Cumulative Sum Chart as Complement to Objective Assessment of Graduating Surgical Resident Competency: An Exploratory Study.

BACKGROUND: Rater-based assessment and objective assessment play an important role in evaluating residents' clinical competencies. We hypothesize that a cumulative sum (CUSUM) chart of operative time is a complement to the assessment of chief general surgery residents' competencies with ACGME Milestones, aiding residency programs' determination of graduating residents' practice readiness. STUDY DESIGN: We extracted ACGME Milestone evaluations of performance of operations and procedures (POP) and 3 objective metrics (operative time, case type, and case complexity) from 3 procedures (cholecystectomy, colectomy, and inguinal hernia) performed by 3 cohorts of residents (N = 15) during their PGY4-5. CUSUM charts were computed for each resident on each procedure type. A learning plateau was defined as at least 4 cases consistently locating around the centerline (target performance) at the end of a CUSUM chart with minimal deviations (range 0 to 1). RESULTS: All residents reached the ACGME graduation targets for the overall POP by the end of chief year. A total of 2,446 cases were included (cholecystectomy N = 1234, colectomy N = 507, and inguinal hernia N = 705), and 3 CUSUM chart patterns emerged: skewed distribution, bimodal distribution, and peaks and valleys distribution. Analysis of CUSUM charts revealed surgery residents' development processes in the operating room towards a learning plateau vary, and only 46.7% residents reach a learning plateau in all 3 procedures upon graduation. CONCLUSIONS: CUSUM charts of operative time complement the ACGME Milestones evaluations. The use of both may enable residency programs to holistically determine graduating residents' practice readiness and provide recommendations for their upcoming career/practice transition.

Comparison of risk adjustment methodologies in surgical quality improvement.

BACKGROUND: All hospitals are required to perform quality assurance activities. Many risk adjustment methodologies have been developed, and many medical centers use 1 or more than 1 risk adjustment program in an attempt to characterize their outcomes better rather than simply assessing unadjusted outcome statistics. The University HealthSystem Consortium (UHC) and American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) both produce risk-adjusted outcome data. Our institution recognized a large disparity between our UHC and NSQIP risk-adjusted mortality. The purpose of this study was to attempt to discover the cause of that disparity. METHODS: One hundred twenty consecutive NSQIP records were matched with their UHC submissions during 2006. All patients' comorbidities and outcomes were reviewed, and the 2 systems, UHC and NSQIP, were compared for degree of discordance. RESULTS: Approximately twice the number of comorbidities per patient were documented in UHC (2.85+/-2.52) submissions compared with NSQIP (1.38+/-1.52, P < .001). The reporting of the comorbidities of hypertension, cardiac disease, pulmonary disease, and diabetes between UHC and NSQIP were similar in the percentage of patients reported as having each of those disease states, but the discordance between the 2 systems was 12%, 13%, 15%, and 5%, respectively (P < .001 in all 4). A total of 28% of patients were reported as suffering complications in NSQIP but only 11% in UHC, with a 26% rate of discordance (P < .01). Overall, 13% of patients were reported as having a surgical site infection in NSQIP, but only 1% in UHC. CONCLUSIONS: We found significant differences in the reporting of both comorbidities and outcomes between our medical center's submissions to UHC and NSQIP in a consecutive series of patients. This may be at least partially responsible for the difference in the risk-adjusted mortality for our institution, as reported by UHC and NSQIP.

Oxygen: at the foundation of wound healing--introduction.

"Wound Healing: Oxygen & Emerging Therapeutics" Columbus, Ohio, September 12-15, 2002. Sponsored by the National Institutes of Health (R13 AR 049171), International Union of Biochemistry & Molecular Biology and UNESCO-Global Network of Molecular & Cell Biology. Conference co-chairs: Chandan K. Sen, the Ohio State University Medical Center and Thomas K. Hunt, University of California-San Francisco. This congress was conceived for two reasons: to consolidate what is known about oxygen in the repair process and to stimulate discussion about new developments of control of healing by redox regulated signaling processes. A historical and evolutionary perspective on the role of oxygen in wound healing--from the classical physiology of oxygen in the wound to the refined concept of redox signaling--is presented.