Centers of Excellence: If We Build It, Will They Come?

Pediatric surgeons have been pursuing high quality, affordable care or value-based care for over 50 years. One approach to streamlining the clinical care for a complex problem was the development of a center of excellence (COE). The concept of COE focuses on a shared vision of providing high quality care through a multidisciplinary approach. The goal is to improve diagnostic accuracy as well as therapeutic outcomes using focused expertise within a group. COEs are often resource intensive before becoming fiscally viable and therefore require initial support from hospital leadership. This review discusses the key steps to consider before building a COE, strategies to help build one, and how to keep one successful as defined by quality, accessibility, equity, training, and maintaining teams within the group.

From far and wide: Geographic distance to pediatric surgical care across Canada.

PURPOSE: Canada is the second largest country in the world, with most of the population located in the southern-most portion of its geography. We sought to define the relative distribution of pediatric surgeons to potential pediatric patients using data from the Canadian census. METHODS: The 2011 Canadian Census and a convenience sample of current Canadian pediatric surgeons were used to calculate straight-line distances between pediatric surgeon postal code centroids and census dissemination block centroids. RESULTS: Currently, there are 74 practicing pediatric surgeons in Canada; 493,345 populated census blocks were identified, and 7,752,075 children were enumerated. The median (IQR) kilometers to the closest pediatric surgeon was 27.99 (11.35, 85.47) kilometers, and 22.7% of Canadian children lived more than 100 km from care. Nearly 13% of children lived greater than 200 km from the nearest pediatric surgeon. CONCLUSION: More than 1.7 million Canadian children, nearly one quarter of all Canadian children, live greater than 100 km from the closest pediatric surgeon. This identifies a disparate group of patients who do not have an equal access-to-care as compared to others in the country. LEVEL OF EVIDENCE: Level IV.

Effects of socioeconomic status on children with well-differentiated thyroid cancer.

BACKGROUND: Well-differentiated thyroid cancer is the most common endocrine malignancy in children. Adult literature has demonstrated socioeconomic disparities in patients undergoing thyroidectomy, but the effects of socioeconomic status on the management of pediatric well-differentiated thyroid cancer remains poorly understood. METHODS: Patients ≤21 years of age with well-differentiated thyroid cancer remains were reviewed from the National Cancer Data Base. Three socioeconomic surrogate variables were identified: insurance type, median income, and educational quartile. Tumor characteristics, diagnostic intervals, and clinical outcomes were compared within each socioeconomic surrogate variable. RESULTS: A total of 9,585 children with well-differentiated thyroid cancer remains were reviewed. In multivariate analysis, lower income, lower educational quartile, and insurance status were associated with higher stage at diagnosis. Furthermore, lower income quartile was associated with a longer time from diagnosis to treatment (P < .002). Similarly, uninsured children had a longer time from diagnosis to treatment (28 days) compared with those with government (19 days) or private (18 days) insurance (P < .001). Despite being diagnosed at a higher stage and having a longer time interval between diagnosis and treatment, there was no significant difference in either overall survival or rates of unplanned readmissions based on any of the socioeconomic surrogate variables. CONCLUSION: Children from lower income families and those lacking insurance experienced a longer period from diagnosis to treatment of their well-differentiated thyroid cancer remains. These patients also presented with higher stage disease. These data suggest a delay in care for children from low-income families. Although these findings did not translate into worse outcomes for well-differentiated thyroid cancer remains, future efforts should focus on reducing these differences.

Between the lines: The 50th anniversary of long-term central venous catheters.

BACKGROUND: Tunneled central venous catheters (CVC) were developed five decades ago. Since then, several clinician-inventors have created a variety of catheters with different functions. Indeed, many catheters have been named after their inventor. Many have wondered who the inventors were of each catheter, and what specifically inspired their inventions. Many of these compelling stories have yet to be told. DATA SOURCE: A literature review of common catheters and personal communication with inventors. Only first person accounts from inventors or those close to the invention were used. CONCLUSIONS: CVCs are now essential devices that have saved countless lives. Though the inventors have earned the honor of naming their catheters, it may be reasonable to consider more consistent terminology to describe these catheters to avoid confusion.

2016 CAPS ethics session/Ein debate: 1. Regionalization of pediatric surgical care 2. Ethical introduction of surgical innovation 3. Addressing stress in a surgical practice: resiliency, well-being, and burnout.

The following is the conference proceeding of the Second Ein Debate from the 48th Annual Meeting of the Canadian Association of Paediatric Surgeons held in Vancouver, BC, from September 22 to 24, 2016. The three main topics for debate, as prepared by the members of the CAPS Ethics Committee, are: 1. Regionalization of care: pros and cons, 2. Innovation in clinical care: ethical considerations, and 3. Surgeon well-being: caring for the caregiver. The authors of this paper, as participants in the debate, were assigned their positions at random. Therefore, the opinions they express within this summary might not reflect their own viewpoints. In the first discussion, arguments for and against the regionalization of pediatric surgical care are discussed, primarily in the context of a case of BA. In the pro argument, the evidence and lessons learned from different European countries are explored as well as different models to provide the best BA care outside of large teaching centers. In the counterargument, the author explains how regionalization of care could be detrimental for the patient, the family, the regional center, and for the health care system in general. In the debate on surgical innovation the authors define surgical innovation. They review the pertinent ethical principles, explore a model for its implementation, and the role of the institution at which the innovation is proposed. In the third section, surgeon well-being is examined, and recent literature on surgeon resiliency and burnout both at the attending and resident level is reviewed.

A national review of the frequency of minimally invasive surgery among general surgery residents: assessment of ACGME case logs during 2 decades of general surgery resident training.

IMPORTANCE: Minimally invasive surgery (MIS) has created a shift in how many surgical diseases are treated. Examining the effect on resident operative experience provides valuable insight into trends that may be useful for restructuring the requirements of resident training. OBJECTIVE: To evaluate changes in general surgery resident operative experience regarding MIS. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of the frequency of MIS relative to open operations among general surgery residents using the Accreditation Council for Graduate Medical Education case logs for academic years 1993-1994 through 2011-2012. EXPOSURES: General surgery residency training among accredited programs in the United States. MAIN OUTCOMES AND MEASURES: We analyzed the difference in the mean number of MIS techniques and corresponding open procedures across training periods using 2-tailed t tests with statistical significance set at P < .05. RESULTS: Of 6,467,708 operations with the option of MIS, 2,393,030 (37.0%) were performed with the MIS approach. Of all MIS operations performed, the 5 most common were cholecystectomy (48.5%), appendectomy (16.2%), groin hernia repair (10.0%), abdominal exploration (nontrauma) (4.4%), and antireflux procedures (3.6%). During the study period, there was a transition from a predominantly open to MIS approach for appendectomy, antireflux procedures, thoracic wedge resection, and partial gastric resection. Cholecystectomy is the only procedure for which MIS was more common than the open technique throughout the study period (P < .001). The open approach is more common for all other procedures, including splenectomy (0.7% MIS), common bile duct exploration (24.9% MIS), gastrostomy (25.9% MIS), abdominal exploration (33.1% MIS), hernia (20.3% MIS), lung resection (22.3% MIS), partial or total colectomy (39.1%), enterolysis (19.0% MIS), ileostomy (9.0% MIS), enterectomy (5.2% MIS), vagotomy (1.8% MIS), and pediatric antireflux procedures (35.9% MIS); P < .001. CONCLUSIONS AND RELEVANCE: Minimally invasive surgery has an increasingly prominent role in contemporary surgical therapy for many common diseases. The open approach, however, still predominates in all but 5 procedures. Residents today must become efficient at performing multiple techniques for a single procedure, which demands a broader skill set than in the past.

The ACGME case log: general surgery resident experience in pediatric surgery.

BACKGROUND: General surgery (GS) residents in ACGME programs log cases performed during their residency. We reviewed designated pediatric surgery (PS) cases to assess for changes in performed cases over time. METHODS: The ACGME case logs for graduating GS residents were reviewed from academic year (AY) 1989-1990 to 2010-2011 for designated pediatric cases. Overall and designated PS cases were analyzed. Data were combined into five blocks: Period I (AY1989-90 to AY1993-94), Period II (AY1994-95 to AY1998-99), Period III (AY1999-00 to AY2002-03), Period IV (AY2003-04 to AY2006-07), and Period V (AY2007-08 to AY2010-11). Periods IV and V were delineated by implementation of duty hour restrictions. Student t-tests compared averages among the time periods with significance at P < .05. RESULTS: Overall GS case load remained relatively stable. Of total cases, PS cases accounted for 5.4% in Period I and 3.7% in Period V. Designated pediatric cases declined for each period from an average of 47.7 in Period I to 33.8 in Period V. These changes are due to a decline in hernia repairs, which account for half of cases. All other cases contributed only minimally to the pediatric cases. The only laparoscopic cases in the database were anti-reflux procedures, which increased over time. CONCLUSIONS: GS residents perform a diminishing number of designated PS cases. This decline occurred before the onset of work-hour restrictions. These changes have implications on the capabilities of the current graduating workforce. However, the case log does not reflect all cases trainees may be exposed to, so revision of this list is recommended.

The general surgery chief resident operative experience: 23 years of national ACGME case logs.

IMPORTANCE: The chief resident (CR) year is a pivotal experience in surgical training. Changes in case volume and diversity may impact the educational quality of this important year. OBJECTIVE: To evaluate changes in operative experience for general surgery CRs. DESIGN, SETTING, AND PARTICIPANTS: Review of Accreditation Council for Graduate Medical Education case logs from 1989-1990 through 2011-2012 divided into 5 periods. Graduates in period 3 were the last to train with unrestricted work hours; those in period 4 were part of a transition period and trained under both systems; and those in period 5 trained fully under the 80-hour work week. Diversity of cases was assessed based on Accreditation Council for Graduate Medical Education defined categories. MAIN OUTCOMES AND MEASURES: Total cases and defined categories were evaluated for changes over time. RESULTS: The average total CR case numbers have fallen (271 in period 1 vs 242 in period 5, P < .001). Total CR cases dropped to their lowest following implementation of the 80-hour work week (236 cases), but rebounded in period 5. The percentage of residents' 5-year operative experience performed as CRs has decreased (30% in period 1 vs 25.6% in period 5, P < .001). Regarding case mix: thoracic, trauma, and vascular cases declined steadily, while alimentary and intra-abdominal operations increased. Recent graduates averaged 80 alimentary and 78 intra-abdominal procedures during their CR years. Compared with period 1, in which these 2 categories represented 47.1% of CR experience, in period 5, they represented 65.2% (P < .001). Endocrine experience has been relatively unchanged. CONCLUSIONS AND RELEVANCE: Total CR cases declined especially acutely following implementation of the 80-hour work week but have since rebounded. Chief resident cases contribute less to overall experience, although this proportion stabilized before the 80-hour work week. Case mix has narrowed, with significant increases in alimentary and intra-abdominal cases. Broad-based general surgery training may be jeopardized by reduced case diversity. Chief resident cases are crucial in surgical training and educators should consider these findings as surgical training evolves.

Utility of lymph node assessment for atypical spitzoid melanocytic neoplasms.

BACKGROUND: Atypical spitzoid melanocytic neoplasms (ASMN) are cutaneous lesions of uncertain malignant potential, which can be difficult to distinguish from cutaneous melanoma. Sentinel lymph node (SLN) biopsy is a safe and useful prognostic tool for staging melanoma, but its role in staging ASMNs is not established nor is the significance of positive SLNs in these patients known. This study attempts to characterize the significance of nodal disease in ASMN. METHODS: Patients with ASMNs who presented to the melanoma service from 1992 to 2007 were identified from a prospective database. Histological review was performed by two dermatopathologists. Demographic, treatment, and outcome data were reviewed. RESULTS: A total of 58 patients with ASMNs were treated during the time analyzed; 31 (53%) underwent wide local excision and observation (WLE); 27 underwent wide excision and SLN biopsy. Median age was 24 (range, 6-60) years. Mean Breslow thickness was 2.9 (range, 0.5-10) mm. Median follow-up was 56 (range, 1-160) months. Ten of 58 (17%) patients had nodal metastasis. Four (13%) of 31 patients who underwent WLE developed nodal recurrences, and 6 of 27 (22%) patients had a positive SLN biopsy. Of patients with positive SLNs, none have recurred after undergoing completion lymphadenectomy. One patient presented with synchronous brain metastasis and inguinal lymphadenopathy and died of disease. CONCLUSIONS: Nodal status does not seem to convey the same prognosis that it does in standard melanoma. There may be a limited ability for progression within the nodal basin in patients with these lesions. This subset of patients would benefit from genetic data complementing histologic analysis.