1351 to 1090 (19.3%). The number of large practices increased by 49.4%; the number of small or solo practices decreased by 42.1%. The mean HHI increased from 0.486 in 2015 to 0.498 in 2020. Both urban and rural regions had a decrease in solo practices (43.3% and 2.3%, respectively) and an increase in HHI (from 0.499 to 0.509 and 0.793 to 0.818, respectively). All changes were statistically significant. CONCLUSIONS: From 2015 to 2020, there is a trend toward vascular providers working in larger practice groups and a corresponding increase in measures of market consolidation.

Perioperative Outcomes After Adrenalectomy for Secondary Adrenal Malignancy.

INTRODUCTION: The risk of adverse outcomes after adrenal metastasectomy is not well defined. Knowledge of these risks is essential to guide patient counseling. METHODS: The 2015-2020 National Surgical Quality Improvement Program datasets were combined. Patients who underwent adrenalectomy for secondary adrenal malignancy (SM) and benign nonfunctional (BNF) adrenal neoplasms were identified; BNF neoplasms were chosen as a comparison as functional neoplasms can contribute to comorbidity. Patients who had additional surgery at the time of adrenalectomy were excluded. Patient demographics, comorbidities, perioperative factors, and outcomes were compared between groups. Multivariable logistic regression analysis was performed. RESULTS: Of 3496 adrenalectomy patients, 332 had SM and 3164 had BNF neoplasms. Patients with SM were older (65 versus 54 y) and more often had chronic obstructive pulmonary disease (7.5% versus 4.4%), chronic steroid use (10.5% versus 3.8%), and bleeding disorders (4.5% versus 2.2%) than patients with BNF, respectively (P < 0.01 for all). Laparoscopic adrenalectomy was the most common operative approach for both groups (74.7% versus 88.3%). Rates of mortality, morbidity, reoperation, readmission, and nonhome discharge did not differ significantly between groups. Patients with SM had higher rates of postoperative bleeding than patients with BNF (6.3% versus 2.6%, P < 0.001). This persisted on multivariable regression analysis that adjusted for demographics, comorbidities, and operative approach (odds ratio 2.34, 95% confidence interval 1.19-4.64). CONCLUSIONS: Adrenalectomy for SM is associated with an increased risk of postoperative bleeding compared to adrenalectomy for BNF adrenal neoplasms. Patients with SM that meet criteria for adrenal metastasectomy should be counseled appropriately.

Adrenalectomy Outcome Variations Across Different Functional Adrenal Tumors.

INTRODUCTION: Adrenalectomy generally has favorable outcomes. It is unknown if patients with functional adrenal tumors experience different clinical outcomes than those with benign adrenal tumors, due to the presence of comorbid conditions secondary to the functional tumor. We investigated outcomes following open and laparoscopic adrenalectomy for benign nonfunctional (BNF) versus functional adrenal masses. METHODS: Patients undergoing adrenalectomy were identified in the 2015-2020 National Surgical Quality Improvement Program database, then categorized as BNF, hyperaldosteronism, hypercortisolism, and pheochromocytoma. The primary outcome of interest was 30-d morbidity and secondary outcomes included 30-d mortality, 30-d readmission, and postoperative length of stay (LOS). Subgroup analysis was performed based upon surgical approach. Univariate analysis was performed, followed by multivariable logistic regression for individual outcomes that differed significantly between patients with BNF and functional neoplasm, factoring in patient demographics and operative approach with statistical significance on univariate analysis. Descriptive statistics and outcomes were analyzed using Pearson's χ2 test and Mann-Whitney U-test as appropriate. RESULTS: There were 3291 patients with BNF while 484 had hyperaldosteronism, 263 hypercortisolism, and 46 pheochromocytomas. Within the laparoscopic group of 3615 (88.5%) of adrenalectomy patients, compared to BNF patients, patients with hyperaldosteronism had lower rates of postoperative morbidity (1.9% versus 5.2%, P < 0.001) and shorter LOS (1 d, interquartile range (IQR) [1-1] versus 1d IQR [1-2], P = 0.003); these persisted on multivariate analysis (OR 0.32, 95% confidence interval [CI] 0.14-0.74 and odds ratio 0.47, 95% CI 0.36-0.60, P < 0.001). Patients with hypercortisolism had higher morbidity (7.3% versus 5.2%, P < 0.001), 30-d readmission rates (5.3% versus 2.9%, P = 0.042) and longer LOS (2d, IQR [1-3] versus 1d, IQR [1-2, P < 0.001). On multivariate analysis, presence of hypercortisolism was independently associated with increased likelihood of readmission within 30 d (OR 2.20, 95% CI 1.11-2.99, P = 0.012) and longer LOS (>1 d) (OR 1.79, 95% CI 1.33-2.40, P < 0.001). Compared to BNF patients, patients with pheochromocytoma had higher rates of postoperative morbidity (6.2% versus 5.2%, P < 0.001). Within the open group of 469 (11.5% of adrenalectomy patients), there were no statistically significant differences in outcomes between patients with BNF and functional adrenal masses. CONCLUSIONS: Outcomes after adrenalectomy performed for functional neoplasms differ based on surgical indication.

Lost in Translation: Multilingual Analysis of Online Breast Cancer Information.

INTRODUCTION: Patients use the internet to learn more about health conditions. Non-English-speaking patients may face additional challenges. The quality of online breast cancer information, the most common cancer in women, is uncertain. This study aims to examine the quality of online breast cancer information for English and non-English-speaking patients. METHODS: Three search engines were queried using the terms: "how to do a breast examination," "when do I need a mammogram," and "what are the treatment options for breast cancer" in English, Spanish, and Chinese. For each language, 60 unique websites were included and classified by type and information source. Two language-fluent reviewers evaluated website quality using the Journal of American Medical Association benchmark criteria (0-4) and the DISCERN tool (1-5), with higher scores representing higher quality. Scores were averaged for each language. Health On the Net code presence was noted. Inter-rater reliability between reviewers was assessed. RESULTS: English and Spanish websites most commonly originated from US sources (92% and 80%, respectively) compared to Chinese websites (33%, P < 0.001). The most common website type was hospital-affiliated for English (43%) and foundation/advocacy for Spanish and Chinese (43% and 45%, respectively). English websites had the highest and Chinese websites the lowest mean the Journal of American Medical Association (2.2 ± 1.4 versus 1.0 ± 0.8, P = 0.002) and DISCERN scores (3.5 ± 0.9 versus 2.3 ± 0.6, P < 0.001). Health On the Net code was present on 16 (8.9%) websites. Inter-rater reliability ranged from moderate to substantial agreement. CONCLUSIONS: The quality of online information on breast cancer across all three languages is poor. Information quality was poorest for Chinese websites. Improvements to enhance the reliability of breast cancer information across languages are needed.

Missed Opportunities to Diagnose and Treat Tertiary Hyperparathyroidism After Transplant.

INTRODUCTION: Tertiary hyperparathyroidism (3HPT) is common after renal transplant. However, guidelines for diagnosis are not clear and few patients are treated surgically. This study aims to determine rates of diagnosis and treatment of 3HPT in renal transplant patients with hypercalcemia. MATERIALS AND METHODS: This retrospective chart review identified all renal transplant recipients at a single tertiary care institution between 2011 and 2021. Patients with post-transplant hypercalcemia (> 10.2 mg/dL) were identified. The time in months of index hypercalcemia was noted. Measurement of parathyroid hormone (PTH) levels after index hypercalcemia was determined and noted as elevated if > 64 pg/mL at least 6 mo after transplant. Documentation of symptoms of hyperparathyroidism, a diagnosis of hyperparathyroidism in the electronic medical record, and medical or surgical management of patients with classic 3HPT (elevated calcium and PTH) were determined. RESULTS: Of 383 renal transplant recipients, hypercalcemia was identified in 132 patients. The majority of hypercalcemic patients had PTH levels measured (127, 96.2%). PTH was elevated in 109 (82.6%). Among the 109 patients with classic 3HPT, 54 (49.5%) had a documented diagnosis of hyperparathyroidism in the electronic medical record (P = 0.01). Kidney stones or abnormal DEXA scan were present in 16 (14.7%) and 18 (16.5%), respectively. Most patients were managed non-surgically (101, 92.6%); calcimimetics were prescribed for 42 (38.5%, P = 0.01). Eight (7.3%) patients with classic 3HPT were referred to a surgeon (P = 0.35); all were initially prescribed calcimimetics (P = 0.001). CONCLUSIONS: 3HPT is underdiagnosed in patients with elevated calcium and PTH levels post-transplant. A significant percentage of these patients go without surgical referral and curative treatment.

From Debt to Dollars: Assessing a General Surgeon's Career Value.

INTRODUCTION: Surgical residents make decisions that may have a dramatic impact on career earnings based off conceptions regarding future income potential. This study examines the effect of debt burden, repayment plan, and practice setting on a general surgeon's career value. METHODS: Debt levels, repayment plans, and practice setting were considered to model a surgeon's career value using net present value (NPV) across 35 scenarios. The NPV was calculated using salary, education debt, yearly spending, and a discount rate of 5%. Salary data were obtained from the Medical Group Management Association, student debt information from the Association of American Medical Colleges, and tax and household spending data from U.S. government records. Assumptions included no gaps in training, no prior debt, single-person household, and career duration of 35 y. RESULTS: A general surgeon's salary adequately repays debt burdens from $100,000-$300,000 over 10-25 y, regardless of repayment plan or practice setting. Practice setting decreased career value for academic surgeons when debt burden and repayment plan were held constant: the NPV for an academic surgeon was $382,000 compared to $500,000 for a nonacademic surgeon with the same debt and repayment plan. Debt burden repaid through unsubsidized and income-based repayment plans reduced NPV for all surgeons, while subsidized plans increased NPV. The projected NPV for all scenarios ranged $2.35M-$2.87 M. CONCLUSIONS: Though the modeled scenarios do not account for prior debt burden, major expenditures, or increases in yearly household spending beyond national averages, surgery residents should be aware that general surgery remains a financially feasible career.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism.

OBJECTIVE: To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND: Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS: Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS: These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS: Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.

Gender Disparities in Presentations at the Society of Surgical Oncology (SSO) Meetings From 2014 to 2019.

BACKGROUND: Participation in surgical society meetings serves as a proxy for academic success and is important for career development. This study aimed to investigate and report the gender breakdown of presenters at recent Society of Surgical Oncology (SSO) meetings. METHODS: Genders of presenters for poster, parallel, plenary, and video sessions at SSO meetings from 2014 through 2019 were collected. These data were broken down to first-last authorship relationships including female-female, female-male, male-female, and male-male. The proportions of female-to-male presenters were compared for each session type. Statistical significance was set at p value lower than 0.05. RESULTS: From 2014 through 2019, the SSO had 2920 presenters, and 47% were female. Women were listed as first authors more often for the poster session (48%) than for other sessions (parallel, plenary, and video) (p = 0.003). Women also were listed more often as senior authors for the poster session (31%) than for other sessions (p = 0.004). Female senior authors were fewer than male senior authors across all session types. Female first authors had the highest representation in breast (75%), endocrine (48%), and cutaneous (46%) specialties (p < 0.001). The most common combination of first and senior authors was male-male (43%), followed by female-male (28%), female-female (19%), and male-female (10%). CONCLUSION: Overall, female presentation at SSO is comparable with society demographics, and female first authorship is relatively equal to male first authorship in poster sessions. Whereas female first authorship improved over time, female senior authorship remained relatively flat. Opportunities to improve gender equality in senior authorship positions should be explored.

Survival After Adrenalectomy for Metastatic Lung Cancer.

BACKGROUND: Adrenal metastasectomy is associated with increased survival in non-small cell lung cancer (NSCLC) with isolated adrenal metastases. Although clinical use of adrenal metastasectomy has expanded, indications remain poorly defined. The aim of this study was to evaluate the clinical benefit of adrenal metastasectomy for all lung cancer subtypes. PATIENTS AND METHODS: We performed a retrospective cohort study of patients who underwent adrenal metastasectomy for metastatic lung cancer at six institutions between 2001 and 2015. The primary outcomes were disease-free survival (DFS) and overall survival (OS). Cox proportional hazards regressions and Kaplan-Meier survival analysis were performed. RESULTS: For 122 patients, the mean age was 60.5 years and 49.2% were female. Median time to detection of the metastasis was 11 months, and 41.8% were ipsilateral to the primary lung cancer. Median DFS was 40 months (1 year: 64.8%; 5 year: 42.9%). Factors associated with longer DFS included primary tumor resection [hazard ratio (HR): 0.001; p = 0.005], longer time to adrenal metastasis (HR: 0.94; p = 0.005), and ipsilateral metastases (HR: 0.13; p = 0.004). Shorter DFS corresponded with older age (HR: 1.11; p = 0.01), R1 resection (HR: 8.94; p = 0.01), adjuvant radiation (HR: 9.45; p = 0.02), and open adrenal metastasectomy (HR: 10.0; p = 0.03). Median OS was 47 months (1 year: 80.2%; 5 year: 35.2%). Longer OS was associated with ipsilateral metastasis (HR: 0.55; p = 0.02) and adjuvant chemotherapy (HR: 0.35; p = 0.02). Shorter OS was associated with extra-adrenal metastases at adrenalectomy (HR: 3.52; p = 0.007), small cell histology (HR: 15.0; p = 0.04), and lung radiation (HR: 3.37; p = 0.002). DISCUSSION: Durable survival was observed in patients undergoing adrenal metastasectomy and should be considered for isolated adrenal metastases of NSCLC. Small cell histology and extra-adrenal metastases are relative contraindications to adrenal metastasectomy.

Predicting Outcomes in Thyroidectomy and Parathyroidectomy: The Modified Five-Point Frailty Index Versus American Society of Anesthesiologists Classification.

INTRODUCTION: Thyroidectomy and parathyroidectomy are relatively safe procedures, with overall morbidity rates of 2%-5%. The increasing age is associated with higher likelihood of poor outcomes. The modified five-point frailty index (mFI-5) is associated with complications, but many surgeons are unfamiliar with mFI-5. We assessed the accuracy of the mFI-5 versus the commonly-used American Society of Anesthesiologists (ASA) classification to predict complications following thyroidectomy and parathyroidectomy. METHODS: Patients undergoing thyroidectomy or parathyroidectomy in 2015-2018 NSQIP datasets were identified. The mFI-5 scores were calculated by adding the number of the following comorbidities: congestive heart failure, hypertension requiring medication, chronic obstructive pulmonary disease, diabetes, and nonindependent functional status. Receiver operating characteristics curves were plotted for 30-d mortality and serious morbidity (defined as deep surgical site infection, dehiscence, unplanned intubation, failure to wean from the ventilator 48-h postoperatively, acute renal failure, pneumonia, pulmonary embolism, myocardial infarction, cardiac arrest requiring cardiopulmonary resuscitation, sepsis, septic shock, cerebrovascular accident, or reoperation) using mFI-5 and ASA classification. Areas under these curves (AUC) were compared. RESULTS: Ninety-two thousand, six hundred and ninety-one patients were studied. The mFI-5 and ASA were fair predictors of 30-d mortality (AUC 0.75 and 0.82, respectively) and good predictors of serious morbidity (AUC 0.61 and 0.64). After stratification by age, ASA was superior to mFI-5 in predicting mortality for patients aged 65, 70, 80 y, and older, for the entire population and for thyroidectomy and parathyroidectomy separately. CONCLUSIONS: The ASA classification is a better predictor of mortality and serious morbidity than mFI-5 among patients undergoing thyroidectomy or parathyroidectomy and may be a better prognostic indicator to use when counseling patients before low-risk neck surgery.

Not Clearing the Air: Hospital Price Transparency for a Laparoscopic Cholecystectomy.

INTRODUCTION: In 2019, Centers for Medicare and Medicaid Services (CMS) established a new requirement that all hospitals publish information on the standard costs of services provided. Increased price transparency allows patients to compare healthcare costs and make informed decisions about their care. We investigated compliance with this rule with regards to laparoscopic cholecystectomy, a commonly performed operation and one of the 70 shoppable services (SSs) included in the CMS requirement, among prominent hospitals in the United States. METHODS: The 2021-2022 US News "Best Hospitals for Gastroenterology and GI Surgery" was used to identify the top 50 hospitals for gastrointestinal surgery. Each hospital's website was assessed for the presence of a machine-readable file (MRF) as required by CMS. Each MRF was then evaluated for inclusion of all seven required elements: description of item/service, gross charge, payer-specific negotiated charge, deidentified minimum and maximum negotiated charges, discounted cash price, and billing code. The presence of a consumer-friendly display of SSs was also evaluated. The Current Procedural Terminology code 47562 (removal of gallbladder with an endoscope) was used to search for all six required elements: payer-specific negotiated charge, discounted cash price, de-identified minimum and maximum negotiated charges, campus location of the SS, and billing code. The SS display was further evaluated for provision of additional information on ancillary charges, which are recommended but not required. The MRF and SS were also evaluated for accessibility and date of last update. Hospitals were analyzed according to rank. Compliance with CMS requirements was compared between hospitals. RESULTS: Fifty one hospitals were included. Of these 51 hospitals, one (2%) provided all the required information for both MRF and SS, 44 (86%) did not provide all necessary components of both the MRF and SS, six (12%) had all necessary elements of an MRF only, and two (4%) had all necessary elements of the SS only. The MRF was accessible in 80% (41) of studied hospitals and 76% (39) provided a gross charge but just 35% (18) of hospitals included the discounted cash price. The SS specified location for all hospitals, indicated a billing code in 96% (49), and provided a payer-specific charge in 96% (48), but less often provided de-identified minimum (30; 59%) and maximum (30; 59%) charges. Thirty nine (76%) hospitals reported that the listed price included an ancillary charge. There was no significant difference between hospitals in having all required elements of both the MRF and SS or the MRF only or SS only. CONCLUSIONS: Hospitals are providing healthcare consumers with standard charge information, although with significant variation in what is disclosed. There is no association between hospital reputation and provision of standard charge information.

Use of Preoperative Laboratory Testing Among Low-Risk Patients Undergoing Elective Anorectal Surgery.

BACKGROUND: Many low-risk patients receive preoperative laboratory testing (PLT) prior to elective outpatient surgery, with no effect on postoperative outcomes. This has not been studied in patients undergoing anorectal surgery. The aim of this study was to determine if PLT in this population was predictive of perioperative complications. MATERIALS AND METHODS: The 2015-2018 National Surgical Quality Improvement Program (NSQIP) databases were queried for elective ambulatory anorectal surgeries. PLT was defined as chemistry, hematology, coagulation, or liver function studies obtained ≤30 days preoperatively. American Society of Anesthesiologists (ASA) class 1 and 2 patients were included who underwent elective, ambulatory, benign anorectal surgery. Patient demographics, comorbidities, and postoperative outcomes were compared between those who did and did not receive PLT. Postoperative outcomes were defined as wound-related, procedure-related, major complications, unplanned readmission, and death occurring within 30 days. Multivariate regression analysis determined patient characteristics predictive of receiving testing. RESULTS: Of 3309 patients studied, 48.6% received PLT. On multivariate analysis, older age, female sex, Black race, ASA class 2, and comorbidities were predictive of receiving testing. The complication rates were similar between patients who did and did not receive testing (4.3% versus 3.5%, P = 0.22). CONCLUSIONS: PLT is performed in over half of low-risk patients receiving elective anorectal surgery. There was no difference in the rate of postoperative complications between patients who received testing or not, nor with normal versus abnormal results. PLT can be used more judiciously in this population.

Adrenalectomy for Secondary Malignancy: Patients, Outcomes, and Indications.

OBJECTIVE: The goal of this study was to examine a multi-institutional experience with adrenal metastases to describe survival outcomes and identify subpopulations who benefit from adrenal metastasectomy. BACKGROUND: Adrenalectomy for metastatic disease is well-described, although indications and outcomes are incompletely defined. METHODS: A retrospective cohort study was performed of patients undergoing adrenalectomy for secondary malignancy (2002-2015) at 6 institutions. The primary outcomes were disease free survival (DFS) and overall survival (OS). Analysis methods included Kaplan-Meier and Cox proportional hazards. RESULTS: Of 269 patients, mean age was 60.1 years; 50% were male. The most common primary malignancies were lung (n = 125, 47%), renal cell (n = 38, 14%), melanoma (n = 33, 12%), sarcoma (n = 18, 7%), and colorectal (n = 12, 5%). The median time to detection of adrenal metastasis after initial diagnosis of the primary tumor was 17 months (interquartile range: 6-41). Post-adrenalectomy, the median DFS was 18 months (1-year DFS: 54%, 5-year DFS: 31%). On multivariable analysis, lung primary was associated with longer DFS [hazard ratio (HR): 0.49, P = 0.008). Extra-adrenal oligometastatic disease at initial presentation (HR: 1.84, P = 0.016), larger tumor size (HR: 1.07, P = 0.013), chemotherapy as treatment of the primary tumor (HR: 2.07 P = 0.027) and adjuvant chemotherapy (HR: 1.95, P = 0.009) were associated with shorter DFS. Median OS was 53 months (1-year OS: 83%, 5-year OS: 43%). On multivariable analysis, extra-adrenal oligometastatic disease at adrenalectomy (HR: 1.74, P = 0.031), and incomplete resection of adrenal metastasis (R1 margins; HR: 1.62, P = 0.034; R2 margins; HR: 5.45, P = 0.002) were associated with shorter OS. CONCLUSIONS: Durable survival is observed in patients undergoing adrenal metastasectomy and should be considered for subjects with isolated adrenal metastases.

Completion Thyroidectomy is Less Common Following Updated 2015 American Thyroid Association Guidelines.

BACKGROUND: The 2015 American Thyroid Association (ATA) guidelines recommended that low-risk, differentiated thyroid cancers (DTC) between 1 and 4 cm may be treated with thyroid lobectomy alone. We sought to determine the effect of these guideline changes on the rate of completion thyroidectomy (CT) for low-risk DTC and factors influencing surgical decision-making. METHODS: All patients from 2014 to 2018 who received an initial thyroid lobectomy at our institution with final pathology demonstrating DTC were included. Patients were divided into "pre" and "post" guideline cohorts (2014-2015 and 2016-2018, respectively). The rate of CT was compared between the two cohorts. Patient demographics and tumor characteristics were examined for association with CT. RESULTS: A total of 163 patients met study criteria: 63 patients in the 2014-2015 ("pre") and 100 in the 2016-2018 ("post") group. In the "pre" period, 41 (65.1%) patients received CT compared with 43 (43.0%) in the "post" period (p < 0.01)-a 34% decrease in the rate of completion surgery (p < 0.01). Of low-risk patients with DTC between 1 and 4 cm in size, 17 of 35 (48.6%) received CT in the "pre" period compared with 15 of 60 (25.0%) in the post period-a 48.6% decrease in the rate of completion surgery (p = 0.02). Greater tumor size, capsular invasion, and multifocality were associated with CT in low-risk "post" guideline patients (p < 0.05 for all). CONCLUSIONS: The rate of CT decreased significantly by 48.6% for low-risk patients with DTC between 1 and 4 cm, demonstrating recognition of the 2015 ATA guidelines. However, 25% of these patients underwent CT, suggesting additional factors influencing the decision for further treatment.

Assessment of Accuracy of a Physician Ratings Website in One Metropolitan Area.

BACKGROUND: Patients frequently use online physician ratings websites (PRWs) to identify physicians for care. PRWs provide physician information and reviews. However, the accuracy of PRWs is uncertain. We investigated the accuracy and validity of Healthgrades with respect to endocrine surgery. We identified factors associated with reported board certification inaccuracy, higher ratings, greater quantity of ratings. MATERIALS AND METHODS: The search term "endocrine surgery specialist" was used and the search was limited to a 25-mile radius around Philadelphia, PA. Data was collected on physician sex, age, board certification, surgical specialty, quantity of ratings, average rating, response to comments, and provision of a self-description. Descriptive statistics were performed to examine surgeon characteristics, ratings, and reported board certifications. Board certification accuracy was determined by searching the corresponding American Board website and calculating a kappa statistic. Logistic regression was performed to identify factors associated with board certification inaccuracy, higher average ratings, and higher quantity of ratings. RESULTS: A total of 300 physicians were identified. Eighty-four percent of listed board certifications were accurate; the kappa statistic for accuracy of board certification was 0.634. Providing a response to comments and greater quantity of ratings were associated with higher average ratings. Provision of a self-description, male sex, and younger age were identified as factors associated with higher quantity of ratings. CONCLUSIONS: A wide range of specialties are identified as endocrine surgery specialists. The reliability of board certification reporting was moderate. Increased surgeon involvement with the Healthgrades site was inconsistently associated with higher average ratings and higher quantity of ratings but lower accuracy.

Utility of Routine Preoperative Laboratory Testing for Low-risk Patients in Ambulatory Gynecologic Surgery.

STUDY OBJECTIVES: To examine the current use of routine preoperative laboratory testing in low-risk patients undergoing ambulatory gynecologic surgery and to determine if such testing affects surgical outcomes. DESIGN: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for ambulatory gynecologic surgeries between 2015 and 2018. Low-risk patients included in this study were defined as being American Society of Anesthesiologists class 1 or 2. The rate of preoperative laboratory testing before ambulatory gynecologic surgery in low-risk patients was determined and factors associated with testing including patient characteristics and comorbidities were evaluated. NSQIP-defined complications were compared between those with and without preoperative laboratory testing. Preoperative laboratory testing was defined as chemistry, hematology, coagulation, or liver function studies obtained within 30 days preoperatively. SETTING: National health systems that participate in the NSQIP. PATIENTS: There were 19 855 patients who underwent an ambulatory gynecologic procedure. INTERVENTIONS: Preoperative laboratory testing in low-risk patients before ambulatory gynecologic surgery. MEASUREMENTS AND MAIN RESULTS: Of the 19 855 patients studied, 14 258 (71.8%) received preoperative laboratory testing. Statistically significant differences were seen between patients who underwent preoperative testing and patients who did not. The most frequent preoperative test was a complete blood cell count (70.4%). Among patients who received preoperative testing, 4053 (28.4%) had at least 1 abnormal result. No statistically significant difference was seen in overall postoperative complication rate when comparing patients who received preoperative laboratory testing with those who did not (2.5% vs 2.2%, p = .30). Specifically, no statistically significant difference was seen among wound complications (1.0% vs 1.0%, p = .78), major complications (1.0% vs 0.8%, p = .11), unplanned return to the operating room (0.1% vs 0.2%, p = .40), unplanned readmission (0.7% vs 0.5%, p = .10), or overall morbidity (2.1% vs 1.9%, p = .38). Chi-square analyses were performed to compare categoric variables. Continuous variables were compared using unpaired t tests. CONCLUSION: This large study using a reputable national database revealed that despite updated evidence-based guidelines that recommend against the practice, preoperative laboratory testing continues to be performed for most low-risk patients undergoing ambulatory gynecologic surgery. This study also further supports current guidelines in demonstrating no difference in surgical outcomes between low-risk patients who did and did not receive preoperative laboratory testing. Preoperative laboratory testing practices for low-risk patients undergoing ambulatory gynecologic surgery do not follow current evidence-based guidelines and should be re-evaluated.

Variation in the Utilization of Minimally Invasive Surgical Operations.

OBJECTIVE: The goal of this study was to examine regional variation in use of minimally invasive surgical (MIS) operations. SUMMARY BACKGROUND DATA: Regional variation exists in performance of surgical operations. Variation in the use of MIS has not been studied. METHODS: Five operations that are performed open or MIS were selected: cholecystectomy, appendectomy, colectomy, antireflux, and bariatric. A 3-state database from 2008 to 2011 was used; states were divided into hospital service areas (HSAs). For each operation, the percentage of MIS operations was calculated. HSAs with less than 50% or more than 150% of the MIS average were considered outliers. Population demographics, geography, and hospital and physician presence were compared between HSAs. Rates of performance by patient disease and the presence of MIS surgeons were also investigated. RESULTS: MIS cholecystectomy was performed with low variation; MIS appendectomy, antireflux, and bariatric operations with medium variation; and MIS colectomy with high variation. With the exception of MIS colectomy, there were no differences in the patient demographics, geography, or disease types treated with an MIS approach between HSAs with low-, non-, or high utilization of MIS. There is no correlation between the number of MIS surgeons and the percentage of procedures performed MIS. CONCLUSIONS: Variation in utilization of MIS exists and differs by operation. Patient demographics, patient disease, and the ability to access care are associated only with variation in use of MIS for colectomy. For all other operations studied, these factors do not explain variation in MIS use. Further investigation is warranted to identify and eliminate causes of variation.

Comparing International and United States Undergraduate Medical Education and Surgical Outcomes Using a Refined Balance Matching Methodology.

OBJECTIVE: The aim of this study is to compare surgical outcomes of international medical graduates (IMGs) and United States medical graduates (USMGs). SUMMARY OF BACKGROUND DATA: IMGs represent 15% of practicing surgeons in the United States (US), and their training pathways often differ substantially from USMGs. To date, differences in the clinical outcomes between the 2 cohorts have not been examined. METHODS: Using a unique dataset linking AMA Physician Masterfile data with hospital discharge claims from Florida and New York (2008-2011), patients who underwent 1 of 32 general surgical operations were stratified by IMG and USMG surgeon status. Mortality, complications, and prolonged length of stay were compared between IMG and USMG surgeon status using optimal sparse network matching with balance. RESULTS: We identified 972,718 operations performed by 4581 surgeons (72% USMG, 28% IMG). IMG and USMG surgeons differed significantly in demographic (age, gender) and baseline training (years of training, university affiliation of training hospital) characteristics. USMG surgeons performed complex procedures (13.7% vs 11.1%, P < 0.01) and practiced in urban settings (79.4% vs 75.6%, P < 0.01) more frequently, while IMG surgeons performed a higher volume of studied operations (50.7 ±â€Š5.1 vs 57.8 ±â€Š8.4, P < 0.01). In the matched cohort analysis of 396,810 patients treated by IMG and USMG surgeons, rates of mortality (USMG: 2.2%, IMG: 2.1%; P < 0.001), complications (USMG: 14.5%, IMG: 14.3%; P = 0.032), and prolonged length of stay (pLOS) (USMG: 22.7%, IMG: 22.8%; P = 0.352) were clinically equivalent. CONCLUSION: Despite considerable differences in educational background, surgical training characteristics, and practice patterns, IMG and USMG-surgeons deliver equivalent surgical care to the patients whom they treat.

Hospitalization in the Year Preceding Major Oncologic Surgery Increases Risk for Adverse Postoperative Events.

BACKGROUND: Hospitalization is associated with negative clinical effects that last beyond discharge. This study aimed to determine whether hospitalization in the year before major oncologic surgery is associated with adverse outcomes. METHODS: Patients 18 years of age or older with stomach, pancreas, colon, or rectal cancer who underwent resection in California and New York (2008-2010) were included in the study. Patients with hospitalization in the year prior to oncologic resection (HYPOR) were identified. Multivariable logistic regression was used to examine the association of prior hospitalization with the following adverse outcomes: inpatient mortality, complications, complex discharge needs, and 90-day readmission. Subset analysis by cancer type was performed. Outcomes based on temporal proximity of hospitalization to month of surgical admission were evaluated. RESULTS: Of 32,292 patients, 16.3% (n = 5276) were HYPOR. Patients with prior hospitalization were older (median age, 72 vs 67 years; p < 0.001) and had more comorbidities (Elixhauser Index ≥3, 86.5 vs 75.3%; p < 0.001). In the multivariable analysis, HYPOR was associated with complications (odds ratio [OR], 1.28; 95% confidence interval [CI] 1.18-1.40), complex discharge (OR, 1.44; 95% CI 1.34-1.55), and 90-day readmission (OR, 1.45; 95% CI 1.35-1.56). The interval from HYPOR to resection was not associated with adverse outcomes. CONCLUSIONS: Patients hospitalized in the year before oncologic resection are at increased risk for postoperative adverse events. Recent hospitalization is a risk factor that is easily ascertainable and should be used by clinicians to identify patients who may need additional support around the time of oncologic resection.