Building relationships to connect cancer researchers with community members: 'bench to community pipeline'.

PURPOSE: Partnerships between researchers and community members and organizations can offer multiple benefits for research relevance and dissemination. The goal of this project was to build infrastructure to create bidirectional relationships between University of Wisconsin Carbone Cancer Center (UWCCC) researchers and community educators in the Division of Extension, which connects the knowledge and resources of the university to communities across the state. METHODS: This project had three aims: (1) create linkages with Extension; (2) establish an in-reach program to educate and train researchers on the science of Community Outreach and Engagement (COE); and (3) identify and facilitate collaborative projects between scientists and communities. Survey and focus group-based needs assessments were completed with both researchers and Extension educators and program activity evaluations were conducted. RESULTS: Most Extension educators (71%) indicated a strong interest in partnering on COE projects. UWCCC faculty indicated interest in further disseminating their research, but also indicated barriers in connecting with communities. Outreach webinars were created and disseminated to community, a "COE in-reach toolkit" for faculty was created and a series of "speed networking" events were hosted to pair researchers and community. Evaluations indicated the acceptability and usefulness of these activities and supported continuation of collaborative efforts. CONCLUSION: Continued relationship and skill building, along with a sustainability plan, is critical to support the translation of basic, clinical, and population research to action in the community outreach and engagement context. Further incentives for faculty should be explored for the recruitment of basic scientists into community engagement work.

Development of the Illinois Surgical Quality Improvement Collaborative (ISQIC): Implementing 21 Components to Catalyze Statewide Improvement in Surgical Care.

INTRODUCTION: In 2014, 56 Illinois hospitals came together to form a unique learning collaborative, the Illinois Surgical Quality Improvement Collaborative (ISQIC). Our objectives are to provide an overview of the first three years of ISQIC focused on (1) how the collaborative was formed and funded, (2) the 21 strategies implemented to support quality improvement (QI), (3) collaborative sustainment, and (4) how the collaborative acts as a platform for innovative QI research. METHODS: ISQIC includes 21 components to facilitate QI that target the hospital, the surgical QI team, and the peri-operative microsystem. The components were developed from available evidence, a detailed needs assessment of the hospitals, reviewing experiences from prior surgical and non-surgical QI Collaboratives, and interviews with QI experts. The components comprise 5 domains: guided implementation (e.g., mentors, coaches, statewide QI projects), education (e.g., process improvement (PI) curriculum), hospital- and surgeon-level comparative performance reports (e.g., process, outcomes, costs), networking (e.g., forums to share QI experiences and best practices), and funding (e.g., for the overall program, pilot grants, and bonus payments for improvement). RESULTS: Through implementation of the 21 novel ISQIC components, hospitals were equipped to use their data to successfully implement QI initiatives and improve care. Formal (QI/PI) training, mentoring, and coaching were undertaken by the hospitals as they worked to implement solutions. Hospitals received funding for the program and were able to work together on statewide quality initiatives. Lessons learned at one hospital were shared with all participating hospitals through conferences, webinars, and toolkits to facilitate learning from each other with a common goal of making care better and safer for the surgical patient in Illinois. Over the first three years, surgical outcomes improved in Illinois. DISCUSSION: The first three years of ISQIC improved care for surgical patients across Illinois and allowed hospitals to see the value of participating in a surgical QI learning collaborative without having to make the initial financial investment themselves. Given the strong support and buy-in from the hospitals, ISQIC has continued beyond the initial three years and continues to support QI across Illinois hospitals.

Gender Differences in Utilization of Duty-hour Regulations, Aspects of Burnout, and Psychological Well-being Among General Surgery Residents in the United States.

OBJECTIVE: The aim of the study was to (1) assess differences in how male and female general surgery residents utilize duty-hour regulations and experience aspects of burnout and psychological well-being, and (2) to explore reasons why these differing experiences exist. BACKGROUND: There may be differences in how women and men enter, experience, and leave residency programs. METHODS: A total of 7395 residents completed a survey (response rate = 99%). Logistic regression models were developed to examine the association between gender and resident outcomes. Semistructured interviews were conducted with 42 faculty and 56 residents. Transcripts were analyzed thematically using a constant comparative approach. RESULTS: Female residents reported more frequently staying in the hospital >28 hours or working >80 hours in a week (≥3 times in a month, P < 0.001) and more frequently feeling fatigued and burned out from their work (P < 0.001), but less frequently "treating patients as impersonal objects" or "not caring what happens" to them (P < 0.001). Women reported more often having experienced many aspects of poor psychological well-being such as feeling unhappy and depressed or thinking of themselves as worthless (P < 0.01). In adjusted analyses, associations remained significant. Themes identified in the qualitative analysis as possible contributory factors to gender differences include a lack of female mentorship/leadership, dual-role responsibilities, gender blindness, and differing pressures and approaches to patient care. CONCLUSIONS: Female residents report working more, experiencing certain aspects of burnout more frequently, and having poorer psychological well-being. Qualitative themes provide insights into possible cultural and programmatic shifts to address the concerns for female residents.

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.

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.

Use and Underlying Reasons for Duty Hour Flexibility in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial.

BACKGROUND: The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial randomly assigned surgical residency programs to either standard duty hour policies or flexible policies that eliminated caps on shift lengths and time off between shifts. Our objectives were to assess adherence to duty hour requirements in the Standard Policy arm and examine how often and why duty hour flexibility was used in the Flexible Policy arm. STUDY DESIGN: A total of 3,795 residents in the FIRST trial completed a survey in January 2016 (response rate >95%) that asked how often and why they exceeded current standard duty hour limits in both study arms. RESULTS: Flexible Policy interns worked more than 16 hours continuously at least once in a month more frequently than Standard Policy residents (86% vs 37.8%). Flexible Policy residents worked more than 28 hours once in a month more frequently than Standard Policy residents (PGY1: 64% vs 2.9%; PGY2 to 3: 62.4% vs 41.9%; PGY4 to 5: 52.2% vs 36.6%), but this occurred most frequently only 1 to 2 times per month. Although residents reported working more than 80 hours in a week 3 or more times in the most recent month more frequently under Flexible Policy vs Standard Policy (19.9% vs 16.2%), the difference was driven by interns (30.9% vs 19.6%), and there were no significant differences in exceeding 80 hours among PGY2 to 5 residents. The most common reasons reported for extending duty hours were facilitating care transitions (76.6%), stabilizing critically ill patients (70.7%), performing routine responsibilities (67.9%), and operating on patients known to the trainee (62.0%). CONCLUSIONS: There were differences in duty hours worked by residents in the Flexible vs Standard Policy arms of the FIRST trial, but it appeared that residents generally used the flexibility for patient care and educational opportunities selectively.

Exploring Qualitative Perspectives on Surgical Resident Training, Well-Being, and Patient Care.

BACKGROUND: The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial found no difference in patient outcomes or resident well-being between more restrictive and flexible duty hour policies. Qualitative methods are appropriate for better understanding the experience and perceptions of those affected by duty hour regulations. We conducted a pilot qualitative study on how resident duty hour regulations are perceived by general surgery program directors, surgical residents, and attending surgeons who participated in the FIRST Trial. STUDY DESIGN: Semi-structured qualitative interviews were pilot tested with program directors, residents, and attendings to examine initial perceptions of the standard and flexible policies implemented during the trial. The transcribed interviews were analyzed thematically using a constant comparative approach and grouped first by study arm and then by level (patient, surgeon, program, and national). RESULTS: More restrictive duty hours were perceived as creating a tension between resident personal and professional well-being. Standard Policy resulted in more transitions, which was perceived as creating vulnerable gaps in patient care. Standard Policy restrictions were seen as particularly challenging for interns and often led to inadequate preparation for promotion and encouraged a shift mentality. CONCLUSIONS: In our pilot study, interviewees valued the flexibility afforded in the Flexible Policy arm, as it allowed them to maximize patient safety and educational attainment. Additional qualitative research will expand on program director, resident, and attending perceptions of resident duty hours as well as perceptions of patient safety. Qualitative methods can contribute to the national debate on resident duty hours.

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.

Evaluation of hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program is well recognized in surgical quality measurement and is used widely in research. Recent calls to make it a platform for national public reporting and pay-for-performance initiatives highlight the importance of understanding which types of hospitals elect to participate in the program. Our objective was to compare characteristics of hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program to characteristics of nonparticipating US hospitals. METHODS: The 2013 American Hospital Association and Centers for Medicare & Medicaid Services Healthcare Cost Report Information System datasets were used to compare characteristics and operating margins of hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program to those of nonparticipating hospitals. RESULTS: Of 3,872 general medical and surgical hospitals performing inpatient surgery in the United States, 475 (12.3%) participated in the American College of Surgeons National Surgical Quality Improvement Program. Participating hospitals performed 29.0% of all operations in the United States. Compared with nonparticipating hospitals, American College of Surgeons National Surgical Quality Improvement Program hospitals had a higher mean annual inpatient surgical case volume (6,426 vs 1,874; P < .001) and a larger mean number of hospital beds (420 vs 167; P < .001); participating hospitals were more often teaching hospitals (35.2% vs 4.1%; P < .001), had more quality-related accreditations (P < .001), and had higher mean operating margins (P < .05). States with the highest proportions of hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program had established surgical quality improvement collaboratives. CONCLUSION: The American College of Surgeons National Surgical Quality Improvement Program hospitals are large teaching hospitals with more quality-related accreditations and financial resources. These findings should be considered when reviewing research studies using the American College of Surgeons National Surgical Quality Improvement Program data, and the findings reinforce that efforts are needed to facilitate participation in surgical quality improvement by all hospital types.

Program Director Perceptions of Surgical Resident Training and Patient Care under Flexible Duty Hour Requirements.

BACKGROUND: The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial was a national, cluster-randomized, pragmatic, noninferiority trial of 117 general surgery programs, comparing standard ACGME resident duty hour requirements ("Standard Policy") to flexible, less-restrictive policies ("Flexible Policy"). Participating program directors (PDs) were surveyed to assess their perceptions of patient care, resident education, and resident well-being during the study period. STUDY DESIGN: A survey was sent to all PDs of the general surgery residency programs participating in the FIRST trial (N = 117 [100% response rate]) in June and July 2015. The survey compared PDs' perceptions of the duty hour requirements in their arm of the FIRST trial during the study period from July 1, 2014 to June 30, 2015. RESULTS: One hundred percent of PDs in the Flexible Policy arm indicated that residents used their additional flexibility in duty hours to complete operations they started or to stabilize a critically ill patient. Compared with the Standard Policy arm, PDs in the Flexible Policy arm perceived a more positive effect of duty hours on the safety of patient care (68.9% vs 0%; p < 0.001), continuity of care (98.3% vs 0%; p < 0.001), and resident ability to attend educational activities (74.1% vs 3.4%; p < 0.001). Most PDs in both arms reported that safety of patient care (71.8%), continuity of care (94.0%), quality of resident education (83.8%), and resident well-being (55.6%) would be improved with a hypothetical permanent adoption of more flexible duty hours. CONCLUSIONS: Program directors involved in the FIRST trial perceived improvements in patient safety, continuity of care, and multiple aspects of resident education and well-being with flexible duty hours.

Does Performance Vary Within the Same Hospital When Separately Examining Different Patient Subgroups?

BACKGROUND: Surgical quality programs, such as the American College of Surgeons NSQIP, provide reports based on specialty or procedure, with patients aggregated together. It is unknown whether hospital performance differs by patient subgroup (eg cancer vs noncancer patients), masking opportunities for improvement. Our objectives were to determine whether performance differs within a given hospital for 6 contrasting patient subgroups and to identify the percentage of hospitals with greater than chance differences in performance. STUDY DESIGN: Using the American College of Surgeons NSQIP data, adults undergoing lung resection, esophagectomy, hepatectomy, pancreatectomy, colectomy, and proctectomy (2005 through 2012) were divided into 6 contrasting subgroups (elderly vs nonelderly, white vs nonwhite, obese vs nonobese, renal insufficiency vs normal renal function, cancer vs noncancer, emergency vs nonemergency). The main end point was serious morbidity or mortality. Observed to expected ratios were constructed using hierarchical models and compared using paired t-tests (eg observed to expected for cancer cases compared with noncancer). Variation in performance differences was assessed using a randomization test and z-tests for proportions. RESULTS: From 433 hospitals, 221,518 patients were included. Overall quality differed for elderly vs nonelderly, renal insufficiency vs normal renal function patients, cancer vs noncancer, and emergency vs nonemergency (p < 0.05). Variation in within-hospital performance differences exceeded chance expectations for renal insufficiency vs normal renal function in 31.1% of hospitals, cancer vs noncancer in 40.8%, and emergency vs nonemergency patients in 55.4% (p < 0.001). CONCLUSIONS: Hospital performance within a given hospital varies by patient subgroup. Quality programs can consider separate reports for these subgroups to identify opportunities for quality improvement.

National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training.

BACKGROUND: Concerns persist regarding the effect of current surgical resident duty-hour policies on patient outcomes, resident education, and resident well-being. METHODS: We conducted a national, cluster-randomized, pragmatic, noninferiority trial involving 117 general surgery residency programs in the United States (2014-2015 academic year). Programs were randomly assigned to current Accreditation Council for Graduate Medical Education (ACGME) duty-hour policies (standard-policy group) or more flexible policies that waived rules on maximum shift lengths and time off between shifts (flexible-policy group). Outcomes included the 30-day rate of postoperative death or serious complications (primary outcome), other postoperative complications, and resident perceptions and satisfaction regarding their well-being, education, and patient care. RESULTS: In an analysis of data from 138,691 patients, flexible, less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P=0.92; unadjusted odds ratio for the flexible-policy group, 0.96; 92% confidence interval, 0.87 to 1.06; P=0.44; noninferiority criteria satisfied) or of any secondary postoperative outcomes studied. Among 4330 residents, those in programs assigned to flexible policies did not report significantly greater dissatisfaction with overall education quality (11.0% in the flexible-policy group and 10.7% in the standard-policy group, P=0.86) or well-being (14.9% and 12.0%, respectively; P=0.10). Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education but were more likely to perceive negative effects on personal activities. There were no significant differences between study groups in resident-reported perception of the effect of fatigue on personal or patient safety. Residents in the flexible-policy group were less likely than those in the standard-policy group to report leaving during an operation (7.0% vs. 13.2%, P<0.001) or handing off active patient issues (32.0% vs. 46.3%, P<0.001). CONCLUSIONS: As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality. (FIRST ClinicalTrials.gov number, NCT02050789.).

Development of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial Protocol: A National Cluster-Randomized Trial of Resident Duty Hour Policies.

IMPORTANCE: Debate continues regarding whether to further restrict resident duty hour policies, but little high-level evidence is available to guide policy changes. OBJECTIVE: To inform decision making regarding duty hour policies, the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial is being conducted to evaluate whether changing resident duty hour policies to permit greater flexibility in work hours affects patient postoperative outcomes, resident education, and resident well-being. DESIGN, SETTING, AND PARTICIPANTS: Pragmatic noninferiority cluster-randomized trial of general surgery residency programs with 2 study arms. Participating in the study are Accreditation Council for Graduate Medical Education (ACGME)-approved US general surgery residency programs (n = 118), their affiliated hospitals (n = 154), surgical residents and program directors, and general surgery patients from July 1, 2014, to June 30, 2015, with additional patient safety outcomes collected through June 30, 2016. The data collection platform for patient outcomes is the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), thus only hospitals participating in the ACS NSQIP were included. INTERVENTIONS: In the usual care arm, programs adhered to current ACGME resident duty hour standards. In the intervention arm, programs were allowed to deviate from current standards regarding maximum shift lengths and minimum time off between shifts through an ACGME waiver. MAIN OUTCOMES AND MEASURES: Death or serious morbidity within 30 days of surgery measured through ACS NSQIP, as well as resident satisfaction and well-being measured through a survey delivered at the time of the 2015 American Board of Surgery in Training Examination (ABSITE). RESULTS: A total of 118 general surgery residency programs and 154 hospitals were enrolled in the FIRST Trial and randomized. Fifty-nine programs (73 hospitals) were randomized to the usual care arm and 59 programs (81 hospitals) were randomized to the intervention arm. Intent-to-treat analysis will be used to estimate the effectiveness of assignment to the intervention arm on patient outcomes, resident education, and resident well-being compared with the usual care arm. Several sensitivity analyses will be performed to determine whether there were differential effects when examining only inpatients, high-risk patients, and emergent/urgent cases. CONCLUSIONS AND RELEVANCE: To our knowledge, the FIRST Trial is the first national randomized clinical trial of duty hour policies. Results of this study may be informative to policymakers and other stakeholders engaged in restructuring graduate medical training to enhance the quality of patient care and resident education. TRIAL REGISTRATION: clinicaltrials.org Identifier: NCT02050789.

Adjusted Hospital Sentinel Lymph Node Positivity Rates in Melanoma: A Novel Potential Measure of Quality.

OBJECTIVE: Our objectives were to examine whether hospital characteristics are associated with lower- and higher-than-expected sentinel lymph node biopsy (SLNB) positivity rates and whether hospitals with lower- or higher-than-expected SLNB positivity rates have worse patient outcomes. BACKGROUND: Surgeon and pathologist SLNB technical errors may lead to incorrect melanoma staging. A hospital's SLNB positivity rate may reflect its SLNB proficiency for melanoma, but this has never been investigated. METHODS: Stage IA-III melanoma patients undergoing SLNB were identified from the National Cancer Data Base (2004-2010). Hospital-level SLNB positivity rates were adjusted for patient- and tumor factors. Hospitals were divided into terciles of adjusted SLNB positivity rates. Hospital characteristics (using multinomial logistic regression) and survival (using Cox modeling) were examined across terciles. RESULTS: Of 33,639 SLNB patients (from 646 hospitals), 2916 (8.7%) had at least 1 positive lymph node. Hospitals with lower- (low tercile) and higher-than-expected (high tercile) SLNB positivity rates were more likely to be low-volume hospitals (low tercile: relative risk ratio (RRR) = 2.57, P = 0.002; high tercile: RRR = 2.3, P = 0.004) compared to hospitals with expected rates (middle tercile). Stage I patients treated at lower-than-expected SLNB positivity rate hospitals had worse 5-year survival than those treated at expected SLNB positivity rate hospitals (90.0% vs 91.9%, P = 0.014; hazard ratio = 1.28, 95% CI: 1.05-1.57); survival differences were not observed by SLNB positivity rates for stage II/III. CONCLUSIONS: Adjusted hospital SLNB positivity rates varied widely. Surgery at hospitals with lower-than-expected SLNB positivity rates was associated with decreased survival. Hospital SLNB positivity rates may be a novel measure to confidentially report to hospitals for internal quality assessment.

Development of a model to predict breast cancer survival using data from the National Cancer Data Base.

BACKGROUND: With the large amounts of data on patient, tumor, and treatment factors available to clinicians, it has become critically important to harness this information to guide clinicians in discussing a patient's prognosis. However, no widely accepted survival calculator is available that uses national data and includes multiple prognostic factors. Our objective was to develop a model for predicting survival among patients diagnosed with breast cancer using the National Cancer Data Base (NCDB) to serve as a prototype for the Commission on Cancer's "Cancer Survival Prognostic Calculator." PATIENTS AND METHODS: A retrospective cohort of patients diagnosed with breast cancer (2003-2006) in the NCDB was included. A multivariable Cox proportional hazards regression model to predict overall survival was developed. Model discrimination by 10-fold internal cross-validation and calibration was assessed. RESULTS: There were 296,284 patients for model development and internal validation. The c-index for the 10-fold cross-validation ranged from 0.779 to 0.788 after inclusion of all available pertinent prognostic factors. A plot of the observed versus predicted 5 year overall survival showed minimal deviation from the reference line. CONCLUSION: This breast cancer survival prognostic model to be used as a prototype for building the Commission on Cancer's "Cancer Survival Prognostic Calculator" will offer patients and clinicians an objective opportunity to estimate personalized long-term survival based on patient demographic characteristics, tumor factors, and treatment delivered.

Association of the 2011 ACGME Resident Duty Hour Reform with Postoperative Patient Outcomes in Surgical Specialties.

BACKGROUND: The 2011 ACGME resident duty hour reform implemented additional restrictions to existing duty hour policies. Our objective was to determine the association between this reform and patient outcomes among several surgical specialties. STUDY DESIGN: Patients from 5 surgical specialties (neurosurgery, obstetrics/gynecology, orthopaedic surgery, urology, and vascular surgery) were identified from the American College of Surgeons NSQIP. Data from 1 year before and 2 years after the reform was implemented were obtained for teaching and nonteaching hospitals. Hospital teaching status was defined based on the percentage of operations with a resident present intraoperatively. Difference-in-differences models were developed separately for each specialty and adjusted for patient demographics, comorbidities, procedural case-mix, and time trends. The association between duty hour reform and a composite measure of death or serious morbidity within 30 days of surgery was estimated for each specialty. RESULTS: The unadjusted rate of death or serious morbidity decreased during the study period in both teaching and nonteaching hospitals for all surgical specialties. In multivariable analyses, there were no significant associations between duty hour reform and the composite outcomes of death or serious morbidity in the 2 years post-reform for any surgical specialty evaluated (neurosurgery: odds ratio [OR] = 0.90; 95% CI, 0.75-1.08; p = 0.26; obstetrics/gynecology: OR = 0.96; 95% CI, 0.71-1.30; p = 0.80; orthopaedic surgery: OR = 0.95; 95% CI, 0.74-1.22; p = 0.70; urology: OR = 1.16; 95% CI, 0.89-1.51; p = 0.26; vascular surgery: OR = 1.07; 95% CI, 0.93-1.22; p = 0.35). CONCLUSIONS: Implementation of the 2011 ACGME resident duty hour reform was not associated with a significant change in patient outcomes for several surgical specialties in the 2 years after reform.

Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.

IMPORTANCE: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted resident duty hour requirements beyond those established in 2003, leading to concerns about the effects on patient care and resident training. OBJECTIVE: To determine if the 2011 ACGME duty hour reform was associated with a change in general surgery patient outcomes or in resident examination performance. DESIGN, SETTING, AND PARTICIPANTS: Quasi-experimental study of general surgery patient outcomes 2 years before (academic years 2009-2010) and after (academic years 2012-2013) the 2011 duty hour reform. Teaching and nonteaching hospitals were compared using a difference-in-differences approach adjusted for procedural mix, patient comorbidities, and time trends. Teaching hospitals were defined based on the proportion of cases at which residents were present intraoperatively. Patients were those undergoing surgery at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). General surgery resident performance on the annual in-training, written board, and oral board examinations was assessed for this same period. EXPOSURES: National implementation of revised resident duty hour requirements on July 1, 2011, in all ACGME accredited residency programs. MAIN OUTCOMES AND MEASURES: Primary outcome was a composite of death or serious morbidity; secondary outcomes were other postoperative complications and resident examination performance. RESULTS: In the main analysis, 204,641 patients were identified from 23 teaching (n = 102,525) and 31 nonteaching (n = 102,116) hospitals. The unadjusted rate of death or serious morbidity improved during the study period in both teaching (11.6% [95% CI, 11.3%-12.0%] to 9.4% [95% CI, 9.1%-9.8%], P < .001) and nonteaching hospitals (8.7% [95% CI, 8.3%-9.0%] to 7.1% [95% CI, 6.8%-7.5%], P < .001). In adjusted analyses, the 2011 ACGME duty hour reform was not associated with a significant change in death or serious morbidity in either postreform year 1 (OR, 1.12; 95% CI, 0.98-1.28) or postreform year 2 (OR, 1.00; 95% CI, 0.86-1.17) or when both postreform years were combined (OR, 1.06; 95% CI, 0.93-1.20). There was no association between duty hour reform and any other postoperative adverse outcome. Mean (SD) in-training examination scores did not significantly change from 2010 to 2013 for first-year residents (499.7 [ 85.2] to 500.5 [84.2], P = .99), for residents from other postgraduate years, or for first-time examinees taking the written or oral board examinations during this period. CONCLUSIONS AND RELEVANCE: Implementation of the 2011 ACGME duty hour reform was not associated with a change in general surgery patient outcomes or differences in resident examination performance. The implications of these findings should be considered when evaluating the merit of the 2011 ACGME duty hour reform and revising related policies in the future.