Gender bias in colorectal surgery fellowship letters of recommendation.

BACKGROUND: As leaders strive to create equitable surgical pipelines, one process under scrutiny is letters of recommendation (LORs). We sought to review the Colon and Rectal Surgery (CRS) Resident Candidate Assessment questionnaire and LORs for gendered differences. METHODS: This retrospective observational study of letters of recommendation to CRS fellowship during the 2018-2019 application cycle utilized linguistic Inquiry and Word Count (LIWC2015) software to assess letter length and themes comparing differences by applicant and referee gender. RESULTS: 103 applicants (35 â€‹% women) with 363 LORs (16 â€‹% written by women) were included. Short answer responses were longer for women applicants, while LORs were longer for men applicants (368 vs 325 words p â€‹= â€‹0.03). Men applicants' strengths had more technical skill descriptors, while women applicants' strengths had more emotional language and cognitive and perceptual words. CONCLUSIONS: This study found significant differences between LORs written for CRS fellowship applicants based on gender.

Quality of Care for Gallstone Pancreatitis-the Impact of the Acute Care Surgery Model and Hospital-Level Operative Resources.

BACKGROUND: Index cholecystectomy is the standard of care for gallstone pancreatitis. Hospital-level operative resources and implementation of an acute care surgery (ACS) model may impact the ability to perform index cholecystectomy. We aimed to determine the influence of structure and process measures related to operating room access on achieving index cholecystectomy for gallstone pancreatitis. METHODS: In 2015, we surveyed 2811 US hospitals on ACS practices, including infrastructure for operative access. A total of 1690 hospitals (60%) responded. We anonymously linked survey data to 2015 State Inpatient Databases from 17 states using American Hospital Association identifiers. We identified patients ≥ 18 years who were admitted with gallstone pancreatitis. Patients transferred from another facility were excluded. Univariate and multivariable regression analyses, clustered by hospital and adjusted for patient factors, were performed to examine multiple structure and process variables related to achieving an index cholecystectomy rate of ≥ 75% (high performers). RESULTS: Over the study period, 5656 patients were admitted with gallstone pancreatitis and 70% had an index cholecystectomy. High-performing hospitals achieved an index cholecystectomy rate of 84.1% compared to 58.5% at low-performing hospitals. On multivariable regression analysis, only teaching vs. non-teaching hospital (OR 2.91, 95% CI 1.11-7.70) and access to dedicated, daytime operative resources (i.e., block time) vs. no/little access (OR 1.93, 95% CI 1.11-3.37) were associated with high-performing hospitals. CONCLUSIONS: Access to dedicated, daytime operative resources is associated with high quality of care for gallstone pancreatitis. Health systems should consider the addition of dedicated, daytime operative resources for acute care surgery service lines to improve patient care.

A contemporary reassessment of the US surgical workforce through 2050 predicts continued shortages and increased productivity demands.

BACKGROUND: We aimed to predict practicing surgeon workforce size across ten specialties to provide an up-to-date, national perspective on future surgical workforce shortages or surpluses. METHODS: Twenty-one years of AMA Masterfile data (1997-2017) were used to predict surgeons practicing from 2030 to 2050. Published ratios of surgeons/100,000 population were used to estimate the number of surgeons needed. MGMA median wRVU/surgeon by specialty (2017) was used to determine wRVU demand and capacity based on projected and needed number of surgeons. RESULTS: By 2030, surgeon shortages across nine specialties: Cardiothoracic, Otolaryngology, General Surgery, Obstetrics-Gynecology, Ophthalmology, Orthopedics, Plastics, Urology, and Vascular, are estimated to increase clinical workload by 10-50% additional wRVU. By 2050, shortages in eight specialties are estimated to increase clinical workload by 7-61% additional wRVU. CONCLUSIONS: If historical trends continue, a majority of surgical specialties are estimated to experience workforce deficits, increasing clinical demands substantially.

In-house intensivist presence does not affect mortality in select emergency general surgery patients.

BACKGROUND: This study aimed to assess the relationship between availability of round-the-clock (RTC) in-house intensivists and patient outcomes in people who underwent surgery for a life-threatening emergency general surgery (LT-EGS) disease such as necrotizing soft-tissue infection, ischemic enteritis, perforated viscus, and toxic colitis. METHODS: Data on hospital-level critical care structures and processes from a 2015 survey of 2,811 US hospitals were linked to patient-level data from 17 State Inpatient Databases. Patients who were admitted with a primary diagnosis code for an LT-EGS disease of interest and underwent surgery on date of admission were included in analyses. RESULTS: We identified 3,620 unique LT-EGS admissions at 368 hospitals. At 66% (n = 243) of hospitals, 83.5% (n = 3,021) of patients were treated at hospitals with RTC intensivist-led care. These facilities were more likely to have in-house respiratory therapists and protocols to ensure availability of blood products or adherence to Surviving Sepsis Guidelines. When accounting for other key factors including overnight surgeon availability, perioperative staffing, and annual emergency general surgery case volume, not having a protocol to ensure adherence to Surviving Sepsis Guidelines (adjusted odds ratio, 2.10; 95% confidence interval, 1.12-3.94) was associated with increased odds of mortality. CONCLUSION: Our results suggest that focused treatment of sepsis along with surgical source control, rather than RTC intensivist presence, is key feature of optimizing EGS patient outcomes. LEVEL OF EVIDENCE: Therapeutic, level III.

Importance of Radiologists in Optimizing Outcomes for Older Americans with Acute Abdomen.

BACKGROUND: Patients presenting with acute abdominal pain often undergo a computed tomography (CT) scan as part of their diagnostic workup. We investigated the relationship between availability, timeliness, and interpretation of CT imaging and outcomes for life-threatening intra-abdominal diseases or "acute abdomen," in older Americans. METHODS: Data from a 2015 national survey of 2811 hospitals regarding emergency general surgery structures and processes (60.1% overall response, n = 1690) were linked to 2015 Medicare inpatient claims data. We identified beneficiaries aged ≥65 admitted emergently with a confirmatory acute abdomen diagnosis code and operative intervention on the same calendar date. Multivariable regression models adjusted for significant covariates determined odds of complications and mortality based on CT resources. RESULTS: We identified 9125 patients with acute abdomen treated at 1253 hospitals, of which 78% had ≥64-slice CT scanners and 85% had 24/7 CT technicians. Overnight CT reads were provided by in-house radiologists at 14% of hospitals and by teleradiologists at 66%. Patients were predominantly 65-74 y old (43%), white (88%), females (60%), and with ≥3 comorbidities (67%) and 8.6% died. STAT radiology reads by a board-certified radiologist rarely/never available in 2 h was associated with increased odds of systemic complication and mortality (adjusted odds ratio 2.6 [1.3-5.4] and 2.3 [1.1-4.8], respectively). CONCLUSIONS: Delays obtaining results are associated with adverse outcomes in older patients with acute abdomen. This may be due to delays in surgical consultation and time to source control while waiting for imaging results. Processes to ensure timely interpretation of CT scans in patients with abdominal pain may improve outcomes in high-risk patients.

Hospital Location and Socioeconomic Disadvantage of Emergency General Surgery Patients.

BACKGROUND: Emergency general surgery (EGS) patients are more socioeconomically vulnerable than elective counterparts. We hypothesized that a hospital's neighborhood disadvantage is associated with vulnerability of its EGS patients. MATERIALS AND METHODS: Area deprivation index (ADI), a neighborhood-level measure of disadvantage, and key characteristics of 724 hospitals in 14 states were linked to patient-level data in State Inpatient Databases. Hospital and EGS patient characteristics were compared across hospital ADI quartiles (least disadvantaged [ADI 1-25] "affluent," minimally disadvantaged [ADI 26-50] "min-da", moderately disadvantaged [ADI 51-75] "mod-da", and most disadvantaged [ADI 76-100] "impoverished") using chi2 tests and multivariable regression. RESULTS: Higher disadvantage hospitals are more often nonteaching (affluent = 38.9%, min-da = 53.5%, mod-da = 72.1%, and impoverished = 67.6%), nonaffiliated with medical schools (50%, 72.4%, 81.8%, and 78.8%), and in rural areas (3.3%, 9.2%, 31.2%, and 27.9%). EGS patients at higher disadvantage hospitals are more likely to be older (43.9%, 48.6%, 49.1%, and 46.6%), have >3 comorbidities (17.0%, 19.0%, 18.4%, and 19.3%), live in low-income areas (21.4%, 23.6%, 32.2%, and 42.5%), and experience complications (23.2%, 23.7%, 24.0%, and 25.2%). Rates of uninsurance/underinsurance were highest at affluent and impoverished hospitals (18.0, 16.4%, 17.7%, and 19.2%). Higher disadvantage hospitals serve fewer minorities (32.6%, 21.3%, 20.7%, and 24.0%), except in rural areas (2.9%, 6.7%, 6.5%, and 15.5%). In multivariable analyses, the impoverished hospital ADI quartile did not predict odds of serving as a safety-net or predominantly minority-serving hospital. CONCLUSIONS: Hospitals in impoverished areas disproportionately serve underserved EGS patient populations but are less likely to have robust resources for EGS care or train future EGS surgeons. These findings have implications for measures to improve equity in EGS outcomes.

The continued urbanization of American surgery: A threat to rural hospitals.

BACKGROUND: In 2011, we predicted that surgeon shortages for rural hospitals would contribute to closures of rural hospitals. Here, we update population trends, the distribution of rural and urban hospitals, and surgeon supply to estimate surgeon demand for rural and urban hospital settings by 2040. METHODS: Surgeon supply was based on new certifications for general surgery, orthopedic surgery, and obstetrics and gynecology adjusted for retirement. Surgeon demand from 2020 to 2040 was projected based on the US Census and published practice ratios: general surgery 10.7/100,000, orthopedic surgery 7.9/100,000, and obstetrics and gynecology 13.0/100,000. RESULTS: The US population grew from 309 million in 2011 to 327 million in 2017 with rural populations unchanged at 56 million. By 2040, the US population will be 374 million (urban 85% and rural 15%) creating shortages of general surgery (-31.5%), orthopedic surgery (-34.3%), and obstetrics and gynecology (-25.3). Future hiring needs for urban hospitals will be 5 times greater than rural hospitals. Urban hospitals will likely recruit most newly certified surgeons. CONCLUSION: Increases in surgery trainees will not meet the demand. The continued urbanization of American surgery may push rural hospitals into a vicious financial cycle leading to additional closures of rural hospitals and worsening issues of access. An alternative training paradigm for the rural surgeon is recommended to meet the unique demands of rural hospitals.

Re-examining "Never Letting the Sun Rise or Set on a Bowel Obstruction" in the Era of Acute Care Surgery.

BACKGROUND: Small bowel obstruction (SBO) no longer mandates urgent surgical evaluation raising the question of the role of operating room (OR) access on SBO outcomes. METHODS: Data from our 2015 survey on emergency general surgery (EGS) practices, including queries on OR availability and surgical staffing, were anonymously linked to adult SBO patient data from 17 Statewide Inpatient Databases (SIDs). Univariate and multivariable associations between OR access and timing of operation, complications, length of stay (LOS), and in-hospital mortality were measured. RESULTS: Of 32,422 SBO patients, 83% were treated non-operatively. Operative patients were older (median 66 vs 65 years), had more comorbidities (53% vs 46% with ≥ 3), and experienced more systemic complications (36% vs 23%), higher mortality (2.8% vs 1.4%), and longer LOS (median 10 vs 4 days). Patients had lower odds of operation if treated at hospitals lacking processes to tier urgent cases (aOR 0.90, 95% CI [0.83-0.99]) and defer elective cases (aOR 0.87 [0.80-0.94]). Patients had higher odds of operation if treated at hospitals with surgeons sometimes (aOR 1.14 [1.04-1.26]) or rarely/never (aOR 1.16 [1.06-1.26]) covering EGS at more than one location compared to always. Odds of systemic complication (OR 2.0 [1.6-2.4]), operative complication (OR 1.5 [1.2-1.8]), and mortality were increased for very late versus early operation (OR 2.6 [1.7-4.0]). CONCLUSIONS: Although few patients with SBO require emergency surgery, we identified EGS structures and processes that are important for providing timely and appropriate intervention for patients whose SBO remains unresolved and requires surgery.

Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach.

BACKGROUND: Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients. METHODS: We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project. RESULTS: Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations. DISCUSSION: Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease. CONCLUSIONS: Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).

The association between self-declared acute care surgery services and critical care resources: Results from a national survey.

PURPOSE: We examined differences in critical care structures and processes between hospitals with Acute Care Surgery (ACS) versus general surgeon on call (GSOC) models for emergency general surgery (EGS) care. METHODS: 2811 EGS-capable hospitals were surveyed to examine structures and processes including critical care domains and ACS implementation. Differences between ACS and GSOC hospitals were compared using appropriate tests of association and logistic regression models. RESULTS: 272/1497 hospitals eligible for analysis (18.2%) reported they use an ACS model. EGS patients at ACS hospitals were more likely to be admitted to a combined trauma/surgical ICU or a dedicated surgical ICU. GSOC hospitals had lower adjusted odds of having 24-h ICU coverage, in-house intensivists or respiratory therapists, and 4/6 critical-care protocols. CONCLUSIONS: Critical care delivery is a key component of EGS care. While harnessing of critical care structures and processes varies across hospitals that have implemented ACS, overall ACS models of care appear to have more robust critical care practices.

Role of interprofessional teams in emergency general surgery patient outcomes.

BACKGROUND: In response to duty hour restrictions, hospitals expanded residency programs and added advanced practice providers. We sought to determine if type of clinical support was associated with emergency general surgery outcomes. METHODS: As part of our 2015 survey of acute care hospitals, we asked hospitals whether residents and advanced practice providers participate in emergency general surgery care. Data from responding hospitals were linked to patient data (≥18 years old admitted with an emergency general surgery diagnosis) from 17 State Inpatient Databases using American Hospital Association identifiers. Analyses compared emergency general surgery patient and hospital characteristics based on type of providers assisting emergency general surgery surgeons (none, only advanced practice providers, only residents, or both). Multivariable analysis determined if presence of advanced practice providers and/or residents was associated with type of management, mortality, or complications. RESULTS: Eighty-three hospitals and 49,271 unique emergency general surgery admissions were included. Hospitals without residents and advanced practice providers were most likely to manage patients operatively. However, hospitals with residents (alone or with advanced practice providers) had reduced odds of systemic complication compared with hospitals without clinical support (adjusted odds ratio 0.77 [95% confidence interval 0.60-0.98] and adjusted odds ratio 0.77 [95% confidence interval 0.62-0.95], respectively), while hospitals with only residents had the lowest odds of operative complication. CONCLUSION: Our findings highlight the positive effect residents (alone or partnering with advanced practice providers) can have on emergency general surgery patient outcomes.

An Updated Physician Workforce Model Predicts a Shortage of Vascular Surgeons for the Next 20 Years.

BACKGROUND: Concern regarding the adequacy of the vascular surgery workforce persists. We aimed to predict future vascular surgery workforce size and capacity using contemporary data on the US population and number, productivity, and practice patterns of vascular surgeons. METHODS: The workforce size needed to maintain current levels of access was estimated to be 1.4 vascular surgeons/100,000 population. Updated population estimates were obtained from the US Census Bureau. We calculated future vascular surgery workforce needs based on the estimated population for every 10 years from 2020 to 2050. American Medical Association Physician Masterfile data from 1997 to 2017 were used to establish the existing vascular surgery workforce size and predict future workforce size, accounting for annual rates of new certificates (increased to an average of 133/year since 2013), retirement (17%/year), and the effects of burnout, reduced work hours, transitions to nonclinical jobs, or early retirement. Based on Medical Group Management Association data that estimate median vascular surgeon productivity to be 8,481 work relative value units (wRVUs)/year, excess/deficits in wRVU capacity were calculated based on the number of anticipated practicing vascular surgeons. RESULTS: Our model predicts declining shortages of vascular surgeons through 2040, with workforce size meeting demand by 2050. In 2030, each surgeon would need to increase yearly wRVU production by 22%, and in 2040 by 8%, to accommodate the workload volume. CONCLUSIONS: Our model predicts a shortage of vascular surgeons in the coming decades, with workforce size meeting demand by 2050. Congruence between workforce and demand for services in 2050 may be related to increases in the number of trainees from integrated residencies combined with decreases in population estimates. Until then, vascular surgeons will be required to work harder to accommodate the workload. Burnout, changing practice patterns, geographic maldistribution, and expansion of health care coverage and utilization may adversely affect the ability of the future workforce to accommodate population needs.

Women surgeons and the emergence of acute care surgery programs.

BACKGROUND: In parallel to women entering general surgery training, acute care surgery (ACS) has been developing as a team-based approach to emergency general surgery (EGS). We sought to examine predictors of women surgeons in EGS generally, and ACS particularly. METHODS: From our national survey, we determined the proportion of women surgeons within EGS hospitals. We compared the proportion of women surgeons based on hospitals characteristics using chi-squared tests, then used regression models to measure odds of ACS relative to the proportion of women. RESULTS: 779 (50.4%) hospitals had zero women surgeons. These hospitals were more likely non-ACS and non-teaching with <200 beds. ACS had a higher median proportion of women surgeons (17%) compared to non-ACS (0%). CONCLUSION: Our study highlights the dearth of women representation within EGS hospitals nationally and illuminates some of the underlying characteristics of ACS that may draw women: urban, academic, and staffed by more recently trained surgeons. SUMMARY: Using a national survey of Emergency General Surgery (EGS) hospitals, we sought to examine predictors of women surgeons in EGS generally, and acute care surgery (ACS) particularly. We found that 779 (50.4%) hospitals had zero women surgeons. Women were more likely to be among EGS surgeons at hospitals with ACS models. Our study highlights the dearth of women representation within EGS hospitals nationally and illuminates some of the underlying characteristics of ACS that may draw women: urban, academic, and staffed by a higher proportion of newly trained surgeons.

The association between self-declared acute care surgery services and operating room access: Results from a national survey.

BACKGROUND: Timely access to the operating room (OR) for emergency general surgery (EGS) diseases is key to optimizing outcomes. We conducted a national survey on EGS structures and processes to examine if implementation of acute care surgery (ACS) would improve OR accessibility compared with a traditional general surgeon on call (GSOC) approach. METHODS: We surveyed 2,811 acute care general hospitals in the United States capable of EGS care. The questionnaire included queries regarding structures and processes related to OR access and on the model of EGS care (ACS vs. GSOC). Associations between the EGS care model and structures and processes to ensure OR access were measured using univariate and multivariate models (adjusted for hospital characteristics). RESULTS: Of 1,690 survey respondents (60.1%), 1,497 reported ACS or GSOC. 272 (18.2%) utilized an ACS model. The ACS hospitals were more likely to have more than 5 days of block time and a tiered system of booking urgent/emergent cases compared with GSOC hospitals (34.2% vs. 7.4% and 85.3% vs. 57.6%, respectively; all p values <0.001). Surgeons at ACS hospitals were more likely to be free of competing clinical duties, be in-house overnight, and cover at a single hospital overnight when covering EGS (40.1% vs. 4.7%, 64.7% vs. 25.6%, and 84.9% vs. 64.9%, respectively; all p values <0.001). The ACS hospitals were more likely to have overnight in-house scrub techs, OR nurses, and recovery room nurses (69.9% vs. 13.8%, 70.6% vs. 13.9%, and 45.6% vs. 5.4%, respectively; all p values <0.001). On multivariable analysis, ACS hospitals had higher odds of all structures and processes that would improve OR access. CONCLUSION: The ACS implementation is associated with factors that may improve OR access. This finding has implications for potential expansion of EGS care models that ensure prompt OR access for the EGS diseases that warrant emergency surgery. LEVEL OF EVIDENCE: Therapeutic, Level III.