A National Survey of Motor Vehicle Crashes Among General Surgery Residents.

OBJECTIVES: Evaluate the frequency of self-reported, post-call hazardous driving events in a national cohort of general surgery residents and determine the associations between duty hour policy violations, psychiatric well-being, and hazardous driving events. SUMMARY OF BACKGROUND DATA: MVCs are a leading cause of resident mortality. Extended work shifts and poor psychiatric well-being are risk factors for MVCs, placing general surgery residents at risk. METHODS: General surgery residents from US programs were surveyed after the 2017 American Board of Surgery In-Training Examination. Outcomes included self-reported nodding off while driving, near-miss MVCs, and MVCs. Group-adjusted cluster Chi-square and hierarchical regression models with program-level intercepts measured associations between resident- and program-level factors and outcomes. RESULTS: Among 7391 general surgery residents from 260 programs (response rate 99.3%), 34.7% reported nodding off while driving, 26.6% a near-miss MVC, and 5.0% an MVC over the preceding 6 months. More frequent 80-hour rule violations were associated with all hazardous driving events: nodding off while driving {59.8% with ≥5 months with violations vs 27.2% with 0, adjusted odds ratio (AOR) 2.86 [95% confidence interval (CI) 2.21-3.69]}, near-miss MVCs, [53.6% vs 19.2%, AOR 3.28 (95% CI 2.53-4.24)], and MVCs [14.0% vs 3.5%, AOR 2.46 (95% CI 1.65-3.67)]. Similarly, poor psychiatric well-being was associated with all 3 outcomes [eg, 8.0% with poor psychiatric well-being reported MVCs vs 2.6% without, odds ratio 2.55 (95% CI 2.00-3.24)]. CONCLUSIONS: Hazardous driving events are prevalent among general surgery residents and associated with frequent duty hour violations and poor psychiatric well-being. Greater adherence to duty hour standards and efforts to improve well-being may improve driving safety.

Multi-institution Evaluation of Adherence to Comprehensive Postoperative VTE Chemoprophylaxis.

OBJECTIVES: The aims of this study were to: (1) measure the rate of failure to provide defect-free postoperative venous thromboembolism (VTE) chemoprophylaxis, (2) identify reasons for failure to provide defect-free VTE chemoprophylaxis, and (3) examine patient- and hospital-level factors associated with failure. SUMMARY BACKGROUND DATA: Current VTE quality measures are inadequate. VTE outcome measures are invalidated for interhospital comparison by surveillance bias. VTE process measures (e.g., SCIP-VTE-2) do not comprehensively capture failures throughout patients' entire hospitalization. METHODS: We examined adherence to a novel VTE chemoprophylaxis process measure in patients who underwent colectomies over 18 months at 36 hospitals in a statewide surgical collaborative. This measure assessed comprehensive VTE chemoprophylaxis during each patient's entire hospitalization, including reasons why chemoprophylaxis was not given. Associations of patient and hospital characteristics with measure failure were examined. RESULTS: The SCIP-VTE-2 hospital-level quality measure identified failures of VTE chemoprophylaxis in 0% to 3% of patients. Conversely, the novel measure unmasked failure to provide defect-free chemoprophylaxis in 18% (736/4086) of colectomies. Reasons for failure included medication not ordered (30.4%), patient refusal (30.3%), incorrect dosage/frequency (8.2%), and patient off-unit (3.4%). Patients were less likely to fail the chemoprophylaxis process measure if treated at nonsafety net hospitals (OR 0.62, 95% CI 0.39-0.99, P = 0.045) or Magnet designated hospitals (OR 0.45, 95% CI 0.29-0.71, P = 0.001). CONCLUSIONS: In contrast to SCIP-VTE-2, our novel quality measure unmasked VTE chemoprophylaxis failures in 18% of colectomies. Most failures were due to patient refusals or ordering errors. Hospitals should focus improvement efforts on ensuring patients receive VTE prophylaxis throughout their entire hospitalization.

Leveraging a Comprehensive Program to Implement a Colorectal Surgical Site Infection Reduction Bundle in a Statewide Quality Improvement Collaborative.

OBJECTIVES: Our objective was to examine the implementation and associated clinical outcomes of a comprehensive surgical site infection (SSI) reduction bundle in a large statewide surgical quality improvement collaborative leveraging a multifaceted implementation strategy. SUMMARY BACKGROUND DATA: Bundled perioperative interventions reduce colorectal SSI rates when enacted at individual hospitals, but the ability to implement comprehensive SSI bundles and to examine the resultant clinical effectiveness within a larger, diverse population of hospitals is unknown. METHODS: A multifaceted SSI reduction bundle was developed and implemented in a large statewide surgical quality improvement collaborative through a novel implementation program consisting of guided implementation, data feedback, mentorship, process improvement training/coaching, and targeted-implementation toolkits. Bundle adherence and ACS NSQIP outcomes were examined preimplementation versus postimplementation. RESULTS: Among 32 hospitals, there was a 2.5-fold relative increase in the proportion of patients completing at least 75% of bundle elements (preimplementation = 19.5% vs. postimplementation = 49.8%, P = 0.001). Largest adherence gains were seen in wound closure re-gowning/re-gloving (24.0% vs. 62.0%, P < 0.001), use of clean closing instruments (32.1% vs. 66.2%, P = 0.003), and preoperative chlorhexidine bathing (46.1% vs. 77.6%, P < 0.001). Multivariable analyses showed a trend toward lower risk of superficial incisional SSI in the postimplementation period compared to baseline (OR 0.70, 95% CI 0.49-10.2, P = 0.06). As the adherence in the number of bundle elements increased, there was a significant decrease in superficial SSI rates (lowest adherence quintile, 4.6% vs. highest, 1.5%, P < 0.001). CONCLUSIONS: A comprehensive multifaceted SSI reduction bundle can be successfully implemented throughout a large quality improvement learning collaborative when coordinated quality improvement activities are leveraged, resulting in a 30% decline in SSI rates. Lower superficial SSI rates are associated with the number of adherent bundle elements a patient receives, rendering considerable benefits to institutions capable of implementing more components of the bundle.

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.

Enzyme-dependent lysine deprotonation in EZH2 catalysis.

Protein lysine methyltransferases (PKMTs) are key players in epigenetic regulation and have been associated with a variety of diseases, including cancers. The catalytic subunit of Polycomb Repressive Complex 2, EZH2 (EC 2.1.1.43), is a PKMT and a member of a family of SET domain lysine methyltransferases that catalyze the transfer of a methyl group from S-adenosyl-l-methionine to lysine 27 of histone 3 (H3K27). Wild-type (WT) EZH2 primarily catalyzes the mono- and dimethylation of H3K27; however, a clinically relevant active site mutation (Y641F) has been shown to alter the reaction specificity, dominantly catalyzing trimethylation of H3K27, and has been linked to tumor genesis and maintenance. Herein, we explore the chemical mechanism of methyl transfer by EZH2 and its Y641F mutant with pH-rate profiles and solvent kinetic isotope effects (sKIEs) using a short peptide derived from histone H3 [H3(21-44)]. A key component of the chemical reaction is the essential deprotonation of the ε-NH3(+) group of lysine to accommodate subsequent methylation. This deprotonation has been suggested by independent studies (1) to occur prior to binding to the enzyme (by bulk solvent) or (2) to be facilitated within the active site following binding, either (a) by the enzyme itself or (b) by a water molecule with access to the binding pocket. Our pH-rate and sKIE data best support a model in which lysine deprotonation is enzyme-dependent and at least partially rate-limiting. Furthermore, our experimental data are in agreement with prior computational models involving enzyme-dependent solvent deprotonation through a channel providing bulk solvent access to the active site. The mechanism of deprotonation and the rate-limiting catalytic steps appear to be unchanged between the WT and Y641F mutant enzymes, despite their activities being highly dependent on different substrate methylation states, suggesting determinants of substrate and product specificity in EZH2 are independent of catalytic events limiting the steady-state rate.

Patient characteristics and diagnostic tests associated with syncopal falls: A Southwestern surgical congress multicenter study.

BACKGROUND: Patients suspected of syncope frequently undergo laboratory and imaging studies to determine the etiology of the syncope. Variability exists in these workups across institutions. The purpose of this study was to evaluate the utilization and diagnostic yield of these workups and the patient characteristics associated with syncopal falls. METHODS: A multi-institutional retrospective review was performed on adult patients admitted after a fall between 1/2017-12/2018. Syncopal falls were compared to non-syncopal falls. RESULTS: 4478 patients were included. There were 795 (18%) patients with a syncopal fall. Electrocardiogram, troponin, echocardiogram, CT angiography (CTA), and carotid ultrasound were more frequently tested in syncope patients compared to non-syncope patients. Syncope patients had higher rates of positive telemetry/Holter monitoring, CTAs, and electroencephalograms. CONCLUSION: Patients who sustain syncopal falls frequently undergo diagnostic testing without a higher yield to determine the etiology of syncope.

Evaluating the utility of the HTRF Transcreener ADP assay technology: a comparison with the standard HTRF assay technology.

The HTRF (homogeneous time-resolved fluorescence) Transcreener ADP assay is a new kinase assay technology marketed by Cis-Bio International (Bagnols-Cèze, France). It measures kinase activity by detecting the formation of ADP using a monoclonal antibody and HTRF detection principles. In this article, we compare this technology with a standard HTRF kinase assay using EGFR [L858R/T790M] mutant enzyme as a case study. We demonstrate that the HTRF Transcreener ADP assay generated similar kinetic constants and inhibitor potency compared with the standard HTRF assay. However, the smaller dynamic window and lower Z' factor of the HTRF Transcreener ADP assay make this format less preferable for high-throughput screening. Based on the assay principle, the HTRF Transcreener ADP assay can detect both kinase and ATPase activities simultaneously. The ability to probe ATPase activity opens up new avenues for assaying kinases with intrinsic ATPase activity without the need to identify substrates, and this can speed up the drug discovery process. However, caution must be exercised because any contaminating ATPase activity will result in an invalid assay. The inability to tolerate high concentrations of ATP in the assay will also limit the application of this technology, especially in compound mechanistic studies such as ATP competition. Overall, the HTRF Transcreener ADP assay provides a new alternative tool to complement existing assay technologies for drug discovery.

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.

Association Between Hospital Safety Culture and Surgical Outcomes in a Statewide Surgical Quality Improvement Collaborative.

BACKGROUND: The "safety culture" within hospital systems is increasingly recognized as important to delivery of high-quality care. We examine the safety culture in a statewide hospital quality improvement collaborative and its associations with surgical outcomes. STUDY DESIGN: A modified Safety Attitudes Questionnaire was sent to administrators, quality improvement teams, nurses, anesthesiologists, and surgeons in 49 hospitals participating in the Illinois Surgical Quality Improvement Collaborative in 2015. Associations between positive safety culture, as measured by percentage of positive responses on the Safety Attitudes Questionnaire, and the following NSQIP 30-day adverse outcomes: hospital-level risk-adjusted morbidity, mortality, death, or serious morbidity and readmission rates. Linear regression models with hospitals clustered by system were used to assess the relationship between safety culture and patient outcomes. RESULTS: Operating room safety culture scores were highest (97.7% positive) compared with the other domains, and ratings of hospital management were lowest (75.9% positive). Hospital administrators consistently had the most positive perception of the safety culture (90.5% positive) and front-line providers were less positive: physicians (85.3%), advanced practice providers (88.1%), and nurses (80%). Teamwork was rated as a strength by patient care providers (physicians 88.3%, advanced practice providers 90.2%, and nurses 82.2%), but was perceived as weakest by administrators. Higher percentage of positive Safety Attitudes Questionnaire responses was significantly associated with lower risk of postoperative morbidity (p = 0.007) and death or serious morbidity (p = 0.04). No significant association between safety culture and the risk of mortality (p = 0.23) or readmissions (p = 0.52) was observed. CONCLUSIONS: Hospital safety culture can influence certain surgical patient outcomes. Improving the safety culture within a hospital can represent a previously unrecognized approach that can be leveraged to strengthen surgical quality improvement efforts at the hospital level.

Current in vitro kinase assay technologies: the quest for a universal format.

The rapidly growing interest in kinases as drug targets has prompted the development of many kinase assay technologies. These technologies can be grouped into three categories: radiometric assays, phospho-antibody-dependent fluorescence/luminescence assays, and phospho-antibody-independent fluorescence/luminescence assays. This article will review some of the major kinase assay technologies on the market, with particular emphasis on the newest systems. We will describe the physical principles, the practical advantages and drawbacks, and the potential applications of these technologies in kinase drug discovery. Most of these technologies are suitable for HTS, but only a few can be utilized for kinetic and mechanistic studies. Significant progress towards development of generic assays, free of radioisotopes and custom reagents such as phospho-specific antibodies, has been made in recent years. However, due to various limitations of each format, none of these generic assay technologies can yet claim to be truly universal. Several factors, including the intended applications, cost, timeline, expertise, familiarity, and comfort level, should be considered prior to pursuing a particular kinase assay technology.

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.

Creating Individual Surgeon Performance Assessments in a Statewide Hospital Surgical Quality Improvement Collaborative.

BACKGROUND: Surgeon performance profiling is of great interest to surgeons, hospitals, health plans, and the public, yet efforts to date have been contested, with stakeholders at odds over the selection, reliability, and validity of metrics used. We sought to create surgeon-level comparative assessments within the Illinois Surgical Quality Improvement Collaborative. STUDY DESIGN: American College of Surgeons NSQIP data were obtained for 51 Illinois hospitals covering a 30-month period from 2014 to 2016. Surgeon-level, risk-adjusted outcomes rates were estimated from 3-level crossed random effects logistic regression models and classified as low, as expected, or high for each of 7 postoperative outcomes. Model intra-class correlations and provider-specific reliability statistics were calculated. RESULTS: A total of 123,141 cases were analyzed for 2,724 surgeons. Median provider case volume was 17 (interquartile range 4 to 54). Overall crude complication rates ranged from 0.62% to 7.14% across the 7 outcomes investigated. Surgeon-level variance estimates were low (intra-class correlation coefficients between 0.007 and 0.074). No performance outliers were detected for 3 of the outcomes measures, while a small number of outliers were identified for any morbidity (11 surgeons), surgical site infection (10 surgeons), death or serious morbidity (8 surgeons), and reoperation (1 surgeon). Among all physicians, median reliability was below 0.1 for each outcome. CONCLUSIONS: Few individual surgeon performance outliers could be detected in NSQIP clinical registry data for a statewide hospital collaborative over a 30-month period using postoperative patient outcomes. Low surgeon-specific case volumes and minimal variance between surgeons may limit the utility of American College of Surgeons NSQIP outcomes measures for individual profiling. Alternative metrics, such as process measures, patient experience, composite measures, or technical skill assessments should be explored for surgeon-level measurement.

Dual Allosteric Inhibition of SHP2 Phosphatase.

SHP2 is a cytoplasmic protein tyrosine phosphatase encoded by the PTPN11 gene and is involved in cell proliferation, differentiation, and survival. Recently, we reported an allosteric mechanism of inhibition that stabilizes the auto-inhibited conformation of SHP2. SHP099 (1) was identified and characterized as a moderately potent, orally bioavailable, allosteric small molecule inhibitor, which binds to a tunnel-like pocket formed by the confluence of three domains of SHP2. In this report, we describe further screening strategies that enabled the identification of a second, distinct small molecule allosteric site. SHP244 (2) was identified as a weak inhibitor of SHP2 with modest thermal stabilization of the enzyme. X-ray crystallography revealed that 2 binds and stabilizes the inactive, closed conformation of SHP2, at a distinct, previously unexplored binding site-a cleft formed at the interface of the N-terminal SH2 and PTP domains. Derivatization of 2 using structure-based design resulted in an increase in SHP2 thermal stabilization, biochemical inhibition, and subsequent MAPK pathway modulation. Downregulation of DUSP6 mRNA, a downstream MAPK pathway marker, was observed in KYSE-520 cancer cells. Remarkably, simultaneous occupation of both allosteric sites by 1 and 2 was possible, as characterized by cooperative biochemical inhibition experiments and X-ray crystallography. Combining an allosteric site 1 inhibitor with an allosteric site 2 inhibitor led to enhanced pharmacological pathway inhibition in cells. This work illustrates a rare example of dual allosteric targeted protein inhibition, demonstrates screening methodology and tactics to identify allosteric inhibitors, and enables further interrogation of SHP2 in cancer and related pathologies.

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.

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.

Cross-sector analysis of socioeconomic, racial/ethnic, and urban/rural disparities in food policy enactment in the United States.

We examined racial/ethnic, socioeconomic, and urban/rural disparities in food policy enactment across different sectors, as well as retail food access, throughout the United States. Policy and retail food store data were obtained from 443 communities as part of the Bridging the Gap Community Obesity Measures Project. Our results indicated that median household income was inversely associated with healthier retail food zoning policies in Hispanic communities, where competitive food policies for schools were also healthier and mean fruit/vegetable access in stores was higher. In contrast, income was positively associated with healthier retail food zoning in rural communities, where competitive food policies were weaker. Black communities had low scores across all policy domains. Overall, Hispanic communities had the strongest food policies across sectors. Barriers to policy adoption in both rural and Black communities must be explored further.

Development and Reliability Testing of a Fast-Food Restaurant Observation Form.

PURPOSE: To develop a reliable observational data collection instrument to measure characteristics of the fast-food restaurant environment likely to influence consumer behaviors, including product availability, pricing, and promotion. DESIGN: The study used observational data collection. SETTING: Restaurants were in the Chicago Metropolitan Statistical Area. SUBJECTS: A total of 131 chain fast-food restaurant outlets were included. MEASURES: Interrater reliability was measured for product availability, pricing, and promotion measures on a fast-food restaurant observational data collection instrument. ANALYSIS: Analysis was done with Cohen's κ coefficient and proportion of overall agreement for categorical variables and intraclass correlation coefficient (ICC) for continuous variables. RESULTS: Interrater reliability, as measured by average κ coefficient, was .79 for menu characteristics, .84 for kids' menu characteristics, .92 for food availability and sizes, .85 for beverage availability and sizes, .78 for measures on the availability of nutrition information,.75 for characteristics of exterior advertisements, and .62 and .90 for exterior and interior characteristics measures, respectively. For continuous measures, average ICC was .88 for food pricing measures, .83 for beverage prices, and .65 for counts of exterior advertisements. CONCLUSION: Over 85% of measures demonstrated substantial or almost perfect agreement. Although some measures required revision or protocol clarification, results from this study suggest that the instrument may be used to reliably measure the fast-food restaurant environment.