Racial and Health Insurance Differences in Patient Outcomes After Surgical Treatment for Cauda Equina Syndrome: A United States Retrospective Hospital Claims Database Analysis.

STUDY DESIGN: Retrospective database evaluation. OBJECTIVES: To study the association between race, health care insurance, mortality, postoperative visits, and reoperation within a hospital setting in patients with cauda equina syndrome (CES) undergoing surgical intervention. SUMMARY OF BACKGROUND DATA: CES can lead to permanent neurological deficits if the diagnosis is missed or delayed. Evidence of racial or insurance disparities in CES is sparse. MATERIALS AND METHODS: Patients with CES undergoing surgery from 2000 to 2021 were identified from the Premier Health care Database. Six-month postoperative visits and 12-month reoperations within the hospital were compared by race ( i.e ., White, Black, or Other [Asian, Hispanic, or other]) and insurance ( i.e. , Commercial, Medicaid, Medicare, or Other) using Cox proportional hazard regressions; covariates were used in the regression models to control for confounding. Likelihood ratio tests were used to compare model fit. RESULTS: Among 25,024 patients, most were White (76.3%), followed by Other race (15.4% [ 8.8% Asian, 7.3% Hispanic, and 83.9% other]) and Black (8.3%). Models with race and insurance combined provided the best fit for estimating the risk of visits to any setting of care and reoperations. White Medicaid patients had the strongest association with a higher risk of 6-month visits to any setting of care versus White patients with commercial insurance (HR: 1.36 (1.26,1.47)). Being Black with Medicare had a strong association with a higher risk of 12-month reoperations versus White commercial patients (HR: 1.43 (1.10,1.85)). Having Medicaid versus Commercial insurance was strongly associated with a higher risk of complication-related (HR: 1.36 (1.21, 1.52)) and ER visits (HR: 2.26 (2.02,2.51)). Medicaid had a significantly higher risk of mortality compared with Commercial patients (HR: 3.19 (1.41,7.20)). CONCLUSIONS: Visits to any setting of care, complication-related, ER visits, reoperation, or mortality within the hospital setting after CES surgical treatment varied by race and insurance. Insurance type had a stronger association with the outcomes than race. LEVEL OF EVIDENCE: Level-III.

Early revision events among patients with a three dimensional (3D) printed cellular titanium or PEEK (polyetheretherketone) spinal cage for single-level lumbar spinal fusion.

INTRODUCTION: Three-dimensional (3D) printed spinal cages are a new design of intervertebral body fusion devices. Clinical data on these devices are limited. The objective of this study was to describe six-month events for a new and older cage design. METHODS: A retrospective, descriptive cohort study of patients that received a 3D-printed-titanium or PEEK (polyetheretherketone) cage with single-level lumbar fusion was performed using a United States hospital-based database. Outcomes evaluated were device-related revision and non-device related reoperation events 6 months after lumbar fusion. The 3D-printed-titanium and PEEK groups were propensity-score matched. Both unmatched and matched groups were descriptively analyzed. There were 93 and 2,082 patients with a 3D-printed-titanium and PEEK cage that met study criteria. The sample size was 93 patients per group after matching. RESULTS: There were no occurrences of revisions in the 3D-printed-titanium and eleven occurrences in the PEEK group before matching; PEEK had no occurrences of revision after matching. Ten total reoperation events were identified. DISCUSSION: Our findings suggest occurrence of 6-month revision or reoperation is similar or lower for both cages than reported in published literature. The low occurrence of early events for 3D-printed-titianium cages is promising. Further, real-world studies on 3D-printed cages are warranted.

Evaluation of Cost, Payments, Healthcare Utilization, and Perioperative and Post-Operative Outcomes of Patients Treated with Posterior Lumbar Spinal Surgery Using Open versus Minimally Invasive Surgical Approaches.

PURPOSE: Minimally invasive surgery (MIS) of the spine has been associated with favorable outcomes compared to open surgery. This study evaluated matched cohorts treated with MIS versus open posterior lumbar fusion for costs, payments, healthcare utilization and outcomes. PATIENTS AND METHODS: This study used the Premier Healthcare and IBM® MarketScan® Commercial and Medicare Databases. Patients with posterior lumbar fusion from 2015 to 2018 were identified and categorized as "Open" or "MIS". Cohorts were matched on patient and provider characteristics. Perioperative complications, hospital costs, healthcare utilization and post-operative outcomes and payments to providers were analyzed. Statistical significance was evaluated using T-tests and chi-square tests. RESULTS: After matching, 2,388 Open and 796 MIS from PHD, and 415 Open and 83 MIS from MarketScan were included. Statistically significant differences between MIS versus Open were found for index hospital costs, $29,181 (SD: $14,363) versus $27,616 (SD: $13,822), p=0.01; length of stay, 2.94 (SD: 2.10) versus 3.15 (SD: 2.03) days, p=0.01; perioperative urinary tract infection, 1.01% and 2.09% (p=0.05); and 30-day risk of hematoma/hemorrhage, 19.28% versus 8.43%, p=0.02. There were observed, but statistically non-significant differences in additional perioperative or post-operative complications, home discharge, 90-day all-cause and spine-related readmission, and 90-day post-operative payments. CONCLUSION: Compared to Open, patients that underwent MIS had statistically significant lower length of stay, lower perioperative UTI, greater hospital costs, and higher 30-day risk of hematoma/hemorrhage. The differences observed in post-operative complications and payments and readmissions warrant further investigation in larger matched cohorts.

Surgeons' Leadership Styles and Team Behavior in the Operating Room.

BACKGROUND: The importance of leadership is recognized in surgery, but the specific impact of leadership style on team behavior is not well understood. In other industries, leadership is a well-characterized construct. One dominant theory proposes that transactional (task-focused) leaders achieve minimum standards and transformational (team-oriented) leaders inspire performance beyond expectations. STUDY DESIGN: We videorecorded 5 surgeons performing complex operations. Each surgeon was scored on the Multifactor Leadership Questionnaire, a validated method for scoring transformational and transactional leadership style, by an organizational psychologist and a surgeon researcher. Independent coders assessed surgeons' leadership behaviors according to the Surgical Leadership Inventory and team behaviors (information sharing, cooperative, and voice behaviors). All coders were blinded. Leadership style (Multifactor Leadership Questionnaire) was correlated with surgeon behavior (Surgical Leadership Inventory) and team behavior using Poisson regression, controlling for time and the total number of behaviors, respectively. RESULTS: All surgeons scored similarly on transactional leadership (range 2.38 to 2.69), but varied more widely on transformational leadership (range 1.98 to 3.60). Each 1-point increase in transformational score corresponded to 3 times more information-sharing behaviors (p < 0.0001) and 5.4 times more voice behaviors (p = 0.0005) among the team. With each 1-point increase in transformational score, leaders displayed 10 times more supportive behaviors (p < 0.0001) and displayed poor behaviors 12.5 times less frequently (p < 0.0001). Excerpts of representative dialogue are included for illustration. CONCLUSIONS: We provide a framework for evaluating surgeons' leadership and its impact on team performance in the operating room. As in other fields, our data suggest that transformational leadership is associated with improved team behavior. Surgeon leadership development, therefore, has the potential to improve the efficiency and safety of operative care.

Reliability of height and weight measurements collected by physical education teachers for a school-based body mass index surveillance and screening system.

BACKGROUND: To address the obesity epidemic among children and youth, school-based body mass index (BMI) screening and surveillance is proposed or mandated in 30 states. In Cambridge, MA, physical education (PE) teachers are responsible for these measurements. This research reports the reliability of height and weight measures collected by these PE teachers. METHODS: Using Bland-Altman plots, mean absolute differences, and intraclass correlation coefficients (ICC), we estimated intra- and inter-rater reliability among PE teachers in a controlled setting and PE teacher-vs-expert inter-rater reliability in a natural classroom setting. We also qualitatively assessed barriers to reliability. RESULTS: For the controlled setting, of 150 measurements, 3 height (2.0%) and 2 weight (1.33%) measurement outliers were detected; intra-rater mean absolute differences for height/weight were 0.52 inches (SD 1.61) and 0.8 lbs (SD 3.2); intra- and inter-rater height/weight ICCs were ≥0.96. For the natural setting, of 105 measurements, 1 weight measurement outlier (0.9%) was detected; PE teacher-vs-expert-rater mean absolute differences for height/weight were 0.22 inches (SD 0.21) and 0.7 lbs (SD 0.8), and ICCs were both 0.99. Equipment deficiencies, data recording issues, and lack of students' preparation were identified as challenges to collecting reliable measurements. CONCLUSION: According to ICC criteria, reliability of PE teachers' measurements was "excellent." However, the criteria for mean absolute differences were not consistently met. Results highlight the importance of staff training and data cleaning.

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

OBJECTIVE: To understand the etiology and resolution of unanticipated events in the operating room (OR). BACKGROUND: The majority of surgical adverse events occur intraoperatively. The OR represents a complex, high-risk system. The influence of different human, team, and organizational/environmental factors on safety and performance is unknown. METHODS: We video-recorded and transcribed 10 high-acuity operations, representing 43.7 hours of patient care. Deviations, defined as delays and/or episodes of decreased patient safety, were identified by majority consensus of a multidisciplinary team. Factors that contributed to each event and/or mitigated its impact were determined and attributed to the patient, providers, or environment/organization. RESULTS: Thirty-three deviations (10 delays, 17 safety compromises, 6 both) occurred--with a mean of 1 every 79.4 minutes. These deviations were multifactorial (mean 3.1 factors). Problems with communication and organizational structure appeared repeatedly at the root of both types of deviations. Delays tended to be resolved with vigilance, communication, coordination, and cooperation, while mediation of safety compromises was most frequently accomplished with vigilance, leadership, communication, and/or coordination. The organization/environment was not found to play a direct role in compensation. CONCLUSIONS: Unanticipated events are common in the OR. Deviations result from poor organizational/environmental design and suboptimal team dynamics, with caregivers compensating to avoid patient harm. Although recognized in other high-risk domains, such human resilience has not yet been described in surgery and has major implications for the design of safety interventions.

Deconstructing intraoperative communication failures.

BACKGROUND: Communication failure is a common contributor to adverse events. We sought to characterize communication failures during complex operations. METHODS: We video recorded and transcribed six complex operations, representing 22 h of patient care. For each communication event, we determined the participants and the content discussed. Failures were classified into four types: audience (key individuals missing), purpose (issue nonresolution), content (insufficient/inaccurate information), and/or occasion (futile timing). We added a systems category to reflect communication occurring at the organizational level. The impact of each identified failure was described. RESULTS: We observed communication failures in every case (mean 29, median 28, range 13-48), at a rate of one every 8 min. Cross-disciplinary exchanges resulted in failure nearly twice as often as intradisciplinary ones. Discussions about or mandated by hospital policy (20%), personnel (18%), or other patient care (17%) were most error prone. Audience and purpose each accounted for >40% of failures. A substantial proportion (26%) reflected flawed systems for communication, particularly those for disseminating policy (29% of system failures), coordinating personnel (27%), and conveying the procedure planned (27%) or the equipment needed (24%). In 81% of failures, inefficiency (extraneous discussion and/or work) resulted. Resource waste (19%) and work-arounds (13%) also were frequently seen. CONCLUSIONS: During complex operations, communication failures occur frequently and lead to inefficiency. Prevention may be achieved by improving synchronous, cross-disciplinary communication. The rate of failure during discussions about/mandated by policy highlights the need for carefully designed standardized interventions. System-level support for asynchronous perioperative communication may streamline operating room coordination and preparation efforts.

The role of National Cancer Institute-designated cancer center status: observed variation in surgical care depends on the level of evidence.

OBJECTIVE: We sought to evaluate differences in guideline concordance between National Cancer Institute (NCI)-designated and other centers and determine whether the level of available evidence influences the degree of variation in concordance. BACKGROUND: The National Cancer Institute recognizes centers of excellence in the advancement of cancer care. These NCI-designated cancer centers have been shown to have better outcomes for cancer surgery; however, little work has compared surgical process measures. METHODS: A retrospective cohort study was conducted using Surveillance, Epidemiology and End Results registry linked to Medicare claims data. Fee-for-service Medicare patients with a definitive surgical resection for breast, colon, gastric, rectal, or thyroid cancers diagnosed between 2000 and 2005 were identified. Claims data from 1999 to 2006 were used. Our main outcome measure was guideline concordance at NCI-designated centers compared to other institutions, stratified by level of evidence as graded by National Comprehensive Cancer Network guideline panels. RESULTS: All centers achieved at least 90%, and often 95%, concordance with guidelines based on level 1 evidence. Concordance rates for guidelines with lower-level evidence ranged from 30% to 97% and were higher at NCI-designated centers. The adjusted concordance ratios for category 1 guidelines were between 1.02 and 1.08, whereas concordance ratios for guidelines with lower-level evidence ranged from 0.97 to 2.19, primarily favoring NCI-designated centers. CONCLUSIONS: When strong evidence supports a guideline, there is little variation in practice between NCI-designated centers and other hospitals, suggesting that all are providing appropriate care. Variation in care may exist, however, for guidelines that are based on expert consensus rather than strong evidence. This suggests that future efforts to generate needed evidence on the optimal approach to care may also reduce institutional variation.

A model of knowledge acquisition in early stage breast cancer patients.

To meaningfully participate in the decision-making regarding a newly diagnosed breast cancer, a patient must acquire new knowledge. We describe a model of knowledge acquisition that can provide a framework for exploring the process and types of knowledge that breast cancer patients gain following their diagnosis. The four types of knowledge presented in this model-authoritative, technical, embodied, and traditional-are described and potential sources discussed. An understanding of knowledge acquisition in early stage breast cancer patients can provide healthcare practitioners with an important framework for optimizing decision-making in this population.

War stories: a qualitative analysis of narrative teaching strategies in the operating room.

BACKGROUND: "War stories" are commonplace in surgical education, yet little is known about their purpose, construct, or use in the education of trainees. METHODS: Ten complex operations were videotaped and audiotaped. Narrative stories were analyzed using grounded theory to identify emergent themes in both the types of stories being told and the teaching objectives they illustrated. RESULTS: Twenty-four stories were identified in 9 of the 10 cases (mean, 2.4/case). They were brief (mean, 58 seconds), illustrative of multiple teaching points (mean, 1.5/story), and appeared throughout the operations. Anchored in personal experience, these stories taught both clinical (eg, operative technique, decision making, error identification) and programmatic (eg, resource management, professionalism) topics. CONCLUSIONS: Narrative stories are used frequently and intuitively by physicians to emphasize a variety of intraoperative teaching points. They socialize trainees in the culture of surgery and may represent an underrecognized approach to teaching the core competencies. More understanding is needed to maximize their potential.

Postgame analysis: using video-based coaching for continuous professional development.

BACKGROUND: The surgical learning curve persists for years after training, yet existing continuing medical education activities targeting this are limited. We describe a pilot study of a scalable video-based intervention, providing individualized feedback on intraoperative performance. STUDY DESIGN: Four complex operations performed by surgeons of varying experience--a chief resident accompanied by the operating senior surgeon, a surgeon with less than 10 years in practice, another with 20 to 30 years in practice, and a surgeon with more than 30 years of experience--were video recorded. Video playback formed the basis of 1-hour coaching sessions with a peer-judged surgical expert. These sessions were audio recorded, transcribed, and thematically coded. RESULTS: The sessions focused on operative technique--both technical aspects and decision-making. With increasing seniority, more discussion was devoted to the optimization of teaching and facilitation of the resident's technical performance. Coaching sessions with senior surgeons were peer-to-peer interactions, with each discussing his preferred approach. The coach alternated between directing the session (asking probing questions) and responding to specific questions brought by the surgeons, depending on learning style. At all experience levels, video review proved valuable in identifying episodes of failure to progress and troubleshooting alternative approaches. All agreed this tool is a powerful one. Inclusion of trainees seems most appropriate when coaching senior surgeons; it may restrict the dialogue of more junior attendings. CONCLUSIONS: Video-based coaching is an educational modality that targets intraoperative judgment, technique, and teaching. Surgeons of all levels found it highly instructive. This may provide a practical, much needed approach for continuous professional development.

Impact of neoadjuvant chemotherapy on breast reconstruction.

BACKGROUND: With advances in oncologic treatment, cosmesis after mastectomy has assumed a pivotal role in patient and provider decision making. Multiple studies have confirmed the safety of both chemotherapy before breast surgery and immediate reconstruction. Little has been written about the effect of neoadjuvant chemotherapy on decisions about reconstruction. METHODS: The authors identified 665 patients with stage I through III breast cancer who received chemotherapy and underwent mastectomy at Dana-Farber/Brigham & Women's Cancer Center from 1997 to 2007. By using multivariate logistic regression, reconstruction rates were compared between patients who received neoadjuvant chemotherapy (n = 180) and patients who underwent mastectomy before chemotherapy (n = 485). The rate of postoperative complications after mastectomy was determined for patients who received neoadjuvant chemotherapy compared with those who did not. RESULTS: Reconstruction was performed immediately in 44% of patients who did not receive neoadjuvant chemotherapy but in only 23% of those who did. Twenty-one percent of neoadjuvant chemotherapy recipients and 14% of adjuvant-only chemotherapy recipients underwent delayed reconstruction. After controlling for age, receipt of radiotherapy, and disease stage, neoadjuvant recipients were less likely to undergo immediate reconstruction (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.37, 0.87) but were no more likely to undergo delayed reconstruction (OR, 1.29; 95% CI, 0.75, 2.20). Surgical complications occurred in 30% of neoadjuvant chemotherapy recipients and in 31% of adjuvant chemotherapy recipients. CONCLUSIONS: The current results suggest that patients who receive neoadjuvant chemotherapy are less likely to undergo immediate reconstruction and are no more likely to undergo delayed reconstruction than patients who undergo surgery before they receive chemotherapy.