Timing to First Whole Blood Transfusion and Survival Following Severe Hemorrhage in Trauma Patients.

Importance: Civilian trauma centers have revived interest in whole-blood (WB) resuscitation for patients with life-threatening bleeding. However, there remains insufficient evidence that the timing of WB transfusion when given as an adjunct to a massive transfusion protocol (MTP) is associated with a difference in patient survival outcome. Objective: To evaluate whether earlier timing of first WB transfusion is associated with improved survival at 24 hours and 30 days for adult trauma patients presenting with severe hemorrhage. Design, Setting, and Participants: This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2019, to December 31, 2020, for adult patients presenting to US and Canadian adult civilian level 1 and 2 trauma centers with systolic blood pressure less than 90 mm Hg, with shock index greater than 1, and requiring MTP who received a WB transfusion within the first 24 hours of emergency department (ED) arrival. Patients with burns, prehospital cardiac arrest, deaths within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from January 3 to October 2, 2023. Exposure: Patients who received WB as an adjunct to MTP (earlier) compared with patients who had yet to receive WB as part of MTP (later) at any given time point within 24 hours of ED arrival. Main Outcomes and Measures: Primary outcomes were survival at 24 hours and 30 days. Results: A total of 1394 patients met the inclusion criteria (1155 male [83%]; median age, 39 years [IQR, 25-51 years]). The study cohort included profoundly injured patients (median Injury Severity Score, 27 [IQR, 17-35]). A survival curve demonstrated a difference in survival within 1 hour of ED presentation and WB transfusion. Whole blood transfusion as an adjunct to MTP given earlier compared with later at each time point was associated with improved survival at 24 hours (adjusted hazard ratio, 0.40; 95% CI, 0.22-0.73; P = .003). Similarly, the survival benefit of earlier WB transfusion remained present at 30 days (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.45; P < .001). Conclusions and Relevance: In this cohort study, receipt of a WB transfusion earlier at any time point within the first 24 hours of ED arrival was associated with improved survival in patients presenting with severe hemorrhage. The survival benefit was noted shortly after transfusion. The findings of this study are clinically important as the earlier timing of WB administration may offer a survival advantage in actively hemorrhaging patients requiring MTP.

The Impact of Residential Racial Segregation on Non-Small Cell Lung Cancer Treatment and Outcomes.

BACKGROUND: Despite decreases in lung cancer incidence, racial disparities in diagnosis and treatment persist. Residential segregation and structural racism have effects on socioeconomic status for black people, affecting health care access. This study aims to determine the impact of residential segregation on racial disparities in non-small cell lung cancer (NSCLC) treatment and mortality. METHODS: Patient data were obtained from Surveillance, Epidemiology, and End Results Program database for black and white patients diagnosed with NSCLC from 2004-2016 in the 100 most populous counties. Regression models were built to assess outcomes of interest: stage at diagnosis and surgical resection of disease. Predicted margins assessed impact of index of dissimilarity (IoD) on these disparities. Competing risk regressions for black and white patients in highest and lowest quartiles of IoD were used to assess cancer-specific mortality. RESULTS: Our cohort had 193,369 white and 35,649 black patients. Black patients were more likely to be diagnosed at advanced stage than white patients, with increasing IoD. With increasing IoD, black patients were less likely to undergo surgical resection than white patients. Disparities were eliminated at low IoD. Black patients at high IoD had lower cancer-specific survival. CONCLUSIONS: Black patients were more likely to present at advanced disease, were less likely to receive surgery for early stage disease, and had higher cancer-specific mortality at higher IoD. Our findings highlight the impact of structural racism and residential segregation on NSCLC outcomes. Solutions to these disparities must come from policy reforms to reverse residential segregation and deleterious socioeconomic effects of discriminatory policies.

Disparities in Utilization of Ambulatory Cholecystectomy: Results From Three States.

BACKGROUND: Inpatient cholecystectomy is associated with higher cost and morbidity relative to ambulatory cholecystectomy, yet the latter may be underutilized by minority and underinsured patients. The purpose of this study was to examine the effects of race, income, and insurance status on receipt of and outcomes following ambulatory cholecystectomy. MATERIALS AND METHODS: Retrospective observational cohort study of patients 18-89 undergoing cholecystectomy for benign indications in Florida, Iowa, and New York, 2011-2014 using administrative databases. The primary outcome of interest was odds of having ambulatory cholecystectomy; secondary outcomes included intraoperative and postoperative complications, and 30-day unplanned admissions following ambulatory cholecystectomy. RESULTS: Among 321,335 cholecystectomies, 190,734 (59.4%) were ambulatory and 130,601 (40.6%) were inpatient. Adjusting for age, sex, insurance, income, residential location, and comorbidities, the odds of undergoing ambulatory versus inpatient cholecystectomy were significantly lower in black (aOR = 0.71, 95% CI [0.69, 0.73], P< 0.001) and Hispanic (aOR = 0.71, 95% CI [0.69, 0.72], P< 0.001) patients compared to white patients, and significantly lower in Medicare (aOR = 0.77, 95% CI [0.75, 0.80] P < 0.001), Medicaid (aOR = 0.56, 95% CI [0.54, 0.57], P< 0.001) and uninsured/self-pay (aOR = 0.28, 95% CI [0.27, 0.28], P< 0.001) patients relative to privately insured patients. Patients with Medicaid and those classified as self-pay/uninsured had higher odds of postoperative complications and unplanned admission as did patients with Medicare compared to privately insured individuals. CONCLUSIONS: Racial and ethnic minorities and the underinsured have a higher likelihood of receiving inpatient as compared to ambulatory cholecystectomy. The higher incidence of postoperative complications in these patients may be associated with unequal access to ambulatory surgery.

Changes in Medical Student Perceptions of Surgery Are Sustainable Through Focused Preclinical Surgical Exposure.

OBJECTIVE: Many medical students hold negative perceptions about the surgical field that deter them from pursuing surgical training. We hypothesize that these perceptions can be sustainably changed with preclinical surgical education. DESIGN: Students were administered a 10-question survey before the educational experience, immediately after completing the experience, and 1-3 years later. Survey questions focused on perceptions about surgery. Changes in responses over time were measured and analyzed. SETTING: The study was performed in the setting of a voluntary preclinical surgical education experience. PARTICIPANTS: Surveys were administered to 217 first-year medical students who all participated in the preclinical surgical education experience from 2017 to 2019. Follow-up surveys were administered to all cohorts simultaneously and anonymously via email. RESULTS: Nine of the ten questions demonstrated statistically significant changes in perceptions from pre-experience to immediately post-experience (p < 0.048). Though attenuation was seen over time, changes in perception regarding the workload and time investment of surgical training, the role of women in surgery, and the relationships between surgeons and their patients were sustained over time (p < 0.044). CONCLUSIONS: The results indicated that our model of surgical education could effect long-term changes in negative perceptions about the surgical field. Many of these negative perceptions are highly concerning to medical students. As such, success in changing perceptions about length and difficulty of training, gender inclusivity, and patient-centered care in surgery is important in increasing student interest in the surgical field. This becomes relevant in the current climate of a nationwide shortage of surgeons and the need to better attract students to this profession.

Residential Racial Segregation and Disparities in Breast Cancer Presentation, Treatment, and Survival.

OBJECTIVE: To understand the role of racial residential segregation on Black-White disparities in breast cancer presentation, treatment, and outcomes. SUMMARY OF BACKGROUND DATA: Racial disparities in breast cancer treatment and outcomes are well documented. Black individuals present at advanced stage, are less likely to receive appropriate surgical and adjuvant treatment, and have lower overall and stage-specific survival relative to White individuals. METHODS: Using data from the Surveillance, Epidemiology, and End Results program, we performed a retrospective cohort study of Black and White patients diagnosed with invasive breast cancer from 2005 to 2015 within the 100 most populous participating counties. The racial index of dissimilarity was used as a validated measure of residential segregation. Multivariable regression was performed, predicting advanced stage at diagnosis (stage III/IV), surgery for localized disease (stage I/II), and overall stage-specific survival. RESULTS: After adjusting for age at diagnosis, estrogen/progesterone receptor status, and region, Black patients have a 49% greater risk (relative risk [RR] 1.49 95% confidence interval [CI] 1.27, 1.74) of presenting at advanced stage with increasing segregation, while there was no observed difference in Whites (RR 1.04, 95% CI 0.93, 1.16). Black patients were 3% less likely to undergo surgical resection for localized disease (RR 0.97, 95% CI 0.95, 0.99) with increasing segregation, while Whites saw no significant difference. Black patients had a 29% increased hazard of death (RR 1.29, 95% CI 1.04, 1.60) with increasing segregation; there was no significant difference among White patients. CONCLUSIONS: Our data suggest that residential racial segregation has a significant association with Black-White racial disparities in breast cancer. These findings illustrate the importance of addressing structural racism and residential segregation in efforts to reduce Black-White breast cancer disparities.

The impact of racial residential segregation on prostate cancer diagnosis and treatment.

OBJECTIVES: To examine the effects of racial residential segregation and structural racism on the diagnosis, treatment, and outcomes of patients with prostate cancer. PATIENTS AND METHODS: This retrospective cohort study examined men diagnosed with prostate cancer between 2005 and 2015. We collected data from Black and White men, aged ≥30 years, living within the 100 most populous counties participating in the Surveillance, Epidemiology, and End Results programme, a nationally representative dataset. The racial Index of Dissimilarity, a validated measure of segregation, was the primary exposure of interest. Outcomes of interest included advanced stage at diagnosis (Stage IV), surgery for localised disease (Stage I-II), and 10-year overall and cancer-specific survival. Multivariable Poisson regression analyses with robust error variance estimated the relative risk (RR) of advanced stage at diagnosis and surgery for localised disease at differing levels of segregation. Survival analysis was performed using competing hazards analysis. RESULTS: Multivariable models estimating stage at diagnosis showed that the disparities between Black and White men disappeared at low levels of segregation. Disparities in receiving surgery for localised disease persisted across all levels of segregation. In racially stratified analyses, segregation had no effect on stage at diagnosis or surgical resection for Black patients. White patients saw a 56% (RR 0.42, P < 0.001) reduced risk of presenting at advanced stage and 20% increased likelihood (RR 1.20, P < 0.001) of surgery for localised disease. Black patients in the lowest segregation areas had the lowest overall mortality, but the highest cancer-specific mortality. CONCLUSIONS: Our study provides evidence that residential segregation has a significant impact on Black-White disparities in prostate cancer, likely through improved outcomes for White patients and worse outcomes for Black patients in more segregated areas. These findings suggest that mitigating segregation and the downstream effects of socioeconomic factors could alleviate these disparities.

Association of Race, Health Insurance Status, and Household Income With Location and Outcomes of Ambulatory Surgery Among Adult Patients in 2 US States.

Importance: The receipt of surgery in freestanding ambulatory surgery centers (ASCs) is often less costly compared with surgery in hospital-based outpatient departments. Although increasing numbers of surgical procedures are now being performed in freestanding ASCs, questions remain regarding the existence of disparities among patients receiving care at ASCs. Objective: To examine the association of patient race, health insurance status, and household income with the location (ASC vs hospital-based outpatient department) of ambulatory surgery. Design, Setting, and Participants: This cohort study used data from the State Ambulatory Surgery and Services Databases of the Healthcare Cost and Utilization Project to perform a secondary analysis of patients who received ambulatory surgery in New York and Florida between 2011 and 2013. Patients aged 18 to 89 years who underwent 12 different types of ambulatory surgical procedures were included. Data were analyzed from December 2018 to June 2019. Main Outcomes and Measures: Receipt of surgery at a freestanding ASC and 30-day unplanned hospital visits after ambulatory surgery. Results: A total of 5.6 million patients in New York (57.4% female; 68.9% aged ≥50 years; and 62.5% White) and 7.5 million patients in Florida (57.3% female; 77.4% aged ≥50 years; 74.3% White) who received ambulatory surgery were included in the analysis. After adjusting for age, comorbidities, health insurance status, household income, location of surgery, and type of surgical procedure, the likelihood of receiving ambulatory surgery at a freestanding ASC was significantly lower among Black patients (adjusted odds ratio [aOR], 0.82; 95% CI, 0.81-0.83; P < .001) and Hispanic patients (aOR, 0.78; 95% CI, 0.77-0.79; P < .001) compared with White patients in New York. This likelihood was also lower among Black patients (aOR, 0.65; 95% CI, 0.65-0.66; P < .001) compared with White patients in Florida. Public health insurance coverage was associated with a significantly lower likelihood of receiving ambulatory surgery at freestanding ASCs in both New York and Florida, particularly among patients with Medicaid (in New York, aOR, 0.22; 95% CI, 0.22-0.22; P < .001; in Florida, aOR, 0.40; 95% CI, 0.40-0.41; P < .001) and Medicare (in New York, aOR, 0.46; 95% CI, 0.46-0.46; P < .001; in Florida, aOR, 0.67; 95% CI, 0.66-0.67; P < .001). Conclusions and Relevance: Differences in the use of freestanding ASCs were found among Black patients and patients with public health insurance. Further exploration of the factors underlying these differences will be important to ensure that all populations have access to the increasing number of freestanding ASCs.

Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening.

INTRODUCTION: Patient health literacy is paramount for optimal outcomes. The Service Learning Project (SLP) aims to merge the need for patient education with the desire of medical students for early clinical experience. METHODS: This pretest-posttest study examined the effect of the SLP on medical students. First-year students spent 8 h each month educating inpatients and screening for social determinants of health (SDH). Students completed a 30-question survey pre- and post-SLP, and longitudinally throughout medical school. We used t-tests to assess changes in attitudes towards surgery, clinical confidence, and SDH screening. RESULTS: Student self-perceived value on surgical teams increased significantly (2.49 vs 3.63 post-SLP, p < 0.001), as did their confidence interacting with patients (3.66-4.14, p = 0.002) and confidence assessing for SDH (3.13-4.75, p = 0.002). 100% of students continued to assess for SDH on clerkships. CONCLUSIONS: The SLP model improves medical students' skills and confidence working with patients and addressing SDH.

Socially Responsible Surgery: Building Recognition and Coalition.

IMPORTANCE: Socially responsible surgery (SRS) integrates surgery and public health, providing a framework for research, advocacy, education, and clinical practice to address the social barriers of health that decrease surgical access and worsen surgical outcomes in underserved patient populations. These patients face disparities in both health and in health care, which can be effectively addressed by surgeons in collaboration with allied health professionals. OBJECTIVE: We reviewed the current state of surgical access and outcomes of underserved populations in American rural communities, American urban communities, and in low- and middle-income countries. EVIDENCE REVIEW: We searched PubMed using standardized search terms and reviewed the reference lists of highly relevant articles. We reviewed the reports of two recent global surgery commissions. CONCLUSION: There is an opportunity for scholarship in rural surgery, urban surgery, and global surgery to be unified under the concept of SRS. The burden of surgical disease and the challenges to management demonstrate that achieving optimal health outcomes requires more than excellent perioperative care. Surgeons can and should regularly address the social determinants of health experienced by their patients. Formalized research and training opportunities are needed to meet the growing enthusiasm among surgeons and trainees to develop their practice as socially responsible surgeons.

Implementation of a Novel Structured Social and Wellness Committee in a Surgical Residency Program: A Case Study.

This article provides a theoretical and practical rational for the implementation of an innovative and comprehensive social wellness program in a surgical residency program at a large safety net hospital on the East Coast of the United States. Using basic needs theory, we describe why it is particularly important for surgical residency programs to consider the residents sense of competence, autonomy, and belonging during residence. We describe how we have developed a comprehensive program to address our residents' (and residents' families) psychological needs for competence, autonomy, and belongingness.