Patients Lost to Follow-up After Injury: Who are They and What are Their Long-Term Outcomes?

INTRODUCTION: Trauma patients are at high risk for loss to follow-up (LTFU) after hospital discharge. We sought to identify risk factors for LTFU and investigate associations between LTFU and long-term health outcomes in the trauma population. METHODS: Trauma patients with an Injury Severity Score ≥9 admitted to one of three Level-I trauma centers, 2015-2020, were surveyed via telephone 6 mo after injury. Univariate and multivariate analyses were performed to assess factors associated with LTFU and several long-term outcomes. RESULTS: Of 3609 patients analyzed, 808 (22.4%) were LTFU. Patients LTFU were more likely to be male (71% versus 61%, P = 0.001), Black (22% versus 14%, P = 0.003), have high school or lower education (50% versus 42%, P = 0.003), be publicly insured (23% versus 13%, P < 0.001), have a penetrating injury (13% versus 8%, P = 0.006), have a shorter length of stay (3.64 d ± 4.09 versus 5.06 ± 5.99, P < 0.001), and be discharged home without assistance (79% versus 50%, P < 0.001). In multivariate analyses, patients who followed up were more likely to require assistance at home (6% versus 11%; odds ratio [OR] 2.23, 1.26-3.92, P = 0.005), have new functional limitations (11% versus 26%; OR 2.91, 1.97-4.31, P = < 0.001), have daily pain (30% versus 48%; OR 2.11, 1.54-2.88, P = < 0.001), and have more injury-related emergency department visits (7% versus 10%; OR 1.93, 1.15-3.22, P = 0.012). CONCLUSIONS: Vulnerable populations are more likely to be LTFU after injury. Clinicians should be aware of potential racial and socioeconomic disparities in follow-up care after traumatic injury. Future studies investigating improvement strategies in follow-up care should be considered.

Changes in Older Adult Trauma Quality When Evaluated Using Longer-Term Outcomes vs In-Hospital Mortality.

Importance: Lack of knowledge about longer-term outcomes remains a critical blind spot for trauma systems. Recent efforts have expanded trauma quality evaluation to include a broader array of postdischarge quality metrics. It remains unknown how such quality metrics should be used. Objective: To examine the utility of implementing recommended postdischarge quality metrics as a composite score and ascertain how composite score performance compares with that of in-hospital mortality for evaluating associations with hospital-level factors. Design, Setting, and Participants: This national hospital-level quality assessment evaluated hospital-level care quality using 100% Medicare fee-for-service claims of older adults (aged ≥65 years) hospitalized with primary diagnoses of trauma, hip fracture, and severe traumatic brain injury (TBI) between January 1, 2014, and December 31, 2015. Hospitals with annual volumes encompassing 10 or more of each diagnosis were included. The data analysis was performed between January 1, 2021, and December 31, 2022. Exposures: Reliability-adjusted quality metrics used to calculate composite scores included hospital-specific performance on mortality, readmission, and patients' average number of healthy days at home (HDAH) within 30, 90, and 365 days among older adults hospitalized with all forms of trauma, hip fracture, and severe TBI. Main Outcomes and Measures: Associations with hospital-level factors were compared using volume-weighted multivariable logistic regression. Results: A total of 573 554 older adults (mean [SD] age, 83.1 [8.3] years; 64.8% female; 35.2% male) from 1234 hospitals were included. All 27 reliability-adjusted postdischarge quality metrics significantly contributed to the composite score. The most important drivers were 30- and 90-day readmission, patients' average number of HDAH within 365 days, and 365-day mortality among all trauma patients. Associations with hospital-level factors revealed predominantly anticipated trends when older adult trauma quality was evaluated using composite scores (eg, worst performance was associated with decreased older adult trauma volume [odds ratio, 0.89; 95% CI, 0.88-0.90]). Results for in-hospital mortality showed inverted associations for each considered hospital-level factor and suggested that compared with nontrauma centers, level 1 trauma centers had a 17 times higher risk-adjusted odds of worst (highest quantile) vs best (lowest quintile) performance (odds ratio, 17.08; 95% CI, 16.17-18.05). Conclusions and Relevance: The study results challenge historical notions about the adequacy of in-hospital mortality as the single measure of older adult trauma quality and suggest that, when it comes to older adults, decisions about how quality is evaluated can profoundly alter understandings of what constitutes best practices for care. Composite scores appear to offer a promising means by which postdischarge quality metrics could be used.

Patients' perceptions of the post-pancreatectomy discharge process.

BACKGROUND: Complications after pancreatectomies contribute to poor outcomes. Patients are expected to identify signs/symptoms leading to these complications but may be poorly educated on how to identify them. We assessed the impact of an educational tool on patient perceptions of, and satisfaction with the discharge process, and its effect on readmission rates. METHODS: A prospective cohort study with retrospective chart review including patients who underwent pancreatic resection was undertaken. An interactive educational module (iBook) that provided information about the procedure, possible complications, and peri-discharge information was implemented. English-speaking patients were equally divided into the pre- and post-iBook cohorts. Primary outcome was patients' satisfaction with discharge; Secondary outcomes were 30- and 90-day readmission rates. RESULTS: 100 patients were included. Mean age was 65.5 ± 12.6, 46% were female, and 92.3% were white. Most patients underwent Whipple procedures (72%), and distal pancreatectomies (26%). In the post-implementation group, 92% were satisfied with the discharge process, and 89% reported it was a good tool. There were no statistical differences in 30- and 90-day readmission rates between cohorts. CONCLUSION: The iBook positively impacted patients' satisfaction and preparedness for discharge. Readmission rates were not statistically significantly impacted but could be investigated with further studies of greater sample sizes.

Defining the emergency general surgery patient population in the era of ICD-10 : Evaluating an established crosswalk from ICD-9 to ICD-10 diagnosis codes.

INTRODUCTION: In 2015, the United States moved from the International Classification of Diseases, Ninth Revision ( ICD-9 ), to the International Classification of Diseases, Tenth Revision ( ICD-10 ), coding system. The American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes previously established a list of ICD-9 diagnoses to define the field of emergency general surgery (EGS). This study evaluates the general equivalence mapping (GEM) crosswalk to generate an equivalent list of ICD-10 -coded EGS diagnoses. METHODS: The GEM was used to generate a list of ICD-10 codes corresponding to the American Association for the Surgery of Trauma ICD-9 EGS diagnosis codes. These individual ICD-9 and ICD-10 codes were aggregated by surgical area and diagnosis groups. The volume of patients admitted with these diagnoses in the National Inpatient Sample in the ICD-9 era (2013-2014) was compared with the ICD-10 volumes to generate observed to expected ratios. The crosswalk was manually reviewed to identify the causes of discrepancies between the ICD-9 and ICD-10 lists. RESULTS: There were 485 ICD-9 codes, across 89 diagnosis categories and 11 surgical areas, which mapped to 1,206 unique ICD-10 codes. A total of 196 (40%) ICD-9 codes have an exact one-to-one match with an ICD-10 code. The median observed to expected ratio among the diagnosis groups for a primary diagnosis was 0.98 (interquartile range, 0.82-1.12). There were five key issues identified with the ability of the GEM to crosswalk ICD-9 EGS diagnoses to ICD-10 : (1) changes in admission volumes, (2) loss of necessary modifiers, (3) lack of specific ICD-10 code, (4) mapping to a different condition, and (5) change in coding nomenclature. CONCLUSION: The GEM provides a reasonable crosswalk for researchers and others to use when attempting to identify EGS patients in with ICD-10 diagnosis codes. However, we identify key issues and deficiencies, which must be accounted for to create an accurate patient cohort. This is essential for ensuring the validity of policy, quality improvement, and clinical research work anchored in ICD-10 coded data. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level III.

Value of Ambulatory Modified Radical Mastectomy.

BACKGROUND: Modified radical mastectomy (MRM) still is largely performed in inpatient settings. This study sought to determine the value (expenditures and complications) of ambulatory MRM. METHODS: Health Care Utilization Project (HCUP) state databases from 2016 were queried for patients who underwent MRM. The study examined rates of 30-day readmission for surgical-site infection (SSI) or hematoma, charges by index care setting, and predictors of 30-day readmission. RESULTS: Overall, 8090 patients underwent MRM: 5113 (63 %) inpatient and 2977 (37 %) ambulatory patients. Compared with the patients who underwent inpatient MRM, those who underwent ambulatory MRM were older (61 vs. 59 years), more often white (66 % vs. 57 %), in the lowest income quartile (28 % vs. 21 %), insured by Medicare (43 % vs. 33 %) and residents in a small metro area (6 % vs. 4 %) (all p < 0.01). Of the 5113 patients treated as inpatients, 126 (2.5 %) were readmitted, whereas 50 (1.7 %) of the ambulatory patients were readmitted (p = 0.02). The adjusted charge for inpatient MRM without readmission was $113,878 (range, $107,355-120,402) compared with $94,463 (range, $86,021-102,907) for ambulatory MRM, and the charge for inpatient MRM requiring readmission was $159,355 (range, $147,142-171,568) compared with $139,940 (range, $125,808-154,073) for ambulatory MRM (all p < 0.01). This difference remained significant after adjustment for hospital length of stay. Adjusted logistic regression showed that the ambulatory setting was protective for readmission (odds ratio, 0.49; 95 % confidence interval, 0.35-0.70; p < 0.01). CONCLUSIONS: The analyses suggest that ambulatory MRM is both safe and less expensive. The findings advocate that MRM, a last holdout of inpatient care within breast surgical oncology, can be transitioned to the ambulatory setting for appropriate patients.

Early surgery for perforated appendicitis: Are we moving the needle on postoperative abscess?

BACKGROUND: Perforated appendicitis is often managed nonoperatively though upfront surgery is becoming more common. We describe postoperative outcomes for patients undergoing surgery at their index hospitalization for perforated appendicitis. METHODS: We used the 2016-2020 National Surgical Quality Improvement Program database to identify patients with appendicitis who underwent appendectomy or partial colectomy. The primary outcome was surgical site infection (SSI). RESULTS: 132,443 patients with appendicitis underwent immediate surgery. Of 14.1% patients with perforated appendicitis, 84.3% underwent laparoscopic appendectomy. Intra-abdominal abscess rates were lowest after laparoscopic appendectomy (9.4%). Open appendectomy (OR 5.14, 95% CI 4.06-6.51) and laparoscopic partial colectomy (OR 4.60, 95% CI 2.38-8.89) were associated with higher likelihoods of SSIs. CONCLUSIONS: Upfront surgical management of perforated appendicitis is now predominantly approached by laparoscopy, often without bowel resection. Postoperative complications occurred less frequently with laparoscopic appendectomy compared to other approaches. Laparoscopic appendectomy during the index hospitalization is an effective approach to perforated appendicitis.

Predictors of care discontinuity in geriatric trauma patients.

BACKGROUND: Readmission to a non-index hospital, or care discontinuity, has been shown to have worse outcomes among surgical patients. Little is known about its effect on geriatric trauma patients. Our goal was to determine predictors of care discontinuity and to evaluate its effect on mortality in this geriatric population. METHODS: This was a retrospective analysis of Medicare inpatient claims (2014-2015) of geriatric trauma patients. Care discontinuity was defined as readmission within 30 days to a non-index hospital. Demographic and clinical characteristics (including readmission diagnosis category) were collected. Multivariate logistic regression analysis was performed to identify predictors of care discontinuity and to assess its association with mortality. RESULTS: We included 754,313 geriatric trauma patients. Mean age was 82.13 years (SD, 0.50 years), 68% were male and 91% were White. There were 21,615 (2.87%) readmitted within 30 days of discharge. Of these, 34% were readmitted to a non-index hospital. Overall 30-day mortality after readmission was 25%. In unadjusted analysis, readmission to index hospitals was more likely to be due to surgical infection, GI complaints, or cardiac/vascular complaints. After adjusted analysis, predictors of care discontinuity included readmission diagnoses, patient- and hospital-level factors. Care discontinuity was not associated with mortality (OR, 0.93; 95% confidence interval, 0.86-1.01). CONCLUSION: More than a third of geriatric trauma patients are readmitted to a non-index hospital, which is driven by readmission diagnosis, travel time and hospital characteristics. However, unlike other surgical settings, this care discontinuity is not associated with increased mortality. Further work is needed to understand the reasons for this and to determine which standardized processes of care can benefit this population. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Psoas attenuation and cross-sectional area improve performance of traditional sarcopenia measurements in predicting one-year mortality among elderly patients undergoing emergency abdominal surgery: a pilot study of five computed tomography techniques.

BACKGROUND: Risk stratification is challenging in the growing population of geriatric patients requiring emergency surgery. Sarcopenia, which assesses muscle bulk, is a surrogate for frailty and predicts 1-year mortality, but does not incorporate potentially valuable additional information about muscle quality. OBJECTIVE: To describe five different CT methods of measuring sarcopenia and muscle quality and to determine which method has the greatest sensitivity for predicting 1-year mortality following emergency abdominal surgery in elderly patients. METHODS: This retrospective study includes 297 patients 70 years and older who underwent "urgent" or "emergent" laparotomy or laparoscopy for acute abdominal disease between 2006 and 2011 at a single quaternary academic medical center. All patients received a CT abdomen and pelvis with intravenous contrast within 1 month of surgery. Five different methods were applied to the psoas muscles on CT: method 1 (total psoas index TPI, which is total psoas area TPA normalized by height), method 2 ("pseudoarea" = anterior-posterior × transverse dimensions), method 3 (average HU), method 4 (TPA × HU), and method 5 ("pseudoarea" × HU). RESULTS: For all five CT measures, mortality was greatest for the lowest quartile by univariate and adjusted Cox proportional hazard analyses at all time points up to 1-year. The C-statistic was highest for Method 4, using a composite index of TPA and Hounsfield Units, indicating the greatest predictive ability to estimate mortality at all time points. CONCLUSION: Muscle quality and muscle size can be used in tandem to refine risk assessment of older patients undergoing emergency abdominal surgery. Routine calculation of the composite score of psoas cross-sectional area and HU in the emergency room setting may provide surgeons and patients valuable insight on the risk of 1-year mortality to guide preoperative decision-making and counseling. CLINICAL IMPACT: Muscle quality and size, both strong independent predictors of surgical outcomes in older patients undergoing emergency abdominal surgery, may be used in tandem to refine risk assessment. A composite score of psoas muscle cross-sectional area and Hounsfield units on CT may provide insight on 1-year mortality in this patient population.

Impact of hospital characteristics on best-practice adherence for gallstone pancreatitis: a nationwide analysis.

BACKGROUND: Current guidelines recommend cholecystectomy during the index admission for gallstone pancreatitis, and a growing body of evidence indicates that patients benefit from cholecystectomy within the first 48 h of admission. We examined the impact of hospital characteristics on adherence to these data-driven practices. METHODS: We queried the National Inpatient Sample for patients admitted for gallstone pancreatitis between October 2015 and December 2018. Patients who underwent same-admission cholecystectomy were identified by procedure codes. Cholecystectomies within the first two days were classified as early cholecystectomies. Multivariable logistic regression was used to determine the association between hospital characteristics and adherence to these practices. RESULTS: Of 163,390 admissions for gallstone pancreatitis, only 90,790 (55.6%) underwent cholecystectomy before discharge. Mean time from admission to cholecystectomy was 2.9 days; 27.0% of patients (44,005) underwent early cholecystectomy. Odds of same-admission cholecystectomy were highest in large hospitals (OR 1.21, 95% CI 1.13-1.28), urban teaching centers (OR 1.33, 95% CI 1.21-1.46), and the South (OR 1.70, 95% CI 1.57-1.83). Odds of early cholecystectomy did not vary with hospital size, urban-rural status, or teaching status but were highest in the West (OR 1.98, 95% CI 1.80-2.18). CONCLUSION: Best-practice adherence for cholecystectomy in gallstone pancreatitis remains low despite an abundance of evidence and clinical practice guidelines. Active interventions are needed to improve delivery of surgical care for this patient population. Implementation efforts should focus on small hospitals, rural areas, and health systems in the Northeast region.

Parental Support Policies and Benefits: A Surgical Training Program Report Card of Transparency.

OBJECTIVE: This study aimed to investigate the transparency of parental benefits available to US surgical residency applicants. BACKGROUND: Medical students prioritize work-family balance in specialty selection. Those applying to surgical residency programs also place a significant value on parental leave policies when deciding where to train. However, little is known about the amount of information that surgical training programs publicly offer to potential applicants regarding family support policies. METHODS: Publicly available websites for 264 general surgery training programs were accessed to determine the availability of information on parental benefits. Twenty-six "items of transparency" included types of leave, contract flexibility, salary, lactation, and childcare support. Programs with fewer than the median items of transparency were contacted to inquire about additional public resources. Academic programs were stratified by their associated medical school rankings in the US News & World Report. RESULTS: A total of 144 (54%) programs were academic and 214 (81.4%) had male program directors. The median number of items of transparency was 8 (29.6%). Of the 131 programs contacted, 33 (25.9%) replied, and 2 (6.1%) improved their transparency score. Academic programs associated with medical schools in the upper third of the rankings were more likely to have ≥8 items of transparency (70.8% vs. 45.6%; P =0.002). In the adjusted analysis, academic programs [odds ratio (OR): 3.44, 95% confidence interval (95% CI): 1.87-6.34], those with female program directors (OR: 2.09, 95% CI: 1.01-4.33), and those located in the Western (OR: 3.13, 95% CI: 1.31-7.45) and Southern (OR: 2.45, 95% CI: 1.21-4.98) regions of the country were more likely to have ≥8 items of transparency. CONCLUSIONS: There are significant deficits in publicly available information related to parental benefits for many surgical training programs, which may impact applicants' decision making. Attracting the most talented candidates requires programs to create and share policies that support the integration of professional and personal success.

Pregnancy During Surgical Training: Are Residency Programs Truly Supporting Their Trainees?

OBJECTIVE: Despite recent national improvements in family leave policies, there has been little focus on program-level support for surgical trainees. Trainees who may require clinical duty adjustments during pregnancy, who experience pregnancy loss, or who struggle with balancing work obligations with the demands of a new infant may face stigma when seeking schedule accommodations. The aim of this study was to describe program and colleague support of surgical trainees for pregnancy-related and postpartum health needs. DESIGN: Survey questionnaire. Participants responded to multiple-choice questions about their history of pregnancy loss, their experience with reduction of clinical duties during pregnancy, and their breastfeeding experience. Those who took time off after miscarriages or reduced their clinical duties during pregnancy were asked whether they perceived their colleagues and/or program leadership to be supportive using a 4-point Likert scale (1-strongly agree, 4-strongly disagree) which was dichotomized to agree/disagree. SETTING: Electronically distributed through social media and surgical societies from November 2020 to January 2021. PARTICIPANTS: Female surgical residents and fellows. RESULTS: 258 female surgical residents and fellows were included. Median age was 32 (IQR 30-35) years and 76.74% were white. Of the 52 respondents (20.2%) who reported a miscarriage, 38 (73.1%) took no time off after pregnancy loss, including 5 of 10 women (50%) whose loss occurred after 10 weeks' gestation. Of the 14 residents who took time off after a miscarriage, 4 (28.6%) disagreed their colleagues and/or leadership were supportive of time away from work. Among trainees who reported at least 1 live birth, only 18/114 (15.8%) reduced their work schedule during pregnancy. Of these, 11 (61.1%) described stigma and resentment from colleagues and 14 (77.8%) reported feeling guilty about burdening their colleagues. 100% of respondents reported a desire to breastfeed their infants, but nearly half (46.0%) were unable to reach their breastfeeding goals. 46 (80.7%) cited a lack of time to express breastmilk and 23 (40.4%) cited inadequate lactation facilities as barriers to achieving their breastfeeding goals. CONCLUSIONS: A minority of female trainees takes time off or reduces their clinical duties for pregnancy or postpartum health needs. National parental leave policies are insufficient without complementary program-level strategies that support schedule adjustments for pregnant trainees without engendering a sense of resentment or guilt for doing so. Surgical program leaders should initiate open dialogue, proactively offer clinical duty reductions, and ensure time and space for lactation needs to safeguard maternal-fetal health and improve the working environment for pregnant residents.

Postpartum Depression in Surgeons and Workplace Support for Obstetric and Neonatal Complication: Results of a National Study of US Surgeons.

BACKGROUND: Postpartum depression has well-established long-term adverse effects on maternal and infant health. Surgeons with rigorous operative schedules are at higher risk of obstetric complications, but they rarely reduce their workload during pregnancy. We evaluated whether lack of workplace support for work reductions during difficult pregnancies or after neonatal complications is associated with surgeon postpartum depression. STUDY DESIGN: An electronic survey was sent to practicing and resident surgeons of both sexes in the US. Female surgeons who had at least one live birth were included. Lack of workplace support was defined as: (1) disagreeing that colleagues/leadership were supportive of obstetric-mandated bedrest or time off to care for an infant in the neonatal intensive care unit; (2) feeling unable to reduce clinical duties during pregnancy despite health concerns or to care for an infant in the neonatal intensive care unit. Multivariate logistic regression was used to determine the association of lack of workplace support with postpartum depression. RESULTS: Six hundred ninety-two surgeons were included. The 441 (63.7%) respondents who perceived a lack of workplace support had a higher risk of postpartum depression than those who did not perceive a lack of workplace support (odds ratio 2.21, 95% CI 1.09 to 4.46), controlling for age, race, career stage, and pregnancy/neonatal complications. Of the surgeons with obstetric-related work restrictions, 22.6% experienced loss of income and 38.5% reported >$50,000 loss. CONCLUSION: Lack of workplace support for surgeons with obstetric or neonatal health concerns is associated with a higher risk of postpartum depression. Institutional policies must address the needs of surgeons facing difficult pregnancies to improve mental health outcomes and promote career longevity.

Lack of Workplace Support for Obstetric Health Concerns is Associated With Major Pregnancy Complications: A National Study of US Female Surgeons.

OBJECTIVE: We sought to assess whether lack of workplace support for clinical work reductions during pregnancy was associated with major pregnancy complications. BACKGROUND: Surgeons are at high risk of major pregnancy complications. Although rigorous operative schedules pose increased risk, few reduce their clinical duties during pregnancy. METHODS: An electronic survey was distributed to US surgeons who had at least 1 live birth. Lack of workplace support was defined as: (1) desiring but feeling unable to reduce clinical duties during pregnancy due to failure of the workplace/training program to accommodate and/or concerns about financial penalties, burden on colleagues, requirement to make up missed call, being perceived as weak; (2) disagreeing colleagues and/or leadership were supportive of obstetrician-prescribed bedrest. Multivariate logistic regression determined the association between lack of workplace support and major pregnancy complications. RESULTS: Of 671 surgeons, 437 (65.13%) reported lack of workplace support during pregnancy and 302 (45.01%) experienced major pregnancy complications. Surgeons without workplace support were at higher risk of major pregnancy complications than those who had workplace support (odds ratio: 2.44; 95% confidence interval: 1.58-3.75). Bedrest was prescribed to 110/671 (16.39%) surgeons, 38 (34.55%) of whom disagreed that colleagues and/or leadership were supportive. Of the remaining surgeons, 417/560 (74.5%) desired work reductions but were deterred by lack of workplace support. CONCLUSIONS: Lack of workplace support for reduction in clinical duties is associated with adverse obstetric outcomes for surgeons. This is a modifiable workplace obstacle that deters surgeons from acting to optimize their infant's and their own health. To ensure the health of expectant surgeons, departmental policies should support reduction of clinical workload in an equitable manner without creating financial penalties, requiring payback for missed call duties, or overburdening colleagues.

Paternity Leave During Surgical Training: Perspectives of Male Residents.

OBJECTIVE: Recent literature on parental leave during residency has focused on the importance of supporting new mothers, but the needs and challenges faced by expectant nonchildbearing residents are less well described. Male residents are more likely than their female counterparts to have children during surgical training, and they experience similar stressors including childcare and conflicts between work and home priorities. As nonchildbearing parents of this generation become more involved in childrearing, the need to establish inclusive parental leave policies is essential. The aim of this study was to provide a deeper understanding of the perspectives of male residents about parental leave. DESIGN: A semi-structured interview guide was developed using a literature search and an expert panel. Interviews were audio-recorded and transcribed verbatim and emergent themes were identified using content analysis. SETTING: Four academic institutions. PARTICIPANTS: Four focus groups were held with of a total of 15 male resident-parents. These were selected using convenience sampling. RESULTS: Multiple themes emerged: 1) male residents perceive greater stigma attached to taking leave compared to female colleagues; 2) paternity leave policies are vague and sometimes non-existent; 3) male residents experience a high burden of guilt related to burdening peers with clinical coverage while on leave; 4) male residents face internal conflict between surgical and parental responsibilities; 5) male residents have little mentorship on successful work-life integration and feel compelled to model the behavior of their attendings who often prioritize career before family; and 6) shifts in family values and priorities are common following childbirth and impact how male resident-parents view other new parents in training. CONCLUSIONS: Significant challenges exist for residents who become fathers during their surgical training. Key stressors include poorly defined leave policies, historic paradigms of prioritizing professional duties before personal duties, stigma against taking time off for parental bonding in the absence of medical need, and guilt related to extra work imposed on colleagues by time away. Establishment of formal parental leave policies for both genders, programmatic support to offset the increased workload on colleagues, and greater mentorship on balancing family and career are needed to foster a culture of work-life integration.

Disparities in uptake of cholecystectomy for idiopathic pancreatitis: A nationwide retrospective cohort study.

BACKGROUND: The majority of cases of idiopathic acute pancreatitis (IAP) are thought to result from occult biliary disease. A growing body of evidence suggests that cholecystectomy for IAP reduces the risk of recurrence by up to two thirds. This study examined nationwide uptake and disparities in adoption of cholecystectomy for IAP. METHODS: The National Inpatient Sample was queried to identify admissions for IAP between October 2015 and December 2018. Patients who underwent cholecystectomy before discharge and those that did not were compared using Wald χ2 tests for categorical variables and Student's t test for continuous variables. Patient- and hospital-level predictors of cholecystectomy were identified using weighted multivariable logistic regression. RESULTS: Of 62,305 estimated admissions for IAP, only 665 (1.1%) underwent cholecystectomy before discharge. Female sex, initiation of total parenteral nutrition (TPN), insurance status, and hospital type were associated with cholecystectomy on univariable analysis. On multivariable analysis, Hispanic patients (odds ration [OR] 1.60, 95% confidence interval [CI] 1.01-2.56), patients on TPN (OR 2.70, 95% CI 1.17-6.24), and those with private insurance (OR 2.18, 95% CI 1.48-3.21 versus Medicare/Medicaid) were more likely to receive operations. Small hospitals and hospitals in rural areas were least likely to perform empiric cholecystectomies. CONCLUSION: Despite increasing evidence supporting cholecystectomy after IAP, the practice remains rare in the United States. Educational efforts and active implementation efforts are needed to promote adoption. Particular attention should be focused on small, rural centers and those that disproportionately care for uninsured patients and patients with public insurance.

Sarcopenia Is Associated With Increased Mortality in Patients With Necrotizing Soft Tissue Infections.

INTRODUCTION: Necrotizing soft tissue infections (NSTIs) are surgical emergencies associated with high morbidity and mortality. Identifying risk factors for poor outcome is a critical part of preoperative decision-making and counseling. Sarcopenia, the loss of lean muscle mass, has been associated with an increased risk of mortality and can be measured using cross-sectional imaging. Our aim was to determine the impact of sarcopenia on mortality in patients with NSTI. We hypothesized that sarcopenia would be associated with an increased risk of mortality in patients with NSTI. METHODS: This is a retrospective cohort study of NSTI patients admitted from 1995 to 2015 to two academic institutions. Operative and pathology reports were reviewed to confirm the diagnosis in all cases. Average bilateral psoas muscle cross-sectional area at L4, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography (CT). Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was in-hospital mortality. Multivariate logistic regression was performed to assess the association between sarcopenia and in-hospital mortality. RESULTS: There were 115 patients with preoperative imaging, 61% male and a median age of 57 y interquartile range (IQR 46.6-67.0). Overall in-hospital mortality was 12.1%. There was no significant difference in sex, body mass index (BMI), comorbidities and American Society of Anesthesiologists classification (Table 1). After multivariate analysis, sarcopenia was independently associated with increased in-hospital mortality (Odds ratio, 3.5; 95% Confidence Interval [CI], 1.05-11.8). CONCLUSIONS: Sarcopenia is associated with increased risk of in-hospital mortality in patients with NSTIs. Sarcopenia identifies patients with higher likelihood of poor outcomes, which can possibly help surgeons in counseling their patients and families.

The Surgeon's Perceived Value of Patient-reported Outcome Measures (PROMs): An Exploratory Qualitative Study of 5 Different Surgical Subspecialties.

OBJECTIVE: To understand the surgeon's perceived value of PROMs in 5 different surgical subspecialties. SUMMARY OF BACKGROUND DATA: PROMs are validated questionnaires that assess the symptoms, function, and quality of life from the patient's perspective. Despite the increasing support for use of PROMs in the literature, there is limited uptake amongst surgeons. Furthermore, there is insufficient understanding of the surgeons' perceived value of PROMs. The aim of this study is to understand how surgeons perceive value in PROMs. METHODS: We conducted an exploratory qualitative study to understand the perceived value of PROMs from the perspective of surgeons in various subspecialties. Per convenience sampling, we conducted semi-structured interviews with 30 surgeons from 5 subspecialties across 3 academic medical centers. The surgical subspecialties included bariatric surgery, breast oncologic surgery, orthopedic surgery, plastic and reconstructive surgery, and rhinology. Interviews were transcribed, coded, and evaluated with thematic analysis. RESULTS: Surgeons endorsed that PROMs can be used to enhance clinical management, counsel patients in the preoperative and postoperative settings, and elicit sensitive information from patients that otherwise may go undetected. Obstacles to PROMs use include failure to generate actionable data, implementation obstacles, and inappropriate use of PROMs as a performance metric, with concerns regarding inadequate risk adjustment. CONCLUSIONS: Establishing an effective PROMs program requires an understanding of the surgeon's perspective of PROMs. Despite obstacles, different subspecialty surgeons find PROMs to be valuable in different settings, depending on the specialty and clinical context.

Adult survivors of moderate and great complexity congenital heart disease undergoing general surgery procedures: How do they fare?

BACKGROUND: Patients with complex congenital heart disease (CHD) are now commonly surviving well into adulthood. We describe the clinical characteristics and outcomes for a cohort of adult patients with moderate and great complexity CHD undergoing general surgery procedures. METHODS: The electronic records of two tertiary centers were queried to identify adult patients with moderate and great complexity CHD who underwent a general surgery procedure between 2007 and 2017. RESULTS: 118 adult patients were included in the analysis. The mean age was 36 ± 17 years and 49.2% were male. The most common cardiac diagnoses were pulmonary valve anomaly (24.6%), tetralogy of Fallot (18.6%), coarctation of the aorta (15.3%) and common/single ventricle (10.2%). The most common general surgery procedures performed were cholecystectomy (23.7%), herniorrhaphy (23.7%) and colorectal resection (9.3%). In-hospital mortality and morbidity were 2.5% and 11.9%, respectively. CONCLUSION: Adults survivors of moderate and great complexity CHD undergoing common general surgery procedures in this study experienced excellent in-hospital outcomes.