Are We Speaking the Same "Language" Regarding Underrepresented Groups in Plastic Surgery and Increasing Diversity Within Our Field?

BACKGROUND: Plastic Surgery is one of the fields that lags behind the rest when it comes to surgeons from backgrounds underrepresented in medicine (URiM). Extensive research has shown that diversity in health care not only fosters inclusivity but also saves lives. The study aim is to quantify how many integrated plastic surgery residency programs have outlined criteria defining diversity goals and/or groups of people they consider to be URiM. METHODS: All American Council for Graduate Medical Education-accredited integrated plastic surgery program Web sites were reviewed for diversity missions/statements and explicit mentions of the racial and ethnic groups. Web sites were deemed "up-to-date" if they were last updated within 6 months before the initial data collection period. The data collection period was from November 20 to 29, 2022. RESULTS: A total of 86 program were reviewed. Only 8 programs (9%) had clear URiM criteria listed on their Web sites, whereas 26 (30%) relied on institution/department-wide criteria, 1 (1%) listed that they were adhering to American Association of Medical Colleges definition of URiM, and 51 programs (60%) had no form of definition for what is considered URiM. When looking at the programs that have some form of criteria for URiM (n = 35 [40%]), all programs (100%) considered African American/Black, Native American/Alaskan Native, Hispanic/Latinx, and Pacific Islander/Native Hawaiian as groups URiM. Assessing the same subset of programs that have a form of criteria listed (n = 35 [40%]), 19 (58%) had listed other groups outside of race/ethnicity considered to be URiM for their program, and 14 (42%) programs did not. Fourteen programs (74%) considered LGBTQIA+ as a URiM group. CONCLUSION AND SIGNIFICANCE: There still is a great deal of heterogeneity among residency programs when it comes to identifying which medical students are URiM. Numerous plastic surgery organizations have placed diversity and inclusive excellence at the forefront of their agendas; however, it is critical that residency programs also actively align their efforts in an equitable and intentional way. This study serves to encourage residency programs to evaluate their mission toward diversity, equity, and inclusion and to spark discussion toward creating a clearer URiM definition to be consistent among all programs.

Alternative Lymphatic Drainage Pathways in the Trunk Following Oncologic Therapy.

BACKGROUND: Anatomic and functional descriptions of trunk and breast lymphedema following breast cancer treatment are emerging as indicators of lymphatic dysfunction. Indocyanine green-lymphangiography has been instrumental in characterizing this dysfunction in the extremity and can be applied to other regions. Previous work has established a validated Pittsburgh Trunk Lymphedema Staging System to characterize such affected areas. This study aims to identify risk and protective factors for the development of truncal and upper extremity lymphedema using alternative lymphatic drainage, providing implications for medical and surgical treatment. METHODS: Patients undergoing revisional breast surgery with suspicion of upper extremity lymphedema between 12/2014 and 3/2020 were offered lymphangiography. The breast and lateral/anterior trunks were visualized and blindly evaluated for axillary and inguinal lymphatic flow. A linear-weighted Cohen's kappa statistic was calculated comparing alternative drainage evaluation. Binomial regression was used to compute relative risks (RRs). Significance was assessed at alpha = 0.05. RESULTS: Eighty-six sides (46 patients) were included. Twelve sides underwent no treatment and were considered controls. Eighty-eight percent of the noncontrols had alternative lymphatic flow to the ipsilateral axillae (64%), ipsilateral groins (57%), contralateral axillae (20.3%), and contralateral groins (9.3%). Cohen's kappa for alternative drainage was 0.631 ± 0.043. Ipsilateral axillary and contralateral inguinal drainage were associated with reduced risk of developing truncal lymphedema [RR 0.78, confidence interval (CI) 0.63-0.97, P = 0.04; RR 0.32, CI 0.13-0.79, P = 0.01, respectively]. Radiation therapy increased risk of truncal and upper extremity lymphedema (RR 3.69, CI 0.96-14.15, P = 0.02; RR 1.92, CI 1.09-3.39, P = 0.03, respectively). Contralateral axillary drainage and axillary lymph node dissection were associated with increased risk of upper extremity lymphedema (RR 4.25, CI 1.09-16.61, P = 0.01; RR 2.83, CI 1.23-6.52, P = 0.01, respectively). CONCLUSIONS: Building upon previous work, this study shows risk and protective factors for the development of truncal and upper extremity lymphedema. Most prevalent alternative channels drain to the ipsilateral axilla and groin. Ipsilateral axillary and contralateral inguinal drainage were associated with reduced risk of truncal lymphedema. Patients with radiation, axillary dissection, and contralateral axillary drainage were associated with increased risk of upper extremity lymphedema. These findings have important clinical implications for postoperative manual lymphatic drainage and for determining eligibility for lymphovenous bypass surgery.

Neighborhood Deprivation and Symptoms, Psychological Distress, and Quality of Life Among Head and Neck Cancer Survivors.

Importance: Socioeconomic deprivation is associated with increased risk of poor health and quality-of-life (QOL) outcomes in head and neck cancer (HNC) survivors. However, there are few data on how neighborhood deprivation affects patient-reported outcome measures (PROMs) in HNC survivors. Objective: To investigate whether neighborhood socioeconomic deprivation is associated with symptom burden, psychological distress, and QOL among HNC survivors. Design, Setting, and Participants: This cross-sectional study used prospectively collected data from patients seen in a university-affiliated multidisciplinary HNC survivorship clinic between September 2018 and September 2021 who received radiotherapy for squamous cell carcinoma of the oral cavity, oropharynx, and larynx or hypopharynx. Exposure: Neighborhood socioeconomic deprivation, measured using the Area Deprivation Index (ADI). Main Outcomes and Measures: The PROMs pertaining to symptom burden and severity of psychological distress were measured using the Neck Disability Index, Insomnia Severity Index, the 10-item Eating Assessment Tool, the Generalized Anxiety Disorder 7-item scale, and the 8-item Patient Health Questionnaire. Physical and social-emotional QOL were obtained using the University of Washington QOL questionnaire. Multivariable linear regression analysis adjusting for individual-level sociodemographic, comorbidity, and treatment characteristics investigated the association between ADI and PROMs. A subgroup analysis was performed to compare the lowest (most affluent areas: ADI, 0%-20%) and highest (most deprived areas: ADI, 80%-100%) ADI quintiles. Results: A total of 277 patients were included in the final analysis (mean [SD] age, 64.18 [9.60] years; 215 [77.6%] male). Cancer sites were the oral cavity (52 [18.8%]), oropharyngeal area (171 [61.7%]), and larynx or hypopharynx (54 [19.5%]). Multivariable analysis showed that for every 1-point increase in ADI, social-emotional QOL changed by -0.14 points (95% CI, -0.24 to -0.05 points), anxiety increased by 0.03 points (95% CI, 0.01-0.06 points), and neck disability worsened by 0.05 points (95% CI, 0.01-0.10 points). Compared with patients in the most affluent areas, those in the most deprived areas had significantly lower physical (-15.89 points; 95% CI, -25.96 to -2.31 points; Cohen d = -0.83) and social-emotional (-13.57 points; 95% CI, -22.79 to -3.49 points; Cohen d = -0.69) QOL and higher depression (2.60 points; 95% CI, 0.21-4.40 points; Cohen d = 0.52), anxiety (3.12 points; 95% CI, 1.56-4.66 points; Cohen d = 0.61), insomnia (3.55 points; 95% CI, 0.33-6.41 points; Cohen d = 0.54), and neck disability (5.65 points; 95% CI, 1.66-9.55 points; Cohen d = 0.66) scores. Conclusions and Relevance: In this cross-sectional study, a higher ADI score was associated with higher risk of increased psychological distress, higher symptom burden, and decreased QOL after treatment among HNC survivors. These findings suggest that proactive, patient-centered interventions are needed to address these disparities.

Upper Extremity Functional Outcomes After Breast Cancer Treatment: An Analysis of DASH Score in Breast Reconstruction Patients.

BACKGROUND: Patients undergoing postoncologic breast reconstruction can experience upper extremity (UE) functional deficits. OBJECTIVES: In this study, we utilized the disabilities of the arm, shoulder, and hand (DASH) questionnaire to identify patient factors that impacted UE functional recovery. METHODS: Patients who underwent oncologic followed by reconstructive surgery by a single surgeon from 2014 to 2019 and completed the DASH survey were included. A DASH score was calculated for each patient, with values ranging from 0 (no impairment) to 100 (severe impairment). Regression analysis was conducted to identify significant predictors for DASH score with a significance level for entry and stay set at P = .15. RESULTS: Among 289 patients who underwent breast reconstruction, 157 completed the questionnaire. The average patient age was 52.6yrs ± 8.6 at the time of reconstruction. A total of 111 had implant-based reconstruction, 15 had autologous reconstruction, and 24 had a combination of both. Average DASH score was 7.7 (range 0.0-52.5), with 74.1% of patients having a score greater than 0. Regression analysis showed 5 variables associated with significantly higher DASH scores: age between 50 and 60 years (P = .13), history of radiation (P = .01), placement of a subpectoral implant (P = .06), postoperative complications (P = .10), and lymphedema (P < .01). Autologous breast reconstruction (P = .04) was associated with a significantly lower DASH score. CONCLUSIONS: Implant-based reconstruction, radiation history, postoperative complications, and age at reconstruction were associated with increased UE functional impairment in patients who underwent breast reconstructive surgery. Identification of these factors can inform areas for potential practice changes and improve patient counseling regarding postoperative expectations.

Evaluation of Perioperative Versus Extended Courses of Antibiotic Prophylaxis After Immediate Implant-Based Breast Reconstruction.

BACKGROUND: Immediate implant-based breast reconstruction (IIBR) is the most commonly used method in breast reconstruction in the United States. However, postoperative surgical site infections (SSIs) can cause devastating reconstructive failure. This study evaluates the use of perioperative versus extended courses of antibiotic prophylaxis after IIBR for the prevention of SSI. METHODS: This is a single-institution retrospective study of patients who underwent IIBR between June 2018 and April 2020. Detailed demographic and clinical information was collected. Patients were divided into subgroups based on antibiotic prophylaxis regimen: group 1 consisted of patients who received 24 hours of perioperative antibiotics and group 2 consisted of patients who received ≥7 days of antibiotics. Statistical analyses were conducted using SPSSv26.0 with P ≤ 0.05 considered statistically significant. RESULTS: A total of 169 patients (285 breasts) who underwent IIBR were included. The mean age was 52.4 ± 10.2 years, and the mean body mass index (BMI) was 26.8 ± 5.7 kg/m2. Twenty-five percent of patients (25.6%) underwent nipple-sparing mastectomy, 69.1% skin-sparing mastectomy, and 5.3% total mastectomy. The implant was placed in the prepectoral, subpectoral, and dual planes in 16.7%, 19.2%, and 64.1% cases, respectively. Acellular dermal matrix was used in 78.7% of cases. A total of 42.0% of patients received 24-hour prophylaxis (group 1), and 58.0% of patients received extended prophylaxis (group 2). Twenty-five infections (14.8%) were identified, of which 9 (5.3%) resulted in reconstructive failure. In bivariate analyses, no significant difference was found between groups in rates of infection (P = 0.273), reconstructive failure (P = 0.653), and seroma (P = 0.125). There was a difference in hematoma rates between groups (P = 0.046). Interestingly, in patients who received only perioperative antibiotics, infection rates were significantly higher in those with BMI ≥ 25 (25.6% vs 7.1%, P = 0.050). There was no difference in overweight patients who received extended antibiotics (16.4% vs 7.0%, P = 0.160). CONCLUSIONS: Our data demonstrate no statistical difference in infection rates between perioperative and extended antibiotics. This suggests that the efficacies of current prophylaxis regimens are largely similar, with choice of regimen based on surgeon preference and patient-specific considerations. Infection rates in patients who received perioperative prophylaxis and were overweight were significantly higher, suggesting that BMI should be taken into consideration when choosing a prophylaxis regimen.

Venous Thromboembolism Rates After Free Flap Reconstruction of the Head and Neck Region.

BACKGROUND: Venous thromboembolism (VTE) is a major concern for the postoperative hospitalized patient, especially after long and complex procedures. Cancer itself also contributes to the hypercoagulable state, further complicating the management of patients. Despite prophylaxis, breakthrough events can occur. We aimed to assess our institutional VTE and bleeding rates after free flap reconstruction of the head and neck (H&N) region and the factors associated with VTE events. METHODS: A retrospective review of the patients who underwent H&N free flap reconstruction at an academic center from 2012 to 2021 was performed from a prospectively maintained database. Data regarding patient demographics, medical history, surgical details, and overall outcomes were collected. Outcomes studied included postoperative 30-day VTE rates and major bleeding events. Patients who had a VTE event were compared with the rest of the cohort to identify factors associated with VTE. RESULTS: Free flap reconstruction of the H&N region was performed in 949 patients. Reconstruction after cancer extirpation for squamous cell carcinoma was the most common etiology (79%). The most common flap was thigh based (50%), followed by the fibula (29%). The most common postoperative VTE chemoprophylaxis regimen was enoxaparin 30 mg twice daily (83%). The VTE and bleeding rates over the 10-year period were 4.6% (n = 44) and 8.7% (n = 83), respectively. Body mass index (28.7 ± 5.8 vs 26.2 ± 6.6, P = 0.013) and pulmonary comorbidities were found to be significantly higher in patients who had a VTE event (43% vs 27%, P = 0.017). Patients with a VTE event had a prolonged hospital stay of 8 more days (19.2 ± 17.4 vs 11 ± 7, P = 0.003) and a higher incidence of bleeding events (27% vs 8%, P < 0.001). CONCLUSIONS: Postoperative VTE is a significant complication associated with increased length of hospitalization in patients undergoing free flap reconstruction of the H&N region. Institutional measures should be implemented on an individualized basis based on patient comorbidities to improve the postoperative VTE rates, while balancing the bleeding events.

Association between venous thromboembolism rates and different prophylactic anticoagulation regimens in patients undergoing free flap reconstruction of the head and neck region.

BACKGROUND: Venous Thromboembolism (VTE) is a serious complication after free tissue transfer to the head and neck (H&N). However, an optimal antithrombotic prophylaxis protocol is not defined in the literature. Enoxaparin 30 mg twice daily (BID) and heparin 5000 IU three times daily (TID) are among the most commonly used regimens for chemoprophylaxis. However, no studies compare these two agents in the H&N population. METHODS: A cohort study of patients who underwent free tissue transfer to H&N from 2012 to 2021 and received either enoxaparin 30 mg BID or Heparin 5000 IU TID postoperatively. Postoperative VTE and hematoma events were recorded within 30 days of index surgery. The cohort was divided into two groups based on chemoprophylaxis. VTE and hematoma rates were compared between the groups. RESULTS: Out of 895 patients, 737 met the inclusion criteria. The mean age and Caprini score were 60.6 [SD 12.5] years and 6.5 [SD 1.7], respectively. 234 [31.88%] were female. VTE and hematoma rates among all patients were 4.47% and 5.56%, respectively. The mean Caprini score between the enoxaparin (n = 664) and heparin (n = 73) groups was not statistically significant (6.5 ± 1.7 vs.6.3 ± 1.3, p = 0.457). The VTE rate in the enoxaparin group was significantly lower than in the heparin group (3.9% vs. 9.6%; OR: 2.602, 95% CI: 1.087-6.225). Hematoma rates were similar between the two groups (5.5% vs. 5.6%; OR: 0.982, 95% CI: 0.339-2.838). CONCLUSIONS: Enoxaparin 30 mg BID was associated with a lower VTE rate while maintaining a similar hematoma rate compared to heparin 5000 units TID. This association may support the use of enoxaparin over heparin for VTE chemoprophylaxis in H&N reconstruction.

Reversal of Roux-en-Y Gastric Bypass for Successful Salvage of Renal Allograft.

Enteric hyperoxaluria (EH) is a known complication of Roux-en-Y gastric bypass (RYGB) and can lead to nephrolithiasis, oxalate-induced nephropathy, and end-stage renal disease. Recurrent EH-induced renal impairment has been reported after kidney transplantation and may lead to allograft loss. EH occurs in up to one quarter of patients following malabsorption-based bariatric operations. We present a report of medically refractory EH in a renal transplant recipient with allograft dysfunction that was successfully managed with reversal of RYGB. The patient developed renal failure 7 years following gastric bypass requiring renal transplant. Following an uneventful living donor kidney transplant, the patient developed recurrent subacute allograft dysfunction. A diagnosis of oxalate nephropathy was made based on biopsy findings of renal tubular calcium oxalate deposition in conjunction with elevated serum oxalate levels and elevated 24-hr urinary oxalate excretion. Progressive renal failure ensued despite medical management. The patient underwent reversal of her RYGB, which resulted in recovery of allograft function. This report highlights an under-recognized, potentially treatable cause of renal allograft failure in patients with underlying gastrointestinal pathology or history of bariatric surgery and proposes a strategy for management of patients with persistent hyperoxaluria based on a review of the literature.

Assessment of BMI and Venous Thromboembolism Rates in Patients on Standard Chemoprophylaxis Regimens After Undergoing Free Tissue Transfer to the Head and Neck.

Importance: Venous thromboembolism (VTE) is a severe complication after free tissue transfer to the head and neck (H&N). Enoxaparin 30 mg twice daily (BID) is a common regimen for chemoprophylaxis. However, differences in enoxaparin metabolism based on body weight may influence its efficacy and safety profile. Objective: To assess the association between BMI and postoperative VTE and hematoma rates in patients treated with prophylactic enoxaparin 30 mg BID. Design, Setting, and Participants: This was a retrospective review of a prospectively collected cohort from 2012 to 2022. Postoperative VTE, hematoma, and free flap pedicle thrombosis were recorded within 30 days of index surgery. The setting was a tertiary academic referral center. Participants included patients undergoing H&N reconstruction with free flaps that received fixed-dose subcutaneous enoxaparin 30 mg BID postoperatively. Statistical analysis was conducted from April to May 2022. Main Outcomes and Measures: Outcomes include incidence of VTE, hematoma, and flap pedicle thrombosis events within 30 days of the surgery. Univariate and multivariable regression models were used to evaluate associations between BMI and other patient factors with these outcomes. Results: Among the 765 patients included, 262 (34.24%) were female; mean (SD) age was 60.85 (12.64) years; and mean (SD) BMI was 26.36 (6.29). The rates of VTE and hematoma in the cohort were 3.92% (30 patients) and 5.09% (39 patients), respectively. After adjusting for patient factors, BMI was the only factor associated with VTE (OR, 1.07; 95% CI, 1.015-1.129). Obesity (BMI >30) was associated with increased odds of VTE (OR, 2.782; 95% CI, 1.197-6.564). Hematoma was not associated with BMI (OR, 0.988; 95% CI, 0.937-1.041). Caprini score of at least 9 was not associated with VTE (OR, 1.259; 95% CI, 0.428-3.701). Conclusions and Relevance: This cohort study found that obesity was associated with an increased risk of VTE in patients after microvascular H&N reconstruction and while on standard postoperative chemoprophylaxis regimens. This association may suggest insufficient VTE prophylaxis in this group and a potential indication for weight-based dosing.

Who Cares about Diversity? Trends in Gender and Racial Authorship and Publications in Plastic Surgery over Time.

The literature in scientific journals represents current standards for plastic surgery (PS) and new observations contributed by leaders in the field. Observations of these trends over time define our progress and document our ever-changing specialty. This study aims to assess the racial/ethnic and gender makeup of authors who have published on the topic of diversity in PS, and to define trends over time, as well as geographic and journal representation of these publications. Methods: Existing published literature was queried through PubMed with the search terms "plastic surgery" AND "diversity" from 2008 to 2021. The race/ethnicity and gender of collated authors were adjudicated using NamSor software. Trends over time regarding quantity and topics covered, as well as gender and race of authors of these publications, were identified. Results: A total of 208 papers were identified with our search strategy; 74 met inclusion criteria, representing 398 authors. White' non-Hispanic authors represented the majority of first authors (45%) and the majority of senior authors (54%). Black/African American authors comprised 18% first authors and 19% senior authors. Male authorship predominated, with 58% of first authorship and 64% of senior authorship. Conclusions: Publications on the topic of diversity have increased in recent years. Trends show a significant shift in authorship, with prevalence of white male contributions rising. Women constitute most authors on the topic of gender diversity. These findings provide important insight into who cares about diversity within our specialty and who shapes its future.

The Pittsburgh Trunk Lymphedema Staging System (PTLSS) - a validated staging system for the description of breast cancer-associated trunk lymphedema.

BACKGROUND: Neither anatomic nor functional descriptions exist of trunk/breast lymphedema following breast cancer treatment. Indocyanine green (ICG)-lymphangiography has been shown to characterize lymph channel dysfunction seen in lymphedema. We propose using ICG-lymphangiography to evaluate trunk and breast lymphedema following breast cancer surgery to characterize the regions affected via a novel, validated staging system. METHODS: Patients undergoing revisional breast surgery with suspicion of upper extremity lymphedema between December 2014 and March 2020 were offered lymphangiography. The breast and lateral/anterior trunks were visualized and blindly evaluated using Koshima's patterns of dermal backflow. Patients were then staged. A linear-weighted Cohen's kappa statistic was calculated comparing each rated area and stage assignment. RESULTS: Fifty-two sides (29 patients) were included. Eight sides underwent no treatment and were considered controls. No lymphedema was identified within this cohort. One patient (two sides) had no transit of ICG. Seventy-six percent of the non-controls had dermal backflow. This was seen in 67% of anterior trunks, 50% of lateral trunks, 50% of inframammary folds (IMFs), 43% of inferior breasts, and 5% of superior breasts. Cohen's kappa for area agreement was 0.4117 ± 0.0535. Stage 0 was seen in 31 (±7)% of sides; stage 1: 21 (±1)%; stage 2: 22 (±5)%; stage 3: 18 (±4)%; stage 4: 5 (±1)%; and stage 5: 4 (±0). Cohen's kappa for staging was 0.8109 ± 0.0868. CONCLUSION: Following breast cancer surgery, lymphedema occurs throughout the trunk and breast. Severe dysfunction appears to be located around the inferior-lateral aspect of the breast and chest wall. Furthermore, the Pittsburgh Trunk Lymphedema Staging System is a validated measure of trunk and breast lymphedema.

Disparities in Access to Postmastectomy Breast Reconstruction: Does Living in a Specific ZIP Code Determine the Patient's Reconstructive Journey?

BACKGROUND: Postmastectomy breast reconstruction (BR) has been shown to provide long-term quality of life and psychosocial benefits. Despite the policies initiated to improve access to BR, its delivery continues to be inequitable, suggesting that barriers to access have not been fully identified and/or addressed. The purpose of this study was to assess the influence of geographic location, socioeconomic status, and race in access to immediate BR (IBR). METHODS: An institutional review board-approved observational study was conducted. All patients who underwent breast cancer surgery from 2014 to 2019 were queried from our institutional Breast Cancer Registry. A geographical analysis was conducted using demographic characteristics and patient's ZIP codes. Euclidean distance from patient home ZIP code to UPMC Magee Women's Hospital was calculated, and χ2, Student t test, Mann-Whitney, and Kruskal-Wallis tests was used to evaluate differences between groups, as appropriate. Statistical significance was set at P < 0.05. RESULTS: Overall, 5835 patients underwent breast cancer surgery. A total of 56.7% underwent lumpectomy or segmental mastectomy, and 43.3% underwent modified, total, or radical mastectomy. From the latter group, 33.5% patients pursued BR at the time of mastectomy: 28.6% autologous, 48.1% implant-based, 19.4% a combination of autologous and implant-based, and 3.9% unspecified reconstruction. Rates of IBR varied among races: White or European (34.1%), Black or African American (27.7%), and other races (17.8%), P = 0.022. However, no difference was found between type of BR among races (P = 0.38). Moreover, patients who underwent IBR were significantly younger than those who did not pursue reconstruction (P < 0.0001). Patients who underwent reconstruction resided in ZIP codes that had approximately US $2000 more annual income, a higher percentage of White population (8% vs 11% non-White) and lower percentage of Black or African American population (1.8% vs 2.9%) than the patients who did not undergo reconstruction. CONCLUSIONS: While the use of postmastectomy BR has been steadily rising in the United States, racial and socioeconomic status disparities persist. Further efforts are needed to reduce this gap and expand the benefits of IBR to the entire population without distinction.

Quantifying the Pipeline of Ethnically Underrepresented in Medicine Physicians in Academic Plastic Surgery Leadership.

BACKGROUND: The lack of underrepresented in medicine (UIM) physicians in academic plastic surgery is emerging as a critical issue. Lack of diversity has a negative effect on patient care and on the culture of our health care system. This study reports the current status of ethnically UIM physicians in the plastic surgery pipeline, starting from the medical student level and progressing to national leadership positions. METHODS: The Electronic Residency Applications Service, National Resident Matching Program, Association of American Medical Colleges, and professional Web sites for journals and national societies were accessed for racial demographic information from 2008 to 2019. RESULTS: Over the past decade, there has been no change or a slight decrease in representation of Blacks among plastic surgery residency applicants, trainees, and academic faculty, at half or less than expected, compared with US Census data. The first point of drop-off occurs at the resident (3.8% of integrated and 5.6% of independent residents) to faculty level (<2.8%). Two percent of program directors and department heads/division chiefs are Black. The next point of drop-off occurs at the national level: there has never been a Black president of American Society of Plastic Surgeons or Plastic Surgery Foundation, and there are no Black editors-in-chiefs of major plastic surgery journals.Following LatinX American surgeons down the pipeline over the past decade, there has been no change or a decrease in representation among plastic surgery residency applicants, resident physicians, and academic faculty, at one-third or less than expected, compared with US Census data. The first point of drop-off occurs at the faculty (4.8%) to local leadership level (0% of program directors and department heads/division chiefs) where there is no representation of LatinX. Once this drop-off occurs, there is no recovery at the national leadership level. CONCLUSIONS: In order for our profession to reflect our nation's demographics, academic plastic surgery is in need of a paradigm shift now. Attrition of UIM physicians in plastic surgery begins at medical school graduation and persists through surgical training, faculty appointments, and attainment of leadership positions. Creative and innovative commitment to diversity and inclusion is necessary.

Opioid-Prescribing Practices in Plastic Surgery: A Juxtaposition of Attendings and Trainees.

BACKGROUND: The rates of opioid abuse and overdose in America have risen in parallel with the rates of opioid prescribing by physicians. As such, we sought to examine the prescribing practices among plastic surgery attendings and trainees to determine the need for more thorough education. METHODS: A survey was distributed to all ACGME-accredited plastic surgery residency programs and included questions regarding opioid-prescribing practices and self-rated ability pertaining to opioid management. Trends in prescribing practices based on prescriber position were analyzed using cumulative odds ordinal logistic regression with proportional odds and Chi-squared tests for ordinal and nominal variables, respectively. RESULTS: We received 78 responses with a wide geographical representation from plastic surgery residency programs: 59% of respondents were male and 39.7% female, 29.5% were attendings, 26.9% senior residents, 29.5% junior residents, and 14.1% interns. Compared with attendings, interns prescribe fewer pills (p < 0.05) and were significantly more likely to prescribe oxycodone (p < 0.03). Junior residents were 4.49 times more likely (p = 0.012) and senior residents 3.65 times more likely (p = 0.029) to prescribe additional opioids to avoid phone calls and follow-up visits. Interns and senior residents were significantly less comfortable than attendings in managing patients requesting additional opioids (p < 0.02). CONCLUSIONS: The results of this survey demonstrate that knowledge deficits do exist among trainees, and that trainees are significantly less comfortable than their attending counterparts with opioid prescribing and patient management. Therefore, the implementation of a thorough postoperative pain management education in residency may be a cogent strategy in mitigating the opioid crisis. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Comparing Prevalence Estimates From Population-Based Surveys to Inform Surveillance Using Electronic Health Records.

INTRODUCTION: Electronic health record (EHR) systems provide an opportunity to use a novel data source for population health surveillance. Validation studies that compare prevalence estimates from EHRs and surveys most often use difference testing, which can, because of large sample sizes, lead to detection of significant differences that are not meaningful. We explored a novel application of the two one-sided t test (TOST) to assess the equivalence of prevalence estimates in 2 population-based surveys to inform margin selection for validating EHR-based surveillance prevalence estimates derived from large samples. METHODS: We compared prevalence estimates of health indicators in the 2013 Community Health Survey (CHS) and the 2013-2014 New York City Health and Nutrition Examination Survey (NYC HANES) by using TOST, a 2-tailed t test, and other goodness-of-fit measures. RESULTS: A ±5 percentage-point equivalence margin for a TOST performed well for most health indicators. For health indicators with a prevalence estimate of less than 10% (extreme obesity [CHS, 3.5%; NYC HANES, 5.1%] and serious psychological distress [CHS, 5.2%; NYC HANES, 4.8%]), a ±2.5 percentage-point margin was more consistent with other goodness-of-fit measures than the larger percentage-point margins. CONCLUSION: A TOST with a ±5 percentage-point margin was useful in establishing equivalence, but a ±2.5 percentage-point margin may be appropriate for health indicators with a prevalence estimate of less than 10%. Equivalence testing can guide future efforts to validate EHR data.

Generalizability of Indicators from the New York City Macroscope Electronic Health Record Surveillance System to Systems Based on Other EHR Platforms.

INTRODUCTION: The New York City (NYC) Macroscope is an electronic health record (EHR) surveillance system based on a distributed network of primary care records from the Hub Population Health System. In a previous 3-part series published in eGEMS, we reported the validity of health indicators from the NYC Macroscope; however, questions remained regarding their generalizability to other EHR surveillance systems. METHODS: We abstracted primary care chart data from more than 20 EHR software systems for 142 participants of the 2013-14 NYC Health and Nutrition Examination Survey who did not contribute data to the NYC Macroscope. We then computed the sensitivity and specificity for indicators, comparing data abstracted from EHRs with survey data. RESULTS: Obesity and diabetes indicators had moderate to high sensitivity (0.81-0.96) and high specificity (0.94-0.98). Smoking status and hypertension indicators had moderate sensitivity (0.78-0.90) and moderate to high specificity (0.88-0.98); sensitivity improved when the sample was restricted to records from providers who attested to Stage 1 Meaningful Use. Hyperlipidemia indicators had moderate sensitivity (≥0.72) and low specificity (≤0.59), with minimal changes when restricting to Stage 1 Meaningful Use. DISCUSSION: Indicators for obesity and diabetes used in the NYC Macroscope can be adapted to other EHR surveillance systems with minimal validation. However, additional validation of smoking status and hypertension indicators is recommended and further development of hyperlipidemia indicators is needed. CONCLUSION: Our findings suggest that many of the EHR-based surveillance indicators developed and validated for the NYC Macroscope are generalizable for use in other EHR surveillance systems.

Characterizing Adults Receiving Primary Medical Care in New York City: Implications for Using Electronic Health Records for Chronic Disease Surveillance.

INTRODUCTION: Electronic health records (EHRs) from primary care providers can be used for chronic disease surveillance; however, EHR-based prevalence estimates may be biased toward people who seek care. This study sought to describe the characteristics of an in-care population and compare them with those of a not-in-care population to inform interpretation of EHR data. METHODS: We used data from the 2013-2014 New York City Health and Nutrition Examination Survey (NYC HANES), considered the gold standard for estimating disease prevalence, and the 2013 Community Health Survey, and classified participants as in care or not in care, on the basis of their report of seeing a health care provider in the previous year. We used χ(2) tests to compare the distribution of demographic characteristics, health care coverage and access, and chronic conditions between the 2 populations. RESULTS: According to the Community Health Survey, approximately 4.1 million (71.7%) adults aged 20 or older had seen a health care provider in the previous year; according to NYC HANES, approximately 4.7 million (75.1%) had. In both surveys, the in-care population was more likely to be older, female, non-Hispanic, and insured compared with the not-in-care population. The in-care population from the NYC HANES also had a higher prevalence of diabetes (16.7% vs 6.9%; P < .001), hypercholesterolemia (35.7% vs 22.3%; P < .001), and hypertension (35.5% vs 26.4%; P < .001) than the not-in-care population. CONCLUSION: Systematic differences between in-care and not-in-care populations warrant caution in using primary care data to generalize to the population at large. Future efforts to use primary care data for chronic disease surveillance need to consider the intended purpose of data collected in these systems as well as the characteristics of the population using primary care.

Design of the New York City Macroscope: Innovations in Population Health Surveillance Using Electronic Health Records.

INTRODUCTION: Electronic health records (EHRs) have the potential to offer real-time, inexpensive standardized health data about chronic health conditions. Despite rapid expansion, EHR data evaluations for chronic disease surveillance have been limited. We present design and methods for the New York City (NYC) Macroscope, an EHR-based chronic disease surveillance system. This methods report is the first in a three part series describing the development and validation of the NYC Macroscope. This report describes in detail the infrastructure underlying the NYC Macroscope; indicator definitions; design decisions that were made to maximize data quality; characteristics of the population sampled; completeness of data collected; and lessons learned from doing this work. The second report describes the methods used to evaluate the validity and robustness of NYC Macroscope prevalence estimates; presents validation results for estimates of obesity, smoking, depression and influenza vaccination; and discusses the implications of our findings for NYC and for other jurisdictions embarking on similar work. The third report applies the same validation methods to metabolic outcomes, including the prevalence, treatment and control of diabetes, hypertension and hyperlipidemia. METHODS: We designed the NYC Macroscope for comparison to a local "gold standard," the 2013-14 NYC Health and Nutrition Examination Survey, and the telephonic 2013 Community Health Survey. NYC Macroscope indicators covered prevalence, treatment, and control of diabetes, hypertension, and hyperlipidemia; and prevalence of influenza vaccination, obesity, depression and smoking. Indicators were stratified by age, sex, and neighborhood poverty, and weighted to the in-care NYC population and limited to primary care patients. Indicator queries were distributed to a virtual network of primary care practices; 392 practices and 716,076 adult patients were retained in the final sample. FINDINGS: The NYC Macroscope covered 10% of primary care providers and 15% of all adult patients in NYC in 2013 (8-47% of patients by neighborhood). Data completeness varied by domain from 98% for blood pressure among patients with hypertension to 33% for depression screening. DISCUSSION: Design and validation efforts undertaken by NYC are described here to provide one potential blueprint for leveraging EHRs for population health monitoring. To replicate a model like NYC Macroscope, jurisdictions should establish buy-in; build informatics capacity; use standard, simple case defnitions; establish documentation quality thresholds; restrict to primary care providers; and weight the sample to a target population.