Fragmented care in localized pancreatic cancer: Is commission on cancer accreditation associated with improved overall survival?

BACKGROUND: Prior studies of fragmentation of care in pancreatic cancer have not adjusted for indicators of hospital quality such as Commission on Cancer accreditation. The effect of fragmentation of care has not been well defined. METHODS: We queried the National Cancer Database to identify patients undergoing pancreaticoduodenectomy and distal pancreatectomy with perioperative systemic therapy for clinical stages I-III pancreatic cancer between 2006 and 2019. Patients who received systemic therapy at a center different than the center performing surgery were categorized as having fragmentation of care. Patients having fragmentation of care were further categorized on the basis of whether (fragmentation of care Commission on Cancer) or not (fragmentation of care non-Commission on Cancer) systemic therapy was administered at a facility accredited by the Commission on Cancer. RESULTS: A total of 11,732 patients met inclusion criteria; 5,668 (48.3%) underwent fragmentation of care, and 3,426 (29.2%) fragmentation of care non-Commission on Cancer. Patients undergoing fragmentation of care non-Commission on Cancer were less likely to receive neoadjuvant systemic therapy than those undergoing fragmentation of care Commission on Cancer or non-fragmented care (27.7% vs 40.1% vs 36.8%, P < .001). On Cox analysis, advanced age, comorbid disease, node-positive disease, and facility type were associated with risk of overall survival. Fragmentation of care was not (adjusted hazard ratio = 0.99, 95% confidence interval [0.94-1.06], P = .8). On Kaplan-Meier analysis, there were no significant differences in 5-year overall survival between treatment cohorts. CONCLUSION: In patients undergoing fragmentation of care for localized pancreatic cancer, those treated with systemic therapy in Commission on Cancer accredited facilities are more likely to be given neoadjuvant therapy but demonstrate no significant improvement in survival relative to those undergoing non-fragmented care or those undergoing fragmentation of care but receiving systemic therapy in nonaccredited facilities.

Does commission on cancer (CoC) accreditation mitigate the effect of care fragmentation on clinical outcome in localized rectal cancer?

BACKGROUND: Studies of fragmented care (FC) in rectal cancer have not adjusted for indicators of hospital quality and may misrepresent the effects of FC. METHODS: We queried the National Cancer Database to identify patients undergoing care for clinical stage II and III rectal adenocarcinoma between 2006 and 2019. Those undergoing FC were sub-categorized based on whether (FC CoC) or not (FC non-CoC) they received systemic therapy at CoC accredited facilities. RESULTS: 44,339 patients met inclusion criteria; 23,921 (54 â€‹%) underwent FC, 16,929 (71 â€‹%) FC non-CoC. Differences in utilization of neoadjuvant therapy (92.3 â€‹% vs 89.7 â€‹% vs 89.5 â€‹%, p â€‹< â€‹0.01) and 5-year overall survival (76.1 vs 75.5 vs 74.1 %, p â€‹< â€‹0.01) between treatment cohorts were marginal. CONCLUSION: In patients undergoing multimodality therapy for rectal cancer, care fragmentation is not associated with long-term clinical outcome. Decisions regarding where these patients go for systemic therapy may be safely made on the basis of ease of access.

Association of Resident Independence With Short-term Clinical Outcome in Core General Surgery Procedures.

Importance: Prior studies evaluating the effect of resident independence on operative outcome draw from case mixes that cross disciplines and overrepresent cases with low complexity. The association between resident independence and clinical outcome in core general surgical procedures is not well defined. Objective: To evaluate the level of autonomy provided to residents during their training, trends in resident independence over time, and the association between resident independence in the operating room and clinical outcome. Design, Setting, and Participants: Using the Veterans Affairs Surgical Quality Improvement Program database from 2005 to 2021, outcomes in resident autonomy were compared using multivariable logistic regression and propensity score matching. Data on patients undergoing appendectomy, cholecystectomy, partial colectomy, inguinal hernia, and small-bowel resection in a procedure with a resident physician involved were included. Exposures: Resident independence was graded as the attending surgeon scrubbed into the operation (AS) or the attending surgeon did not scrub (ANS). Main Outcomes and Measures: Outcomes of interest included rates of postoperative complication, severity of complications, and death. Results: Of 109 707 patients who met inclusion criteria, 11 181 (10%) underwent operations completed with ANS (mean [SD] age of patients, 61 [14] years; 10 527 [94%] male) and 98 526 (90%) operations completed with AS (mean [SD] age of patients, 63 [13] years; 93 081 [94%] male). Appendectomy (1112 [17%]), cholecystectomy (3185 [11%]), and inguinal hernia (5412 [13%]) were more often performed with ANS than small-bowel resection (527 [6%]) and colectomy (945 [4%]). On multivariable logistic regression adjusting for procedure type, age, body mass index, functional status, comorbidities, American Society of Anesthesiologists class, wound class, case priority, admission status, facility type, and year, factors associated with a complication included increasing age (adjusted odds ratio [aOR], 1.19 [95% CI, 1.16-1.22]), emergent case priority (aOR, 1.41 [95% CI, 1.33-1.50]), and resident independence (aOR, 1.12 [95% CI, 1.03-1.22]). On propensity score matching, AS cases were score matched 1:1 to ANS cases based on the variables listed above. Comparing matched cohorts, there was no difference in complication rates (817 [7%] vs 784 [7%]) or death (91 [1%] vs 102 [1%]) based on attending physician involvement. Conclusions and Relevance: Core general surgery cases performed by senior-level trainees in such a way that the attending physician is not scrubbed into the case are being done safely with no significant difference in rates of postoperative complication.

Are Residents Able to Perform a Laparoscopic Cholecystectomy with Acceptable Outcomes When the Attending Is Not Scrubbed?

BACKGROUND: Recent socioeconomic pressures in healthcare and work hour resections have limited opportunities for resident autonomy and independent decision-making. We sought to evaluate whether contemporary senior residents are being given the opportunity to operate independently and whether patient outcomes are affected when the attending is not directly involved in an operation. STUDY DESIGN: The VA Surgical Quality Improvement Program (VASQIP) Database was queried to identify patients undergoing elective laparoscopic cholecystectomy between 2004 and 2019. Cases were categorized as "attending" or "resident" depending on whether the attending surgeon was scrubbed. Cohorts were 1:1 propensity score-matched (PSM) for demographics, comorbidities, and facility case-mix. Clinical outcomes for matched cohorts were compared by standard methods. RESULTS: There were 23,831 records for patients who underwent laparoscopic cholecystectomy; 20,568 (86%) performed with the attending scrubbed, and 3,263 (14%) without the attending scrubbed. Over time there was a significant decrease in the proportion of cases without the attending scrubbed, 18% in 2004-2009 to 13% in 2015-2019 (p < 0.001). On PSM, 3,263 patients undergoing laparoscopic cholecystectomy by the residents without the attending scrubbed were successfully matched (1:1) to cases with the attending scrubbed. On comparison of matched cohorts, procedures performed without the attending scrubbed were statistically longer (102 vs 98 minutes, p = 0.001) but with no difference in rates of postoperative complications (5% vs 5%, p = 0.9). CONCLUSION: In comparison with cases done with more direct attending involvement, residents perform laparoscopic cholecystectomies efficiently without increased complications. Over time, attendings are more frequently scrubbed for the operation.

Contemporary Matched-Cohort Comparison of Surgical Approach to Inguinal Hernia Repair: Are Minimally Invasive Approaches Associated with Higher Rates of Recurrence?

BACKGROUND: Current studies evaluating outcomes for open, laparoscopic, and robotic inguinal hernia repair, in general, include small numbers of robotic cases and are not powered to allow a direct comparison of the 3 approaches to repair. STUDY DESIGN: We queried the Veterans Affairs Surgical Quality Improvement Program Database to identify patients undergoing initial elective inguinal hernia repair between 2013 and 2017. Propensity score matching and multivariable logistic regression were used to make risk-adjusted assessments of association between surgical approach and outcome. RESULTS: A total of 39,358 patients underwent initial elective inguinal hernia repair; 32,881 (84%) underwent an open approach, 6,135 (16%) underwent a laparoscopic approach, and 342 (1%) underwent a robotic-assisted approach. Two hundred sixty-six (1%) patients had a recurrent repair performed during follow-up. On univariate comparison, patients undergoing a robotic-assisted approach had longer operative times for unilateral repair than those undergoing either an open or laparoscopic (73 ± 31 vs 74 ± 29 vs 107 ± 41 minutes; p < 0.001) approach. On multivariable logistic regression, patients with a higher BMI had an increased adjusted risk of a postoperative complication, but there was no association between surgical approach and complication rate. Three hundred forty-two patients undergoing robotic repair were 1:3:3 propensity score matched to 1,026 patients undergoing laparoscopic and 1,026 undergoing open repair. On comparison of matched cohorts, there were no statistical differences between approaches regarding recurrence (0.6% vs 0.8% vs 0.6%, p > 0.05) or complication rate (0.6% vs 1.2% vs 1.2%, p > 0.05). CONCLUSIONS: In patients undergoing initial elective inguinal hernia repair, rates of hernia recurrence are low independent of surgical approach. Both robotic and laparoscopic approaches demonstrate rates of early postoperative morbidity and recurrence similar to those for the open approach. The robotic approach is associated with longer operative time than either laparoscopic or open repair.

Professionalism of Admitting and Consulting Services and Trauma Patient Outcomes.

OBJECTIVE: To determine whether trauma patients managed by an admitting or consulting service with a high proportion of physicians exhibiting patterns of unprofessional behaviors are at greater risk of complications or death. SUMMARY BACKGROUND DATA: Trauma care requires high-functioning interdisciplinary teams where professionalism, particularly modeling respect and communicating effectively, is essential. METHODS: This retrospective cohort study used data from 9 level I trauma centers that participated in a national trauma registry linked with data from a national database of unsolicited patient complaints. The cohort included trauma patients admitted January 1, 2012 through December 31, 2017. The exposure of interest was care by 1 or more high-risk services, defined as teams with a greater proportion of physicians with high numbers of patient complaints. The study outcome was death or complications within 30 days. RESULTS: Among the 71,046 patients in the cohort, 9553 (13.4%) experienced the primary outcome of complications or death, including 1875 of 16,107 patients (11.6%) with 0 high-risk services, 3788 of 28,085 patients (13.5%) with 1 high-risk service, and 3890 of 26,854 patients (14.5%) with 2+ highrisk services (P < 0.001). In logistic regression models adjusting for relevant patient, injury, and site characteristics, patients who received care from 1 or more high-risk services were at 24.1% (95% confidence interval 17.2% to 31.3%; P < 0.001) greater risk of experiencing the primary study outcome. CONCLUSIONS: Trauma patients who received care from at least 1 service with a high proportion of physicians modeling unprofessional behavior were at an increased risk of death or complications.

Supervised independence in elective inguinal hernia repairs performed by surgical residents is not associated with compromised short clinical outcome or rates of reoperation for recurrence.

BACKGROUND: We evaluate the association between attending surgeon involvement and clinical outcome in elective inguinal hernia repairs performed by residents. METHODS: Patients undergoing initial elective unilateral inguinal hernia repair between 2004 and 2019 were identified using the Veterans Administration Surgical Quality Improvement Program Database. The level of attending surgeon involvement was categorized as active (attending scrubbed [AS]) or passive (supervising the resident's performance but not scrubbed [ANS]). AS and ANS herniorrhaphies were 1:1 propensity matched for patient demographics, comorbidities, surgical approach, resident postgraduate level, and year of repair. Rates of complication and recurrence for matched cohorts were compared by standard methods. RESULTS: 30,784 patients met inclusion criteria. 5136 (17%) repairs were performed without the attending scrubbed. On comparison of matched-cohorts, overall complication rates (1.7% vs 1.2%, p = 0.07) and rates of recurrence (1.9% vs 1.4%, p = 0.041) for patients undergoing herniorrhaphy AS were statistically similar to those performed ANS. CONCLUSION: Supervised independence in elective inguinal hernia repair performed by surgical residents is not associated with inferior clinical outcomes.

Does resident autonomy in colectomy procedures result in inferior clinical outcomes?

BACKGROUND: The amount of time surgical trainees spend operating independently has been reduced by work-hour restrictions and shifts in the health care environment that impede autonomy. Few studies evaluate the association between clinical outcome and resident autonomy. METHODS: The Veterans Affairs Surgical Quality Improvement Program database was queried to identify patients undergoing partial colectomy for neoplasm between 2004 and 2019. Rectal resections, emergency procedures, and those involving postgraduate year 1 and 2 residents were excluded. Records were categorized as performed with the attending scrubbed or not scrubbed. Hierarchical logistic regression was used to identify factors independently associated with operative time, morbidity, and mortality. RESULTS: In total, 7,347 patients met inclusion criteria; 6,890 (93.6%) were categorized as attending scrubbed and 457 (6.4%) as attending not scrubbed. The cohorts were similar in terms of patient demographics, including age, race, body mass index, and American Society of Anesthesiologists class. There were no differences between cohorts in terms of operative time (attending not scrubbed 3.02 hours, attending scrubbed 3.07 hours, P = .42). On hierarchical logistic regression adjusted for age, gender, race, body mass index, functional status, cancer location, facility operative level, wound class, American Society of Anesthesiologists class, length of operation, operative modality (open or minimally invasive), postgraduate year of resident, and year, there were no differences in odds of complications, major morbidity, or mortality based on attending involvement. CONCLUSION: Colectomies performed by residents with appropriate levels of autonomy are efficient and safe. Our results indicate that attending surgeon judgment regarding resident autonomy is sound and that educational environments can be designed to foster resident independence and preserve clinical quality, safety, and efficiency.

Advanced Surgical Skills for Exposure in Trauma (ASSET): the first 25 courses.

BACKGROUND: The Advanced Surgical Skills for Exposure in Trauma (ASSET) course was developed to address limited experience of residents and practicing surgeons (PS) in rapid exposure of major blood vessels for trauma. This one day, case based, scenario driven, fresh cadaver dissection course emphasizes rapid surgical exposure of the vasculature of the neck, chest, abdomen, pelvis and extremities with additional focus on fasciotomies and pelvic packing. Contained herein are the results of the first 25 courses. METHODS: Data collected from 25 ASSET courses conducted between September 2010 and February 2012 included self-reported comfort level (5 point Likert scale) with each of 25 specific skills before and upon completion of the course, and evaluation of the course content. Statistical analysis was accomplished using the Student t-test with α set at P < 0.05. RESULTS: Ninety-one surgical trainees and 123 PS were taught at 11 ASSET sites. Self-assessed comfort levels for all 25 queried skills and exposures improved significantly over baseline with P values ranging from 1.6 × 10(-7) to 3.9 × 10(-41). Participants gained new knowledge (4.83 on 5 point scale); learned new techniques (4.83), felt better prepared to expose traumatically injured vessels (4.88), and would recommend the course to a colleague (4.92). CONCLUSIONS: The ASSET course was well received and significantly improved self-reported confidence in the exposures needed to care for trauma in both surgical trainees and PS. Ongoing experience with this course will enable more comprehensive psychometric analysis and further validation of this curriculum.

Analysis of compliance and outcomes in a trauma system with a 2-hour transfer rule.

HYPOTHESIS: Minimizing time to definitive care in an effort to optimize outcomes is the goal of trauma systems. Toward this end, some systems have imposed standards on time to interfacility transfer. This study evaluates compliance and outcome in a system with a 2-hour transfer rule. DESIGN: Retrospective review. SETTING: State trauma registry data from 1999 to 2003. PATIENTS: Trauma patients who underwent interfacility transfer and those who did not. MAIN OUTCOME MEASURES: Time to transfer; Injury Severity Score; mortality; and time to operating room at second facility. These variables were then stratified by time to transfer. RESULTS: During the study period, there were 22 447 interfacility transfers. Overall transfer rate was 10.4%. Of the transfers, 4502 (20%) occurred within 2 hours. Median transfer time was 2 hours 21 minutes. Injury Severity Score, mortality, and number of patients with operation performed on same day of transfer were all higher for the group transferred within 2 hours in comparison with patients transferred on the same day of injury at greater than 2 hours. CONCLUSIONS: While the majority of transfers occur at greater than the mandated 2-hour interval, the most seriously injured patients are reaching definitive care within 2 hours. Markers of acuity for patients transferred at greater than 2 hours parallel those of the general trauma patient population. These data suggest that, in this system, provider-determined transfer time that exceeds 2 hours has no adverse effect on patient outcome. It appears to accomplish recognition and rapid transport of the most seriously ill. This may obviate the need for onerous system mandates that are not feasible or have poor compliance.