Incentives and individualized coaching improves completion rates of supervised exercise therapy for claudication.

OBJECTIVE: Supervised exercise therapy (SET) provides clinical benefit for patients suffering from intermittent claudication and has been widely recommended as first-line therapy before endovascular or surgical intervention. However, published rates of SET program completion range from 5% to 55%, with historic completion of 54% at our own institution. As such, we sought to identify if targeted patient-supportive interventions improve SET completion rates while still maintaining efficacious SET programming. METHODS: Patients who were diagnosed with intermittent claudication, as defined by ankle-brachial index (ABI) <0.9 without rest pain, were offered enrollment in a prospective quality improvement protocol for our 12-week SET for peripheral artery disease program. Program completion was defined as ≥24 of 36 offered sessions over 12 weeks. A three-pronged approach was utilized to improve completion during the study, including financial incentives up to $180, scheduled coaching with our advanced practitioner staff, and informational materials on the importance of SET programming and lifestyle modification. Patient-reported improvements in walking symptoms were tracked via regularly administered questionnaires. Functional measures of SET programming including total walking duration and distance, metabolic equivalent of task, and ABIs; vascular intervention within 12-months after enrollment was also collected and compared using univariate paired analysis. RESULTS: In total, seventy-three patients were enrolled in SET for peripheral artery disease programming over the study period. Utilizing our three-pronged coaching approach, 56 patients completed SET programming, increasing our SET completion rate to 76.7% over a 2-year study period. Compared with pre-SET baseline, patients who completed SET noted less pain, aching, cramps in calves when walking (P = .004), and less difficulty walking 1 block (P = .038). Additionally, patients significantly increased their metabolic equivalent of task (3.1 vs 2.6; P < .001), total walking duration (30 mins vs 13.5 mins; P < .001), and total walking distance (0.7 vs 0.3 miles; P < .001) from their pre-SET baseline. There were no changes in participant ABIs from enrollment to completion in participants. Patients who completed SET programming also delayed vascular intervention compared with those who did not complete SET or declined participation (213.5 vs 122.5 days from enrollment; P = .041). CONCLUSIONS: Targeted incentives, including cost-coverage vouchers and personalized coaching with instructional materials, successfully improved patient completion of a prescribed SET program. Patients who completed SET programming reported subjective improvement in walking symptoms and objective walking benefits. In addition, these patients had delayed time to vascular intervention, supporting current vascular guidelines advocating for effective SET therapy prior to offering vascular intervention for intermittent claudication.

Patient Reported Barriers for Participation in Supervised Exercise Therapy for Symptomatic Peripheral Artery Disease.

BACKGROUND: Supervised exercise therapy (SET) provides clinical benefit for patients suffering from intermittent claudication due to peripheral artery disease (PAD). However, enrollment in programs when offered remains low. We sought to identify patient-reported barriers to enrollment in SET as part of a prospective quality improvement program. METHODS: Patients who presented to clinic and were diagnosed with claudication were offered enrollment in a prospective quality improvement protocol, offered at 9 regional offices throughout our health system. Both patients who enrolled and declined enrollment were offered a 12-question questionnaire to identify potential barriers to enrollment. Additional data including gender, smoking status, ankle-brachial index (ABI), proximity to the nearest regional office, and disadvantage levels of neighborhoods (low: 1-3, medium: 4-7, and high: 8-10 area deprivation index [ADI]) was collected and compared by program participation using univariate analysis. RESULTS: Patients enrolled in the SET program (n = 66 patients) versus those who declined (n = 84 patients) were of similar age (medium age: 71.4 vs. 69.7 years, P = 0.694), baseline ABI (0.6 vs. 0.6, P = 0.944), smoking status (former 56.1% vs. 53.6%, P = 0.668), distance away from outpatient center (8.2 mi vs. 8.4 mi, P = 0.249), and had similar Connecticut state ADIs (2021 high-disadvantage: 35.4% vs. 33.3%, P = 0.549). Patients participating in the SET program were more likely to be male (78.8% vs. 56.0%, P = 0.003). Top self-reported barriers for patients who declined participation included transportation/distance (39.3%), preference for independent walking (56.0%), inability to commit to 3 sessions per week (52.4%), and lack of interest (20.2%). In addition, a higher proportion of patients who declined participation identified severe barriers of preference for independent walking (39.3% vs. 1.5%, P < 0.001), inability to commit to 3 sessions per week (26.2% vs. 3.0% P < 0.001), transportation/distance issues (23.8% vs. 7.6% P = 0.008), and cost (27.4% vs. 9.1%, P = 0.005) as significant barriers for participation in SET. CONCLUSIONS: Patients who declined participation in SET for PAD had similar disease status and access to care than participating counterparts. Top reported barriers to enrollment include a preference for independent walking, transportation/distance, commitment to 3x/week program, and cost, which highlight areas of focus for equitable access to these limb-saving services.

Rectus Sheath Block Improves Patient Recovery Following Open Aortic Surgery.

BACKGROUND: Postoperative pain management remains a barrier to recovery following aortic surgery. Although epidural catheters help in adjunctive pain management, less is known about the use of rectus sheath blocks. We compared patient recovery following open abdominal aortic surgery (OAS) with and without adjunctive rectus block. METHODS: Adult patients undergoing open abdominal aortic aneurysm repair and aortobifemoral or aortoiliac bypass for occlusive disease were identified and stratified by use of general anesthesia alone (GA) versus adjunctive use of a rectus sheath block (GA + RB). A small number of patients with GA and concomitant epidural analgesia, along with patients that had retroperitoneal repairs, were not included in further analysis. Outcomes included time to extubation, intraoperative and postoperative morphine milligram equivalents (MME) utilization, length of stay, discharge MME, and postoperative complications. Categorial data were compared with Person Chi-Square tests or Fisher's exact tests. Continuous data were tested with independent t-tests or Mann-Whitney U-tests. RESULTS: From January 2017 to April 2022, there were 106 patients who underwent open aortic surgery, 55 patients with GA alone, 39 with GA + RB, and 12 patients who had a GA with concomitant epidural analgesia. Between GA and GA + RB, patients were comparable in both groups in terms of age, BMI (body mass index), smoking history, hypertension, diabetes, CAD (coronary artery disease), COPD (chronic obstructive pulmonary disease), and ASA (American Society of Anesthesiologists) class and prior opioid use. Patients with GA + RB were more likely to have scheduled elective procedures (80% GA cohort vs. 94.9% RB, P = 0.040), and a lower incidence of retroperitoneal exposure (14.5% GA cohort vs. 0% RB, P = 0.019). Patients with GA + RB had shorter time to extubation than GA (84.6% < 12 hr vs. 44.4%, P < 0.001), greater rate of procedural ketamine usage (GA + RB: 61.5% vs. GA: 40.0%, P = 0.049), lower MME at first postoperative day (median MME GA + RB: 25.0 vs. GA: 67.5, P = 0.002), lower discharge MME (median MME GA + RB: 142.5 vs. GA: 225.0, P = 0.036), and overall shorter length of stay (median stay GA + RB: 5 vs. GA: 6 days, P = 0.006). Postoperative complications were similar between groups. Similar findings were found in the comparison between elective-only GA and GA + RB patients and after exclusion of patients who only had a single shot of regional anesthesia. CONCLUSIONS: Patients that receive adjunctive rectus sheath blocks for pain control following OAS utilize fewer opioid medications during hospital stay and at discharge. Rectus sheath blocks represent an alternative option to other periprocedural analgesia following open aortic surgery.

Use of the right retroperitoneum as an alternative approach to the abdominal aorta.

OBJECTIVE: The left retroperitoneal approach to the aorta is a well-established technique for aortic exposure. The right retroperitoneal approach to the aorta is performed less commonly, and the outcomes remain unknown. This study aimed to evaluate the outcomes of right retroperitoneal aortic-based procedures and to determine its utility in aortic reconstruction when faced with hostile anatomy or infection in the abdomen or left flank. METHODS: A retrospective query of a vascular surgery database from a tertiary referral center was performed for all retroperitoneal aortic procedures. Individual patient charts were reviewed, and data were collected. Demographics, indications, intraoperative details, and outcomes were tabulated. RESULTS: From 1984 through 2020, there have been 7454 open aortic procedures; 6076 were retroperitoneal-based, and 219 of which were performed from the right retroperitoneal approach (Rrp). Aneurysmal disease was the most common indication (48.9%), and graft occlusion was the most common postoperative complication (11.4%). The average aneurysm size was 5.5 cm, and the most common reconstruction was with a bifurcated graft (77.6%). Average intraoperative blood loss was 923.8 mL (range, 50-6800 mL; median, 600 mL). Perioperative complications occurred in 56 patients (25.6%) for a total of 70 complications. Perioperative mortality occurred in two patients (0.91%). The 219 patients treated with Rrp required 66 subsequent procedures in 31 patients. These included 29 extra-anatomic bypasses, 19 thrombectomies/embolectomies, 10 bypass revisions, 5 infected graft excisions, and 3 aneurysm revisions. Eight Rrp eventually underwent a left retroperitoneal approach for aortic reconstruction. Fourteen patients with a left-sided aortic procedure required a Rrp. CONCLUSIONS: The right retroperitoneal approach to the aorta is a useful technique in the setting of prior surgery, anatomic abnormality, or infection that complicates the use of other more frequently employed approaches. This review demonstrates comparable outcomes and the technical feasibility of this approach. The right retroperitoneal approach to aortic surgery should be considered a viable alternative to left retroperitoneal and transperitoneal access in patients with complex anatomy or prohibitive pathology for more traditional exposure.

Female Sex is Associated with Worse Outcomes following Complex Fenestrated or Branched Endovascular Aortic Repair.

BACKGROUND: Sex-related discrepancies after standard endovascular aneurysm repair (EVAR) are noted to disproportionally affect females. A growing body of literature suggests similar disparities may extend to complex fenestrated or branched endovascular aneurysm repair (FBEVAR). However, recent examination of complex FBEVAR by a consortium of high-volume centers noted equivalent mortality among sexes. Whether similar results extend to non-trial data is unknown. METHODS: We examined all juxta-renal through type IV thoraco-abdominal aneurysms (sealing zones 6-8) which underwent elective FBEVAR within the Vascular Quality Initiative (VQI) database from January 2012 to December 2020. Urgent, symptomatic, ruptured, and staged cases were excluded, as were parallel stent grafts. Demographics, comorbid conditions, and technical factors were compared between sexes. Univariate analysis with Wilcoxon ranked sum tests and Chi-square tests of proportion were performed, followed by multivariate logistic regression for failure of target vessel technical success, reintervention, complications, and in-hospital mortality. RESULTS: Our analysis included 1,521 patients, 1,180 males (77.6%) and 341 females (22.4%). There were noted differences in pre-operative demographics, medical optimization, and technical aspects of the procedure. However, no difference was noted in proximal or distal sealing stents, number of fenestrations, or immediate endoleaks. On a multi variate logistic regression, female sex was an independent predictor of failure of target vessel technical success (odds ratio (OR) 3.339, 95% confidence interval (CI): 2.173-5.132, P < 0.001), reintervention (OR 2.192, 95% CI: 1.304-3.683, P = 0.003), complications (OR 1.747, 95% CI: 1.282-2.381, P < 0.001), and in-hospital mortality (OR 2.836, 95% CI: 1.510-5.328, P = 0.001). CONCLUSIONS: Females suffer worse outcomes after FBEVAR despite similar extent of disease, number of fenestrations, and incidence of immediate endoleak. Notable discrepancies were higher rates of chronic obstructive pulmonary disease (COPD) and lower rates of pre-operative aspirin, statin, and beta blocker therapy in females. Controlling for pre-operative demographics, female sex remained an independent predictor of worse outcomes. These discrepancies warrant further examination and should impact case planning for female patients undergoing complex aortic aneurysm repair.

Comparison of Social Media Utilization Among Vascular Surgeons, Interventional Cardiologists, and Interventional Radiologists at Academic Training Institutions.

BACKGROUND: Social media platforms, especially Twitter, are increasingly utilized across medical practice, education, and research. However, little is known about differences in social media use among physicians of varying specialties and its impact on recruitment of trainees. Our objective was to describe differences in social media use among vascular interventional proceduralists at academic training institutions. METHODS: We identified institutions with training programs in vascular surgery (VS), interventional radiology (IR), and interventional cardiology (IC). Faculty providers were identified in each specialty at these institutions. A standardized search was used to identify non-anonymous social media profiles on Facebook, Instagram, and Twitter in September 2019. Influencers were defined as physicians with more than 1,000 Twitter followers. Follow ratio was defined as the number of followers divided by the number of accounts followed. Between-specialty differences were analyzed. RESULTS: A total of 1,330 providers (n = 454 VS, n=451 IR, n = 425 IC) were identified across 47 institutions in 27 states. Across all physicians, a minority of providers utilize social media (Facebook: 24.9%, n = 331; Instagram: 10.8%, n = 143; Twitter: 18.0%, n = 240). VS were significantly more likely to use Instagram (P = 0.001) but there was not a significant difference in utilization of Facebook and Twitter. Among Twitter users, VS had fewer followers on average (median 178, inter-quartile range [IQR] 39-555) than IR (median 272, IQR 50-793, P = 0.26) and IC (median 286, IQR 71-1257, P = 0.052). IC were most likely to be influencers (30.9%, n = 25) followed by IR (17.9%, n = 15) and VS (10.7%, n = 8, P = 0.006). On average, interventional cardiologists had the highest follow ratio (mean 4.9 ± 7.1) compared to interventional radiologists (mean 3.2 ± 5.5) and vascular surgeons (mean 2.5 ± 3.3, P < 0.001). CONCLUSION: A minority of academic vascular interventional proceduralists utilize social media in a non-anonymous manner. On Twitter, interventional cardiologists are most likely to be influencers based on number of followers and, on average, have the highest follow ratio. Vascular surgeons could potentially benefit from pursuing greater influence and visibility on social media as a means to recruit trainees.

Society for Vascular Surgery best practice recommendations for use of social media.

The use of social media (SoMe) in medicine has demonstrated the ability to advance networking among clinicians and other healthcare staff, disseminate research, increase access to up-to-date information, and inform and engage medical trainees and the public at-large. With increasing SoMe use by vascular surgeons and other vascular specialists, it is important to uphold core tenets of our commitment to our patients by protecting their privacy, encouraging appropriate consent and use of any patient-related imagery, and disclosing relevant conflicts of interest. Additionally, we recognize the potential for negative interactions online regarding differing opinions on optimal treatment options for patients. The Society for Vascular Surgery (SVS) is committed to supporting appropriate and effective use of SoMe content that is honest, well-informed, and accurate. The Young Surgeons Committee of the SVS convened a diverse writing group of SVS members to help guide novice as well as veteran SoMe users on best practices for advancing medical knowledge-sharing in an online environment. These recommendations are presented here with the goal of elevating patient privacy and physician transparency, while also offering support and resources for infrequent SoMe users to increase their engagement with each other in new, virtual formats.

Intraoperative electroencephalographic changes during transcarotid artery revascularization are more frequent than previously reported.

OBJECTIVE: Up to 14% of patients undergoing carotid endarterectomy with continuous electroencephalographic (EEG) neuromonitoring will require shunt placement because of EEG changes. However, the initial studies of transcarotid artery revascularization (TCAR) found only one patient with temporary EEG changes. We report our experience with intraoperative EEG monitoring during TCAR. METHODS: We conducted a retrospective review of patients who underwent TCAR at two urban hospitals within an integrated healthcare network from May 2017 to January 2020. The data included demographic information, patient comorbidities, symptom status, previous carotid interventions, anatomic details, contralateral disease, intraoperative vital signs and EEG changes, and postoperative major adverse events (transient ischemic attack, stroke, myocardial infarction [MI], and death) both initially and at 30 days postoperatively. The Fisher exact test was used for categorical data and the Wilcoxon rank sum test for continuous data. RESULTS: A total of 89 patients underwent TCAR during the study period, of whom 71 (79.8%) received intraoperative EEG neuromonitoring. Of the 89 patients, 70.8% were men and 29.2% were women. The median age was 75 years (IQR, 68-82.5 years). Symptomatic patients accounted for 41.6% of the cohort. Of the 71 patients who received continuous neuromonitoring, 9 experienced EEG changes during TCAR (12.7%). The changes resolved in seven patients with pressure augmentation in three and switching to a low flow toggle in three. One patient who had sustained EEG changes had a new postoperative neurologic deficit. The median carotid stenosis percentage on preoperative computed tomography angiography was lower for patients with EEG changes than for those without (67% vs 80%; P = .01). No correlation was found between symptom status or 30-day stroke in patients with and without EEG changes (P = .49 and P = .24, respectively). Overall, three postoperative strokes, two postoperative deaths, and one MI occurred, for a composite 30-day stroke, death, and MI rate of 6.7%. CONCLUSIONS: Changes in continuous EEG monitoring were more frequent in our study than previously reported. Less severe carotid stenosis might be associated with a greater incidence of EEG changes. Limited data are available on the prognostic ability of EEG to detect clinically relevant changes during TCAR, and further studies are warranted.

Patient and institutional factors associated with postoperative opioid prescribing after common vascular procedures.

OBJECTIVE: Overprescription of postoperative opioid medication is a major contributor to the opioid abuse epidemic in the United States. Research into prescribing practices has suggested that patients be limited to 7 days or <200 morphine milligram equivalents (MME) after surgical procedures. Our aim was to identify patient or institutional factors associated with increased opioid prescriptions. METHODS: Opioid naive patients from an integrated health system undergoing one of nine surgical and endovascular procedures tracked within the Vascular Quality Initiative from 2015 to 2017 were identified and matched to their discharge and refill opioid prescriptions. Discharge opioid prescriptions were converted to MME. The primary outcome was discharge MME >200, and secondary outcomes were procedure-specific top-quartile opioid prescription and medication refills. Multivariable logistic regression was used to assess patient and perioperative factors associated with each outcome. RESULTS: Among 1546 opioid naive patients, 739 (48%) received a discharge opioid prescription; median MME was 0 (interquartile range, 0-150), and 349 (23%) had >200 MME. Among those with a discharge prescription, median MME was 180 (interquartile range, 150-300). MME varied by procedure (P < .001), with highest MME after suprainguinal bypass (median, 225) and infrainguinal bypass (200) and lowest MME after carotid artery stenting, carotid endarterectomy, and percutaneous peripheral vascular intervention (all medians of 0). On multivariable analysis, factors associated with MME >200 included younger patient age (<65 vs ≥ 80 years; odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.6; P < .001), treating institution B vs A (OR, 3.50; 95% CI, 2.42-5.07; P < .001) and C vs A (OR, 3.90; 95% CI, 2.66-5.74; P < .001), procedure-specific top-quartile length of stay (OR, 1.45; 95% CI, 1.01-2.08; P = .047), and prior tobacco use (OR, 1.60; 95% CI, 1.07-2.37; P = .02). The same variables along with current tobacco use and lack of preoperative aspirin were associated with procedure-specific top-quartile MME at discharge. Chronic beta-blocker use was protective of top-quartile MME. Based on the observed variability, an institutional standard for opioid prescribing has been developed for standardization. CONCLUSIONS: Opioid prescriptions at discharge vary with the invasiveness of vascular surgical procedures. Less than 25% of patients receive >200 MME. Variation by center represents a lack of standardization in prescribing practices and an opportunity for further improvement based on developed guidelines. Patient factors and procedure type can alert clinicians to patients at risk of higher than recommended MME.

Safety and outcomes of simultaneous vasospasm and endovascular aneurysm treatment (SVAT) in subarachnoid hemorrhage.

BACKGROUND: Simultaneous vasospasm and endovascular aneurysm treatment (SVAT) has been shown to be effective with good clinical outcomes in small series, but these studies have not examined predictive factors for clinical outcome after treatment. OBJECTIVE: To identify the safety and efficacy of SVAT in a large multicenter patient cohort and evaluate prognostic markers of clinical outcome following SVAT. METHODS: This study retrospectively enrolled 50 consecutive patients undergoing SVAT at 11 different centers. We analyzed Hunt and Hess and Fisher grades, aneurysm location, angiographic vasospasm grade, Glasgow Outcome Scale (GOS) at discharge, and 90-day modified Rankin Scale (mRS) scores. RESULTS: A total of 50 patients undergoing SVAT between the years 2003 and 2009 were identified. Patients presented, on average, 6.48±4.45 days after subarachnoid hemorrhage. Hunt and Hess and Fisher grades were 1 (n=7), 2 (n=12), 3 (n=14), 4 (n=15), 5 (n=2), and 3 and 4 (n=33), respectively. Aneurysm location was distributed as follows: anterior (n=32), posterior (n=16), anterior and posterior (n=2). Patients with good clinical condition (Hunt and Hess score 1-3) had significantly higher odds of surviving (OR=17.5, 95% CI 1.9 to 161.5), favorable GOS (OR=4.2, 95% CI 1.2 to 14.8), and favorable 90-day mRS (OR=4.2, 95% CI 1.2 to 14.8). CONCLUSIONS: SVAT is safe, with the majority of patients achieving good clinical outcome. Patients with lower Hunt and Hess grades have higher odds of surviving and favorable clinical prognosis.

The effect of residents as teaching assistants on operative time in laparoscopic cholecystectomy.

BACKGROUND: We examined the effect of primary surgeon (PS) and teaching assistant (TA) seniority on operative time and outcomes for residents performing laparoscopic cholecystectomy (LC). METHODS: This was a retrospective analysis of urgent LC at a county teaching hospital. Relevant data included postgraduate year (PGY) of the PS and TA and markers of disease severity. Primary outcome was operative time. Secondary outcomes were conversion to open cholecystectomy and complications. RESULTS: There were 1,202 LCs; 415 included an intraoperative cholangiogram. On multivariable analysis, every PGY increase of PS decreased operative time by 3.2 minutes (P = .02). For every PGY increase of TA, operative time decreased 10.8 minutes (P < .001). Acute or gangrenous pathology increased conversion to open surgery (P < .001). Seniority of PS and TA was not associated with increases in conversion or complication rates. CONCLUSIONS: Residents' operative time improves as experience with LC increases. These improvements become more profound after adjusting for the seniority of the TA.

General Anesthesia Is Not Necessary for Hemodialysis Access Surgery.

Chronic kidney disease has been identified as a risk factor for mortality after procedures under general anesthesia (GA). However, a recent study showed that 85 per cent of arteriovenous fistulas in the United States are performed under GA. Our aim was to demonstrate that GA can be avoided in patients with chronic kidney disease and end-stage renal disease by using local anesthesia (LA) with monitored anesthesia care or brachial plexus block (BPB) during hemodialysis access surgery. A retrospective review was performed at a single institution. Outcome measures included need for conversion to GA, major perioperative complications, and 30-day mortality. Four hundred and fourteen access procedures were performed by seven vascular surgeons between 2011 and 2014. Arteriovenous fistulas were placed in 379 (92%), arteriovenous grafts were placed in 31 (7%), and four (1%) received unsuccessful extremity exploration. Anesthetic approach was LA in 344 (83%) and BPB in 64 (15%). GA was initially induced in three (0.7%) and three (0.7%) additional patients required conversion to GA from LA. There were no cardiopulmonary events or perioperative deaths. Of the 32 patients who received an arteriovenous graft, only three (10%) required GA. In conclusion, LA and BPB are safe and conversion to GA is rare. GA should be avoided in hemodialysis access surgery.

Predictors of Mortality in Patients with Penetrating Inferior Vena Cava Injuries Surviving to the Operating Room.

Inferior vena cava (IVC) injuries are associated with significant morbidity and mortality. To identify clinical factors associated with mortality in patients undergoing operative intervention for penetrating IVC injuries, a retrospective review of 98 patients was performed, excluding blunt injuries (n = 20) and deaths before surgery (n = 16). The overall mortality was 58 per cent. Nonsurvivors more commonly presented with hypotension (50% vs 23%, P = 0.03) and underwent resuscitative thoracotomy more frequently (42% vs 4%, P = 0.01). Retrohepatic injuries were more common among nonsurvivors (P = 0.04). There was no difference in the use of ligation (7% vs 17%, P = 0.29) or the massive transfusion protocol (35% vs 25%, P = 0.41). On multivariate analysis, after controlling for mechanism of injury, admission hypotension, Glasgow Coma Scale score , preoperative cumulative fluids, resuscitative thoracotomy , absence of spontaneous tamponade, and location of IVC injury, the only independent predictor of mortality was the absence of spontaneous tamponade at the time of laparotomy (odds ratio = 5.4, 95% confidence interval: 1.11-25.95; P = 0.04). Penetrating IVC injuries continue to be associated with a high mortality, particularly among patients with free intraabdominal hemorrhage at laparotomy. Large multicenter studies are required to define the optimal resuscitative and operative management techniques in these severely injured patients.

General Surgery Residents can Be a Reliable Resource in the Evaluation of Residency Applications.

OBJECTIVE: Surgical residents' ability to screen general surgery (GS) applicants has not been previously investigated. The objective of this study was to compare surgical residents' evaluation of Electronic Residency Application Service (ERAS) applicants to that of faculty using a standardized assessment instrument. DESIGN: A prospective analysis of ERAS applications using a standardized assessment tool. SETTING: A university-affiliated, academic, county GS residency program. PARTICIPANTS: Before the interview day, 51 ERAS (2013-2014) applications were reviewed by 10 different assessors (6 GS faculty, including the program director, and 4 GS residents), who evaluated applicants on 10 characteristics (subjective and objective) using a 5-point Likert scale, a total score, and a Global Rating Scale that ranked candidates into deciles. RESULTS: There were a total of 510 assessments. In 8 of 10 individual domains the interrater reliability (IRR) between residents and faculty was good. The IRRs of the total score and global score were excellent. The Spearman ρ between the total score and final rank list were similar for faculty (-0.558) and residents (-0.592). CONCLUSIONS: The excellent IRR score between the total and global scores of faculty and residents demonstrates the reliability of GS residents in evaluating ERAS applications. The low correlations between the total score and final rank are consistent with those in previous studies, in which the interview has been demonstrated to be the most important factor in determining final selection.

Program Factors That Influence American Board of Surgery In-Training Examination Performance: A Multi-Institutional Study.

OBJECTIVE: To determine the influence of program strategies, such as program directors' (PD) attitudes about the American Board of Surgery In-Training Examination (ABSITE) and approach to ABSITE preparation, on residents' ABSITE performance. DESIGN: A 17-item questionnaire was sent to PDs at surgical residency programs. The questions were designed to elicit information regarding the educational curriculum, remediation protocols, and opinions relating to the ABSITE. Main outcome measure was categorical resident ABSITE percentile scores from the January 2014 examination. Statistical analysis was performed using the Student t-test, analysis of variance, and linear regression as appropriate. SETTING: The study was carried out at general surgery residency programs across the country. PARTICIPANTS: In total, 15 general surgery residency PDs participated in the study. RESULTS: The PD response rate was 100%. All 460 resident ABSITE scores from the 15 programs were obtained. In total, 10 programs (67%) identified as university affiliated, 4 programs (27%) as independent academic, and 1 program (7%) as hybrid. The mean number of residents per program was 30.7 (range: 15-57). In total, 14 PDs (93%) indicated that an ABSITE review curriculum was in place and 13 PDs (87%) indicated they had a remediation protocol for residents with low ABSITE scores (with differing thresholds of <30th, <35th, and <40th percentile). The median overall ABSITE score for all residents was 61st percentile (interquartile range = 39.5). The mean ABSITE score for each program ranged from 39th to 75th percentile. Program factors associated with higher ABSITE scores included tracking resident reading throughout the year (median 63rd percentile with tracking vs 59th percentile without, p = 0.040) and the type of remediation (by PD: 77th percentile, by PD and faculty: 57th percentile, faculty only: 64th percentile, with Surgical Education and Self-Assessment Program (SESAP): 63rd percentile, outside review course: 43rd percentile; p < 0.001). Programs with a remediation protocol trended toward higher ABSITE scores compared with programs without remediation protocols (median 61st percentile vs 53rd percentile, p = 0.098). Factors not significantly associated with ABSITE performance included number of structured educational hours per week and frequency of ABSITE review sessions. CONCLUSIONS: Program factors appear to significantly influence ABSITE performance. Programs where the PD was actively involved in remediation mentorship and the tracking of resident reading achieved higher ABSITE percentile scores on the January 2014 examination. Counterintuitively, residents from programs with a lower ABSITE threshold for remediation performed better on the examination.

Reading Habits of General Surgery Residents and Association With American Board of Surgery In-Training Examination Performance.

IMPORTANCE: Few large-scale studies have quantified and characterized the study habits of surgery residents. However, studies have shown an association between American Board of Surgery In-Training Examination (ABSITE) scores and subsequent success on the American Board of Surgery Qualifying and Certifying examinations. OBJECTIVES: To identify the quantity of studying, the approach taken when studying, the role that ABSITE preparation plays in resident reading, and factors associated with ABSITE performance. DESIGN, SETTING, AND PARTICIPANTS: An anonymous 39-item questionnaire including demographic information, past performance on standardized examinations, reading habits, and study sources during the time leading up to the 2014 ABSITE and opinions pertaining to the importance of the ABSITE was administered August 1, 2014, to August 25, 2014, to 371 surgery residents in 15 residency programs nationwide. MAIN OUTCOMES AND MEASURES: Scores from the 2014 ABSITE. RESULTS: A total of 273 residents (73.6%) responded to the survey. Seven respondents did not provide their January 2014 ABSITE score, leaving 266 for statistical analysis. Most respondents were male (162 of 266 [60.9%]), with a mean (SD) age of 29.8 (2.6) years. The median number of minutes spent studying per month was 240 (interquartile range, 120-600 minutes) for patient care or clinical duties and 120 for the ABSITE (interquartile range, 30-360 minutes). One hundred sixty-four of 266 respondents (61.7%) reported reading consistently throughout the year for patient care or clinical duties. With respect to ABSITE preparation, 72 of 266 residents (27.1%) reported reading consistently throughout the year, while 247 of 266 residents (92.9%) reported preparing between 1 and 8 weeks prior to the examination. Univariate analysis (with results reported as effect on median ABSITE percentile scores [95% CIs]) identified the following factors as positively correlated with ABSITE scores: prior United States Medical Licensing Examination (USMLE) 1 and 2 scores (per 1-point increase: USMLE 1, 0.1 [0.02-0.14], P = .03; USMLE 2, 0.3 [0.19-0.44], P < .001), prior Medical College Admission Test (MCAT) scores (per 1-point increase, 1.2 [1.3-2.0]; P = .002), high opinion of ABSITE significance (P < .001), surgical textbook use (11 [6-16]; P = .02), daily studying (13 [4-23]; P = .02), and high satisfaction with study materials (P < .001). On multivariable analysis, USMLE 2 score (per 1-point increase, 0.4 [0.2-0.6]; P < .001), MCAT score (0.6 [0.2-1.0]; P = .003), opinion of ABSITE significance (9.2 [6.9-11.6]; P < .001), and having an equal focus on patient care and ABSITE preparation during study (6.1 [0.6-11.5]; P = .03) were identified as positive predictors of ABSITE performance. CONCLUSIONS AND RELEVANCE: Most residents reported reading consistently for patient care throughout the year. Daily studying and textbook use were associated with higher ABSITE scores on univariate analysis. Scores on the USMLE 2 and MCAT, as well as resident attitude regarding the importance of the ABSITE results, were independent predictors of ABSITE performance.

Increased use of brachiocephalic arteriovenous fistulas improves functional primary patency.

OBJECTIVE: As vascular surgeons strive to meet the Fistula First Initiative, some authors have observed a decrease in arteriovenous fistula (AVF) maturation rates in association with an increase in AVF creation. In May 2012, we adopted a practice change in an attempt to maintain the same high level of AVF creation while leading to a decrease in fistula failures. METHODS: A retrospective study was conducted of all dialysis access procedures performed by a single vascular surgeon before (period 1; before May 1, 2012) and after (period 2; after May 1, 2012) the change in practice pattern. The adopted change included favoring the brachiocephalic location unless the patient was an ideal anatomic candidate for a radiocephalic AVF, creating a larger and standardized arteriotomy, and using a large venous footplate whenever possible. The main outcome measure was primary functional patency at 1 year. Secondary outcome measures included primary patency at 1 year, time to maturation, type of fistula created, steal syndrome, and tunneled hemodialysis catheter infections. RESULTS: Of 213 vascular access procedures performed, 191 (90%) were AVFs. There was no difference in use of AVFs between period 1 (93% AVFs) and period 2 (88% AVFs; P = .2). Use of brachiocephalic AVFs increased from 38% in period 1 to 56% in period 2 (P = .01), with a corresponding trend toward a decrease in radiocephalic AVFs in period 2 (36% in period 1 to 27% in period 2; P = .2). Primary functional patency at 1 year was 47% in period 1 and 63% in period 2 (P = .03). Primary patency at 1 year was 51% in period 1 and 70% in period 2 (P = .001). Time to reach functional maturation was decreased in period 2 (median, 76 vs 82.5 days; P = .046). There was no difference in steal syndrome (P = 1.0), and the incidence of hemodialysis catheter infections was lower in period 2 (0 vs 7 [7%]; P = .006). CONCLUSIONS: Increasing brachiocephalic AVF creation and reducing our reliance on radiocephalic AVFs resulted in a significant increase in primary functional patency at 1 year. This was achieved while maintaining the same high percentage of fistulas, a lower rate of central catheter infections, and the same low incidence of steal syndrome.

Variation in the learning curves of general surgery residents performing arteriovenous fistulas.

BACKGROUND: An arteriovenous fistula (AVF), performed for hemodialysis access, provides one of the few remaining opportunities for general surgery residents to perform an open vascular anastomosis (VA). Limited data exist regarding the learning curve of residents performing this procedure. The objective of this study was to determine how residents improve in performance of VA by implementing real-time tracking of anastomosis time as well as technical errors. STUDY DESIGN: From April 2012 to January 2014, we conducted a prospective intraoperative assessment of 9 postgraduate year 3 general surgery residents during the performance of AVFs using a checklist of common errors in VA. Time for AVF anastomosis completion and number and types of technical errors during anastomosis were recorded. Primary end points were the change in anastomosis time and change in technical errors over time. RESULTS: A total of 86 AVFs were performed and assessed intraoperatively. Each resident performed a median of 10 AVFs (interquartile range [IQR]: 7-11). The mean anastomosis time was 18.1 minutes. The mean number of technical errors was 13.8 per case. Overall, for every additional AVF performed, mean anastomosis time decreased by 0.63 minutes (95% CI: 0.45-0.81, p < 0.0001) and the mean number of technical errors decreased by 1.0 (95% CI: 0.7-1.3, p < 0.0001). The greatest improvement in overall errors (mean difference = 7.9, p = 0.03) and time (mean difference = 4.7min, p = 0.03) occurred after the performance of 3 AVFs. However, when analyzed by individual resident, the R(2) value for anastomotic time by number of AVFs performed ranged from 0.01 to 0.69. Similarly, for technical errors, the R(2) value by number of AVFs performed ranged from 0.04 to 0.62. CONCLUSIONS: In novice surgical residents performing AVFs, improvement in VA skill can readily be tracked via anastomosis time and technical errors. Collectively, there is a strong association between number of cases performed and reduction in time and errors. However, individually, the number of cases completed did not correlate well with time and errors. These findings suggest that for VA skills, determining progression from novice to competence cannot rely on case volume but rather needs to be individualized.