Divergent Trends in Postoperative Length of Stay and Postdischarge Complications over Time.

BACKGROUND: There is a push toward shorter length of stay (LOS) after surgery by hospitals, payers, and policymakers. However, the extent to which these changes have shifted the occurrence of complications to the postdischarge setting is unknown. The objectives of this study were to (1) evaluate changes in LOS and postdischarge complications over time and (2) assess factors associated with postdischarge complications. STUDY DESIGN: Patients who underwent surgery across five specialties (colorectal, esophageal, hepatopancreatobiliary [HPB], gynecology, and urology) were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) procedure-targeted database (2014-2019). Trends in the proportion of postdischarge complications within 30 days of surgery and predictors of postdischarge complications were assessed using multivariable logistic regression. RESULTS: Among 538,172 patients evaluated, median LOS decreased from 3 (2014) to 2 days (2019) (p < 0.001). Overall, 12.2% of patients experienced a 30-day complication, with 50.4% occurring postdischarge. with the highest in hysterectomy (80.9%), prostatectomy (74.6%), and cystectomy (54.6%). The overall postoperative complication decreased, but the proportion of postdischarge complications increased from 44.6% (2014) to 56.4% (2019) (p < 0.001), including surgical site infection (superficial/deep/organ space/wound dehiscence), other infection (pneumonia/urinary tract infection/sepsis), cardiovascular (myocardial infarction/cardiac arrest/stroke), and venous thromboembolism. Factors associated with an increased odds of postdischarge complications included Hispanic or other race, higher American Society of Anesthesiologists class, dependent functional status, increased body mass index, higher wound class, inpatient complication, longer operation, and procedure type (HPB/colorectal/hysterectomy/esophagectomy, vs. prostatectomy) (all p < 0.001). CONCLUSION: This comprehensive retrospective analysis across five representative surgical specialties highlighted that although LOS has decreased over time, the proportion of postdischarge complications has increased over time. Focusing on the development of a comprehensive, proactive, postdischarge monitoring system to better identify and manage postdischarge complications is necessary.

Evaluation of emergency department treat-and-release encounters after major gastrointestinal surgery.

BACKGROUND AND OBJECTIVES: Emergency department (ED) utilization after gastrointestinal cancer operations is poorly characterized. Our study objectives were to determine the incidence of, reasons for, and predictors of ED treat-and-release encounters after gastrointestinal cancer operations. METHODS: Patients who underwent elective esophageal, hepatobiliary, gastric, pancreatic, small intestinal, or colorectal operations for cancer were identified in the 2015-2017 Healthcare Cost and Utilization Project State Inpatient and State Emergency Department Databases for New York, Maryland, and Florida. The primary outcomes were the incidence of ED treat-and-release encounters and readmissions within 30 days of discharge. RESULTS: Among 51 527 patients at 406 hospitals, 4047 (7.9%) had an ED treat-and-release encounter, and 5573 (10.8%) had an ED encounter with readmission. In total, 40.7% of ED encounters were treat-and-release encounters. ED treat-and-release encounters were most frequently for pain (12.0%), device/ostomy complaints (11.7%), or wound complaints (11.4%). ED treat-and-release encounters predictors included non-Hispanic Black race/ethnicity (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.12-1.37) and Medicare (OR 1.27, 95% CI 1.16-1.40) or Medicaid (OR 1.82, 95% CI 1.62-2.40) coverage. CONCLUSIONS: ED treat-and-release encounters are common after major gastrointestinal operations, making up nearly half of postdischarge ED encounters. The reasons for ED treat-and-release encounters differ from those for ED encounters with readmissions.

National Evaluation of the Association Between Resident Labor Union Participation and Surgical Resident Well-being.

Importance: Labor unions are purported to improve working conditions; however, little evidence exists regarding the effect of resident physician unions. Objective: To evaluate the association of resident unions with well-being, educational environment, salary, and benefits among surgical residents in the US. Design, Setting, and Participants: This national cross-sectional survey study was based on a survey administered in January 2019 after the American Board of Surgery In-Training Examination (ABSITE). Clinically active residents at all nonmilitary US general surgery residency programs accredited by the American Council of Graduate Medical Education who completed the 2019 ABSITE were eligible for participation. Data were analyzed from December 5, 2020, to March 16, 2021. Exposures: Presence of a general surgery resident labor union. Rates of labor union coverage among non-health care employees within a region were used as an instrumental variable (IV) for the presence of a labor union at a residency program. Main Outcomes and Measures: The primary outcome was burnout, which was assessed using a modified version of the abbreviated Maslach Burnout Inventory and was defined as experiencing any symptom of depersonalization or emotional exhaustion at least weekly. Secondary outcomes included suicidality, measures of job satisfaction, duty hour violations, mistreatment, educational environment, salary, and benefits. Results: A total of 5701 residents at 285 programs completed the pertinent survey questions (response rate, 85.6%), of whom 3219 (56.5%) were male, 3779 (66.3%) were White individuals, 449 (7.9%) were of Hispanic ethnicity, 4239 (74.4%) were married or in a relationship, and 1304 (22.9%) had or were expecting children. Among respondents, 690 residents were from 30 unionized programs (10.5% of programs). There was no difference in burnout for residents at unionized vs nonunionized programs (297 [43.0%] vs 2175 [43.4%]; odds ratio [OR], 0.92 [95% CI, 0.75-1.13]; IV difference in probability, 0.15 [95% CI, -0.11 to 0.42]). There were no significant differences in suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, salary, or benefits except that unionized programs more frequently offered 4 weeks instead of 2 to 3 weeks of vacation (27 [93.1%] vs 52 [30.6%]; OR, 19.18 [95% CI, 3.92-93.81]; IV difference in probability, 0.77 [95% CI, 0.09-1.45]) and more frequently offered housing stipends (10 [38.5%] vs 9 [16.1%]; OR, 2.15 [95% CI, 0.58-7.95]; IV difference in probability, 0.62 [95% CI 0.04-1.20]). Conclusions and Relevance: In this evaluation of surgical residency programs in the US, unionized programs offered improved vacation and housing stipend benefits, but resident unions were not associated with improved burnout, suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, or salary.

National Evaluation of Surgical Resident Grit and the Association With Wellness Outcomes.

Importance: Grit, defined as perseverance and passion for long-term goals, is predictive of success and performance even among high-achieving individuals. Previous studies examining the effect of grit on attrition and wellness during surgical residency are limited by low response rates or single-institution analyses. Objectives: To characterize grit among US general surgery residents and examine the association between resident grit and wellness outcomes. Design, Setting, and Participants: A cross-sectional national survey study of 7464 clinically active general surgery residents in the US was administered in conjunction with the 2018 American Board of Surgery In-Training Examination and assessed grit, burnout, thoughts of attrition, and suicidal thoughts during the previous year. Multivariable logistic regression models were constructed to assess the association of grit with resident burnout, thoughts of attrition, and suicidal thoughts. Statistical analyses were performed from June 1 to August 15, 2019. Exposures: Grit was measured using the 8-item Short Grit Scale (scores range from 1 [not at all gritty] to 5 [extremely gritty]). Main Outcomes and Measures: The primary outcome was burnout. Secondary outcomes were thoughts of attrition and suicidal thoughts within the past year. Results: Among 7464 residents (7413 [99.3%] responded; 4469 men [60.2%]) from 262 general surgery residency programs, individual grit scores ranged from 1.13 to 5.00 points (mean [SD], 3.69 [0.58] points). Mean (SD) grit scores were significantly higher in women (3.72 [0.56] points), in residents in postgraduate training year 4 or 5 (3.72 [0.58] points), and in residents who were married (3.72 [0.57] points; all P ≤ .001), although the absolute magnitude of the differences was small. In adjusted analyses, residents with higher grit scores were significantly less likely to report duty hour violations (odds ratio [OR], 0.85; 95% CI, 0.77-0.93), dissatisfaction with becoming a surgeon (OR, 0.53; 95% CI, 0.48-0.59), burnout (OR, 0.53; 95% CI, 0.49-0.58), thoughts of attrition (OR, 0.61; 95% CI, 0.55-0.67), and suicidal thoughts (OR, 0.58; 95% CI, 0.47-0.71). Grit scores were not associated with American Board of Surgery In-Training Examination performance. For individual residency programs, mean program-level grit scores ranged from 3.18 to 4.09 points (mean [SD], 3.69 [0.13] points). Conclusions and Relevance: In this national survey evaluation, higher grit scores were associated with a lower likelihood of burnout, thoughts of attrition, and suicidal thoughts among general surgery residents. Given that surgical resident grit scores are generally high and much remains unknown about how to employ grit measurement, grit is likely not an effective screening instrument to select residents; instead, institutions should ensure an organizational culture that promotes and supports trainees across this elevated range of grit scores.

Association of Surgical Resident Wellness With Medical Errors and Patient Outcomes.

OBJECTIVES: The aims of this study were to: (1) measure the prevalence of self-reported medical error among general surgery trainees, (2) assess the association between general surgery resident wellness (ie, burnout and poor psychiatric well-being) and self-reported medical error, and (3) examine the association between program-level wellness and objectively measured patient outcomes. SUMMARY OF BACKGROUND DATA: Poor wellness is prevalent among surgical trainees but the impact on medical error and objective patient outcomes (eg, morbidity or mortality) is unclear as existing studies are limited to physician and patient self-report of events and errors, small cohorts, or examine few outcomes. METHODS: A cross-sectional survey was administered immediately following the January 2017 American Board of Surgery In-training Examination to clinically active general surgery residents to assess resident wellness and self-reported error. Postoperative patient outcomes were ascertained using a validated national clinical data registry. Associations were examined using multivariable logistic regression models. RESULTS: Over a 6-month period, 22.5% of residents reported committing a near miss medical error, and 6.9% reported committing a harmful medical error. Residents were more likely to report a harmful medical error if they reported frequent burnout symptoms [odds ratio 2.71 (95% confidence interval 2.16-3.41)] or poor psychiatric well-being [odds ratio 2.36 (95% confidence interval 1.92-2.90)]. However, there were no significant associations between program-level resident wellness and any of the independently, objectively measured postoperative American College of Surgeons National Surgical Quality improvement Program outcomes examined. CONCLUSIONS: Although surgical residents with poor wellness were more likely to self-report a harmful medical error, there was not a higher rate of objectively reported outcomes for surgical patients treated at hospitals with higher rates of burnout or poor psychiatric well-being.

Association of State Certificate of Need Regulation With Procedural Volume, Market Share, and Outcomes Among Medicare Beneficiaries.

Importance: Certificate of need laws provide state-level regulation of health system expenditure. These laws are intended to limit spending and control hospital expansion in order to prevent excess capacity and improve quality of care. Several states have recently introduced legislation to modify or repeal these regulations, as encouraged by executive order 13813, issued in October 2017 by the Trump administration. Objective: To evaluate the difference in markers of hospital activity and quality by state certificate of need status. These markers include hospital procedural volume, hospital market share, county-level procedures per 10 000 persons, and patient-level postoperative outcomes. Design, Setting, and Participants: A cross-sectional study involving Medicare beneficiaries aged 65 years or older who underwent 1 of the following 10 procedures from January 1, 2016, through November 30, 2018: total knee or hip arthroplasty, coronary artery bypass grafting, colectomy, ventral hernia repair, lower extremity vascular bypass, lung resection, pancreatic resection, cystectomy, or esophagectomy. Exposures: State certificate of need regulation status as determined by data from the National Conference of State Legislatures. Main Outcomes and Measures: Outcomes of interest included hospital procedural volume; hospital market share (range, 0-1; reflecting 0%-100% of market share); county-level procedures per 10 000 persons; and patient-level postoperative 30-day mortality, surgical site infection, and readmission. Results: A total of 1 545 952 patients (58.0% women; median age 72 years; interquartile range, 68-77 years) at 3631 hospitals underwent 1 of the 10 operations. Of these patients, 468 236 (30.3%) underwent procedures in the 15 states without certificate of need regulations and 1 077 716 (69.7%) in the 35 states with certificate of need regulations. The total number of procedures ranged between 729 855 total knee arthroplasties (47.21%) and 4558 esophagectomies (0.29%). When comparing states without vs with certificate of need regulations, there were no significant differences in overall hospital procedural volume (median hospital procedure volume, 241 vs 272 operations per hospital for 3 years; absolute difference, 31; 95% CI, -27.64 to 89.64; P = .30). There were no statistically significant differences between states without vs with certificate of need regulations for median hospital market share (median, 28% vs 52%; absolute difference, 24%; 95% CI, -5% to 55%; P = .11); procedure rates per 10 000 Medicare-eligible population (median, 239.23 vs 205.41 operations per Medicare-eligible population in 3 years; absolute difference, 33.82; 95% CI, -84.08 to 16.43; P = .19); or 30-day mortality (1.17% vs 1.33%, odds ratio [OR], 1.04; 95% CI, 0.93 to 1.16; P = .52), surgical site infection (1.24% vs 1.25%; OR, 0.93; 95% CI, 0.83 to 1.04; P = .21), or readmission rate (9.69% vs 8.40%; OR, 0.80; 95% CI, 0.57 to 1.12; P = .19). Conclusions and Relevance: Among Medicare beneficiaries who underwent a range of surgical procedures from 2016 through 2018, there were no significant differences in markers of hospital volume or quality between states without vs with certificate of need laws. Policy makers should consider reevaluating whether the current approach to certificate of need regulation is achieving the intended objectives and whether those objectives should be updated.

A National Mixed-Methods Evaluation of Preparedness for General Surgery Residency and the Association With Resident Burnout.

Importance: Differences in medical school experiences may affect how prepared residents feel themselves to be as they enter general surgery residency and may contribute to resident burnout. Objectives: To assess preparedness for surgical residency, to identify factors associated with preparedness, to examine the association between preparedness and burnout, and to explore resident and faculty perspectives on resident preparedness. Design, Setting, and Participants: This cross-sectional study used convergent mixed-methods analysis of data from a survey of US general surgery residents delivered at the time of the 2017 American Board of Surgery In-Training Examination (January 26 to 31, 2017) in conjunction with qualitative interviews of residents and program directors conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. A total of 262 Accreditation Council for Graduate Medical Education-approved US general surgery residency programs participated. Survey data were collected from 3693 postgraduate year (PGY) 1 and PGY2 surgical residents (response rate, 99%) and 98 interviews were conducted with residents and faculty from September 1 to December 15, 2018. Data were analyzed from June 1, 2017, to February 15, 2018. Main Outcomes and Measures: Hierarchical regression models were developed to examine factors associated with preparedness and to assess the association between preparedness and resident burnout. Qualitative interviews were conducted to identify themes associated with preparation for residency. Results: Of the 3693 PGY1 and PGY2 residents who participated (2258 male [61.1%]), 1775 (48.1%) reported feeling unprepared for residency. Approximately half of surgery residents took overnight call infrequently (≤2 per month) during their core medical student clerkship (1904 [51.6%]) or their subinternship (1600 [43.3%]); 524 (14.2%) took no call during their core clerkship. In multivariable analysis, residents were more likely to report feeling unprepared for residency if they were female (odds ratio [OR], 1.34; 95% CI, 1.15-1.57) or did not take call as a medical student (OR for 0 vs >4 calls, 2.72; 95% CI, 2.10-3.52). Residents who did not complete a subinternship were less likely to report feeling prepared for residency (OR, 0.68; 95% CI, 0.48-0.96). Feeling adequately prepared for residency was associated with a nearly 2-fold lower risk of experiencing burnout symptoms (OR, 0.57; 95% CI, 0.48-0.68). In interviews, the dominant themes associated with preparedness included the following: (1) various regulations limit the medical school experience, (2) overnight call facilitates preparation and selection of a specialty compatible with their preferences, and (3) adequate perceptions of residency improve expectations, resulting in improved preparedness, lower burnout rates, and lower risk of attrition. Conclusions and Relevance: In this cross-sectional study, the perception of feeling unprepared was associated with inadequate exposure to resident responsibilities while in medical school. These findings suggest that effective preparation of medical students for residency may result in lower rates of subsequent burnout.

Association between surgical approach and survival following resection of abdominopelvic malignancies.

BACKGROUND AND OBJECTIVES: Recent studies demonstrating decreased survival following minimally invasive surgery (MIS) for cervical cancer have generated concern regarding oncologic efficacy of MIS. Our objective was to evaluate the association between surgical approach and 5-year survival following resection of abdominopelvic malignancies. METHODS: Patients with stage I or II adenocarcinoma of the prostate, colon, rectum, and stage IA2 or IB1 cervical cancer from 2010-2015 were identified from the National Cancer Data Base. The association between surgical approach and 5-year survival was assessed using propensity-score-matched cohorts. Distributions were compared using logistic regression. Hazard ratio for death was estimated using Cox proportional-hazard models. RESULTS: The rate of deaths at 5 years was 3.4% following radical prostatectomy, 22.9% following colectomy, 18.6% following proctectomy, and 6.8% following radical hysterectomy. Open surgery was associated with worse survival following radical prostatectomy (HR, 1.18; 95% CI, 1.05-1.33; P = .005), colectomy (HR, 1.45; 95% CI, 1.39-1.51; P < .001), and proctectomy (HR, 1.28; 95% CI, 1.10-1.50; P = .002); however, open surgery was associated with improved survival following radical hysterectomy (HR, 0.61; 95% CI, 0.44-0.82; P = .003). CONCLUSIONS: These results suggest that MIS is an acceptable approach in selected patients with prostate, colon, and rectal cancers, while concerns regarding MIS resection of cervical cancer appear warranted.

National Evaluation of Needlestick Events and Reporting Among Surgical Residents.

BACKGROUND: Needlestick injuries pose significant health hazards; however, the nationwide frequency of needlesticks and reporting practices among surgical residents are unknown. The objectives of this study were to examine the rate and circumstances of self-reported needlestick events in US surgery residents, assess factors associated with needlestick injuries, evaluate reporting practices, and identify reporting barriers. STUDY DESIGN: A survey administered after the American Board of Surgery In-Training Examination (January 2017) asked surgical residents how many times they experienced a needlestick during the last 6 months, circumstances of the most recent event, and reporting practices and barriers. Factors associated with needlestick events were examined using multivariable hierarchical regression models. RESULTS: Among 7,395 resident survey respondents from all 260 US general surgery residency programs (99.3% response rate), 27.7% (n = 2,051) noted experiencing a needlestick event in the last 6 months. Most events occurred in the operating room (77.5%) and involved residents sticking themselves (76.2%), mostly with solid needles (84.7%). Self-reported factors underlying needlestick events included residents' own carelessness (48.8%) and feeling rushed (31.3%). Resident-level factors associated with self-reported needlestick events included senior residents (PGY5 29.9% vs PGY1 22.4%; odds ratio 1.66; 95% CI 1.41 to 1.96), female sex (31.9% vs male 25.2%; odds ratio 1.31; 95% CI 1.18 to 1.46), or frequently working more than 80 hours per week (odds ratio 1.42; 95% CI 1.20 to 1.68). More than one-fourth (28.7%) of residents did not report the needlestick event to employee health. CONCLUSIONS: In this comprehensive national survey of surgical residents, needlesticks occurred frequently. Many needlestick events were not reported and numerous reporting barriers exist. These findings offer guidance in identifying opportunities to reduce needlesticks and encourage reporting of these potentially preventable injuries among trainees.

Comparison of Hospitals Affiliated With PPS-Exempt Cancer Centers, Other Hospitals Affiliated With NCI-Designated Cancer Centers, and Other Hospitals That Provide Cancer Care.

IMPORTANCE: Congress has exempted 11 specialized cancer centers in the United States from the Prospective Payment System (PPS). These centers are also exempt from reporting many of the process-of-care and outcome measures to the Centers for Medicare & Medicaid Services that are required for hospitals in the PPS. It is not known how hospitals affiliated with PPS-exempt cancer centers differ from other hospitals affiliated with National Cancer Institute cancer centers (NCI-CCs) or other US hospitals that provide cancer care. OBJECTIVE: To examine differences between hospitals affiliated with PPS-exempt cancer centers, other hospitals affiliated with NCI-CCs, and other hospitals that provide cancer care on metrics that could be used in public reporting. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study compared hospital characteristics and cancer-related services using data from the American Hospital Association Annual Survey and US News Best Hospitals rankings. With a 100% sample of Medicare beneficiaries who underwent 1 of 9 cancer operations (brain tumor resection, colorectal resection, cystectomy, esophagectomy, gastrectomy, liver resection, lung resection, pancreatic resection, prostatectomy) from January 1, 2011, to May 31, 2015, we used hierarchical logistic regression methods to compare differences in 18 postoperative outcomes. Data analysis was conducted from February 2018 to August 2018. MAIN OUTCOMES AND MEASURES: This study evaluated hospital characteristics, including cancer-specific services, patient comorbidity burden, and cancer surgery postoperative outcomes, from PPS-exempt cancer centers, NCI-affiliated cancer centers, and other US hospitals that provide cancer care. RESULTS: Hospitals affiliated with PPS-exempt cancer centers (n = 15) and NCI-CCs (n = 54) were similar in hospital characteristics, basic cancer-related services, and patient comorbidity burden. Compared with NCI-CCs, PPS-exempt cancer centers had significantly higher US News reputation scores (mean [SD], 17.5 [24.0] vs 2.6 [4.8]; P < .001) but no differences in oncology patient volume, patient safety ratings, comorbidity burden, nurse staffing, US News total cancer scores, or US News survival scores. Hospitals affiliated with PPS-exempt cancer centers and NCI-CCs had similar adjusted postoperative outcomes for 15 of 18 measures, including mortality, readmission, and surgical site infections. Compared with hospitals affiliated with PPS-exempt cancer centers, patients treated at NCI-CCs were more likely to have postoperative sepsis (3.1% vs 1.7%; P = .002), acute renal failure (6.2% vs 3.9%; P = .01), and urinary tract infection (6.4% vs 4.0%; P = .002). Compared with the other hospitals that provide cancer care (n = 3578), PPS-exempt cancer center status was associated with improved outcomes for 7 of 18 measures, including mortality, sepsis, acute renal failure, pulmonary failure, and failure to rescue. CONCLUSIONS AND RELEVANCE: Hospitals affiliated with PPS-exempt cancer centers and NCI-CCs had generally similar hospital characteristics, patient comorbidity burden, and cancer surgery outcomes. These findings raise questions about why some cancer centers are designated as PPS-exempt and why most hospitals are not required to publicly report cancer-specific quality metrics.

Estimation of Population Average Treatment Effects in the FIRST Trial: Application of a Propensity Score-Based Stratification Approach.

OBJECTIVE/STUDY QUESTION: To estimate and compare sample average treatment effects (SATE) and population average treatment effects (PATE) of a resident duty hour policy change on patient and resident outcomes using data from the Flexibility in Duty Hour Requirements for Surgical Trainees Trial ("FIRST Trial"). DATA SOURCES/STUDY SETTING: Secondary data from the National Surgical Quality Improvement Program and the FIRST Trial (2014-2015). STUDY DESIGN: The FIRST Trial was a cluster-randomized pragmatic noninferiority trial designed to evaluate the effects of a resident work hour policy change to permit greater flexibility in scheduling on patient and resident outcomes. We estimated hierarchical logistic regression models to estimate the SATE of a policy change on outcomes within an intent-to-treat framework. Propensity score-based poststratification was used to estimate PATE. DATA COLLECTION/EXTRACTION METHODS: This study was a secondary analysis of previously collected data. PRINCIPAL FINDINGS: Although SATE estimates suggested noninferiority of outcomes under flexible duty hour policy versus standard policy, the noninferiority of a policy change was inconclusively noninferior based on PATE estimates due to imprecision. CONCLUSIONS: Propensity score-based poststratification can be valuable tools to address trial generalizability but may yield imprecise estimates of PATE when sparse strata exist.

Association Between State Medical Malpractice Environment and Postoperative Outcomes in the United States.

BACKGROUND: The US medical malpractice system assumes that the threat of liability should deter negligence, but it is unclear whether malpractice environment affects health care quality. We sought to explore the association between state malpractice environment and postoperative complication rates. STUDY DESIGN: This observational study included Medicare fee-for-service beneficiaries undergoing one of the following operations in 2010: colorectal, lung, esophageal, or pancreatic resection, total knee arthroplasty, craniotomy, gastric bypass, abdominal aortic aneurysm repair, coronary artery bypass grafting, or cystectomy. The state-specific malpractice environment was measured by 2010 medical malpractice insurance premiums, state average award size, paid malpractice claims/100 physicians, and a composite malpractice measure. Outcomes of interest included 30-day readmission, mortality, and postoperative complications (eg sepsis, myocardial infarction [MI], pneumonia). Using Medicare administrative claims data, associations between malpractice environment and postoperative outcomes were estimated using hierarchical logistic regression models with hospital random-intercepts. RESULTS: Measures of malpractice environment did not have significant, consistent associations with postoperative outcomes. No individual tort reform law was consistently associated with improved postoperative outcomes. Higher-risk state malpractice environment, based on the composite measure, was associated with higher likelihood of sepsis (odds ratio [OR] 1.22; 95% CI 1.07 to 1.39), MI (OR 1.14; 95% CI 1.06 to 1.23), pneumonia (OR 1.09; 95% CI 1.03 to 1.16), acute renal failure (OR 1.15; 95% CI 1.08 to 1.22), deep vein thrombosis/pulmonary embolism (OR 1.22; 95% CI 1.13 to 1.32), and gastrointestinal bleed (OR 1.18; 95% CI 1.08 to 1.30). CONCLUSIONS: Higher risk malpractice environments were not consistently associated with a lower likelihood of surgical postoperative complications, bringing into question the ability of malpractice lawsuits to promote health care quality.

Association Between Flexible Duty Hour Policies and General Surgery Resident Examination Performance: A Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial Analysis.

BACKGROUND: Concerns persist about the effect of current duty hour reforms on resident educational outcomes. We investigated whether a flexible, less-restrictive duty hour policy (Flexible Policy) was associated with differential general surgery examination performance compared with current ACGME duty hour policy (Standard Policy). STUDY DESIGN: We obtained examination scores on the American Board of Surgery In-Training Examination, Qualifying Examination (written boards), and Certifying Examination (oral boards) for residents in 117 general surgery residency programs that participated in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial. Using bivariate analyses and regression models, we compared resident examination performance across study arms (Flexible Policy vs Standard Policy) for 2015 and 2016, and 1 year of the Qualifying Examination and Certifying Examination. Adjusted analyses accounted for program-level factors, including the stratification variable for randomization. RESULTS: In 2016, FIRST trial participants were 4,363 general surgery residents. Mean American Board of Surgery In-Training Examination scores for residents were not significantly different between study groups (Flexible Policy vs Standard Policy) overall (Flexible Policy: mean [SD] 502.6 [100.9] vs Standard Policy: 502.7 [98.6]; p = 0.98) or for any individual postgraduate year level. There was no difference in pass rates between study arms for either the Qualifying Examination (Flexible Policy: 90.4% vs Standard Policy: 90.5%; p = 0.99) or Certifying Examination (Flexible Policy: 86.3% vs Standard Policy: 88.6%; p = 0.24). Results from adjusted analyses were consistent with these findings. CONCLUSIONS: Flexible, less-restrictive duty hour policies were not associated with differences in general surgery resident performance on examinations during the FIRST Trial. However, more years under flexible duty hour policies might be needed to observe an effect.

Association Between Resident Perceptions of Patient Safety and Duty Hour Violations.

BACKGROUND: Residents are often required to balance whether to adhere to duty hour policies or violate them to care for patients and obtain educational experiences. Little is known about why residents violate duty hour policies and whether there is a relationship between how often residents violate duty hours and concerns about patient safety. Our objective was to assess the association between resident duty hour violations and resident concerns about patient safety. STUDY DESIGN: We analyzed survey data collected from surgery residents who completed the 2015 American Board of Surgery In-Training Examination, excluding those in the Flexible Policy arm of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. Perceptions of how duty hour restrictions affect patient safety were dichotomized as either "positive/neutral" or "negative." Resident duty hour violations in a typical month were separated as "frequently" (≥3 times) or "infrequently" (<3 times). Rates were compared and regression models were used to examine the association between negative perceptions and duty hour violations, adjusting for resident and program-level covariates. RESULTS: Overall, 25.3% of trainees under current policies perceived that current ACGME duty hour policies negatively affected patient safety. This negative perception increased with PGY level (PGY1: 18.5%, PGY2 to 3: 22.6%, PGY4 to 5: 32.0%; p < 0.001). Residents with negative perceptions more often reported frequent duty violations (positive/neutral: 20.0% vs negative: 32.7%; p < 0.001). After adjustment for covariates, a negative perception of how duty hour policies affect patient safety was significantly associated with a higher likelihood of frequent duty hour violations among all trainees grouped together (odds ratio [OR] = 1.89; 95% CI, 1.60-2.22), and separately for interns (OR = 2.59; 95% CI, 1.70-3.93), junior (OR = 1.62; 95% CI 1.22-2.16), and senior residents (OR = 1.99; 95% CI, 1.54-2.58). CONCLUSIONS: Trainees who reported perceiving negative effects of duty hour policies on patient safety were more likely to report frequent duty hour violations.

Gender-Based Differences in Surgical Residents' Perceptions of Patient Safety, Continuity of Care, and Well-Being: An Analysis from the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial.

BACKGROUND: Little is known about gender differences in residency training experiences and whether duty hour policies affect these differences. Using data from the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial, we examined gender differences in surgical resident perceptions of patient safety, education, health and well-being, and job satisfaction, and assessed whether duty hour policies affected gender differences. STUDY DESIGN: We compared proportions of male and female residents expressing dissatisfaction or perceiving a negative effect of duty hours on aspects of residency training (ie patient safety, resident education, well-being, job satisfaction) overall and by PGY. Logistic regression models with robust clustered SEs were used to test for significant gender differences and interaction effects of duty hour policies on gender differences. RESULTS: Female PGY2 to 3 residents were more likely than males to be dissatisfied with patient safety (odds ratio [OR] = 2.50; 95% CI, 1.29-4.84) and to perceive a negative effect of duty hours on most health and well-being outcomes (OR = 1.51-2.10; all p < 0.05). Female PGY4 to 5 residents were more likely to be dissatisfied with resident education (OR = 1.56; 95% CI, 1.03-2.35) and time for rest (OR = 1.55; 95% CI, 1.05-2.28) than males. Flexible duty hours reduced gender differences in career dissatisfaction among interns (p = 0.028), but widened gender differences in negative perceptions of duty hours on patient safety (p < 0.001), most health and well-being outcomes (p < 0.05), and outcomes related to job satisfaction (p < 0.05) among PGY2 to 3 residents. CONCLUSIONS: Gender differences exist in perceptions of surgical residency. These differences vary across cohorts and can be influenced by duty hour policies.

Differences in Resident Perceptions by Postgraduate Year of Duty Hour Policies: An Analysis from the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial.

BACKGROUND: In the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial, there were several differences in residents' perceptions of aspects of their education, well-being, and patient care that differed between standard and flexible duty hour policies. Our objective was to assess whether these perceptions differed by level of training. STUDY DESIGN: A survey assessed residents participating in the FIRST trial's perceptions of the effect of duty hour policies on aspects of patient safety, continuity of care, resident education, clinical training, and resident well-being. Hierarchical logistic regression models were used to examine the association between residents' perceptions, study arm, and level of training (interns, junior residents, and senior residents). RESULTS: In the Standard Policy arm, as the PGY level increased, residents more frequently reported that duty hour policies negatively affected patient safety, professionalism, morale, and career choice (all interactions p < 0.001). However, in the Flexible Policy arm, as the PGY level increased, residents less frequently perceived negative effects of duty hour policies on resident health, rest, and time for family and friends and extracurricular activities (all interactions p < 0.001). Overall, there was an increase by PGY level in the proportion of residents expressing a preference for training in programs with flexible duty hour policies, and this preference for flexible duty hour policies was even more apparent among residents who were in the Flexible Policy arm (p < 0.001). CONCLUSIONS: As PGY level increased, residents had increasing concerns about patient care and resident education and training under standard duty hour policies, but they had decreasing concerns about well-being under flexible policies. When given the choice between training under standard or flexible duty hour policies, only 14% of residents expressed a preference for standard policies.

Association Between State Medical Malpractice Environment and Surgical Quality and Cost in the United States.

CONTEXT: The US medical malpractice system is designed to deter negligence and encourage quality of care through threat of liability. OBJECTIVE: To examine whether state-level malpractice environment is associated with outcomes and costs of colorectal surgery. DESIGN, SETTING, AND PATIENTS: Observational study of 116,977 Medicare fee-for-service beneficiaries who underwent colorectal surgery using administrative claims data. State-level malpractice risk was measured using mean general surgery malpractice insurance premiums; paid claims per surgeon; state tort reforms; and a composite measure. Associations between malpractice environment and postoperative outcomes and price-standardized Medicare payments were estimated using hierarchical logistic regression and generalized linear models. MAIN OUTCOME MEASURES: thirty-day postoperative mortality; complications (pneumonia, myocardial infarction, venous thromboembolism, acute renal failure, surgical site infection, postoperative sepsis, any complication); readmission; total price-standardized Medicare payments for index hospitalization and 30-day postdischarge episode-of-care. RESULTS: Few associations between measures of state malpractice risk environment and outcomes were identified. However, analyses using the composite measure showed that patients treated in states with greatest malpractice risk were more likely than those in lowest risk states to experience any complication (OR: 1.31; 95% CI: 1.22-1.41), pneumonia (OR: 1.36; 95%: CI, 1.16-1.60), myocardial infarction (OR: 1.44; 95% CI: 1.22-1.70), venous thromboembolism (OR:2.11; 95% CI: 1.70-2.61), acute renal failure (OR: 1.34; 95% CI; 1.22-1.47), and sepsis (OR: 1.38; 95% CI: 1.24-1.53; all P < 0.001). There were no consistent associations between malpractice environment and Medicare payments. CONCLUSIONS: There were no consistent associations between state-level malpractice risk and higher quality of care or Medicare payments for colorectal surgery.