Smoking Cessation for Preoperative Optimization.

Cigarette smoking is associated with pulmonary and cardiovascular disease and confers increased postoperative morbidity and mortality. Smoking cessation in the weeks before surgery can mitigate these risks, and surgeons should screen patients for smoking before a scheduled operation so that appropriate smoking cessation education and resources can be given. Interventions that combine nicotine replacement therapy, pharmacotherapy, and counseling are effective to achieve durable smoking cessation. When trying to stop smoking in the preoperative period, surgical patients experience much higher than average cessation rates compared with the general population, indicating that the time around surgery is ripe for motivating and sustaining behavior change. This chapter summarizes the impact of smoking on postoperative outcomes in abdominal and colorectal surgery, the benefits of smoking cessation, and the impact of interventions aimed to reduce smoking before surgery.

Surgeon behaviors related to engaging patients in smoking cessation at the time of elective surgery.

BACKGROUND: Despite the abundance of evidence supporting smoking cessation before elective surgery, there is wide variation in surgeon adherence to these best practices. METHODS: This qualitative study used convenience sampling to recruit General Surgery trained surgeons. Surgeons participated in semi-structured interviews based on domains from the Theoretical Domains Framework (TDF). Content analysis was guided by the TDF. RESULTS: Of the 14 TDF domains, social or professional role/identity, memory, attention and decision processes, environmental context and resources, and beliefs about consequences emerged most frequently. Mapping these domains to the Behavior Change Wheel identified education, enablement, and incentivization as effective intervention functions. CONCLUSIONS: Using the TDF, this study identified a widespread sense of responsibility among surgeons to engage patients in perioperative smoking cessation despite workplace barriers and lacking resources. These findings provide valuable insight to facilitate surgeon participation in health promotion through targeted, theory-based interventions informed by surgeon identified barriers to perioperative smoking cessation.

What We Talk About When We Talk About Coping: A Qualitative Study of Surgery Resident's Coping After Complications and Deaths.

OBJECTIVE: To explore how surgery residents cope with unwanted patient outcomes including postoperative complications and death. BACKGROUND: Surgery residents face a variety of work-related stressors that require them to engage in coping strategies. Postoperative complications and deaths are common sources of such stressors. Although few studies examine the response to these events and their impacts on subsequent decision-making, there has been little scholarly work exploring coping strategies among surgery residents specifically. METHODS: This study investigated the ways, in which general surgery residents cope with unwanted patient outcomes, including complications and deaths. Mid-level and senior residents (n = 28) from 14 academic, community, and hybrid training programs across the United States participated in exploratory semistructured interviews conducted by an experienced anthropologist. Interview transcripts were analyzed iteratively, informed by thematic analysis. RESULTS: When discussing how they cope with complications and deaths, residents described both internal and external strategies. Internal strategies included a sense of inevitability, compartmentalization of emotions or experiences, thoughts of forgiveness, and beliefs surrounding resilience. External strategies included support from colleagues and mentors, commitment to change, and personal practices or rituals, such as exercise or psychotherapy. CONCLUSIONS: In this novel qualitative study, general surgery residents described the coping strategies that they organically used after postoperative complications and deaths. To improve resident well-being, it is critical to first understand the natural coping processes. Such efforts will facilitate structuring future support systems to aid residents during these difficult periods.

High-risk surgery among Medicare beneficiaries living in health professional shortage areas.

PURPOSE: Americans who reside in health professional shortage areas currently have less than half of the needed physician workforce. While the shortage designation has been associated with poor outcomes for chronic medical conditions, far less is known about outcomes after high-risk surgical procedures. METHODS: We performed a retrospective review of Medicare beneficiaries living in health professional shortage areas and nonshortage areas who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, esophagectomy, liver resection, pancreatectomy, or rectal resection between 2014 and 2018. Risk-adjusted multivariable logistic regression was used to determine whether rates of postoperative complications and 30-day mortality differed between patient cohorts. Beneficiary and hospital ZIP codes were used to quantify travel time to obtain care. FINDINGS: Compared with patients living in nonshortage areas, patients living in health professional shortage areas traveled longer (median 60.0 vs 28.0 minutes, P<.001). There were no differences in risk-adjusted rates of complications (28.5% vs 28.6%, OR = 1.00, 95% CI 1.00-1.00, P = .59) and small differences in rates of 30-day mortality (4.2% vs 4.4%, OR = 0.95, 95% CI 0.95-0.95, P<.001) between beneficiaries living in shortage areas versus those not in shortage areas, respectively. CONCLUSIONS: Patients living in health professional shortage area undergoing high-risk surgery traveled more than 2 times longer for their care to obtain similar outcomes. While reassuring for clinical outcomes, additional efforts may be needed to mitigate the travel burden experienced by shortage area patients.

"I Wish There had been Resources": A Photo-Elicitation Study of Rectal Cancer Survivorship Care Needs.

BACKGROUND: Rectal cancer survivors experience unique, prolonged posttherapy symptoms. Previous data indicate that providers are not skilled at identifying the most pertinent rectal cancer survivorship issues. Consequently, survivorship care is incomplete with the majority of rectal cancer survivors reporting at least one unmet posttherapy need. METHODS: This photo-elicitation study combines participant-submitted photographs and minimally structured qualitative interviews to explore one's lived experiences. Twenty rectal cancer survivors from a single tertiary canter provided photographs representative of their life after rectal cancer therapy. The iterative steps informed by inductive thematic analysis were used to analyze the transcribed interviews. RESULTS: Rectal cancer survivors had several recommendations to improve their survivorship care, which fell into three major themes: (1) informational needs (e.g., more details about posttherapy side effects); (2) continued multidisciplinary follow up care (e.g., dietary support); and (3) suggestions for support services (e.g., subsidized bowel altering medications and ostomy supplies). CONCLUSIONS: Rectal cancer survivors desired more detailed and individualized information, access to longitudinal multidisciplinary follow-up care, and resources to ease the burdens of daily life. These needs may be met through the restructuring of rectal cancer survivorship care to include disease surveillance, symptom management, and support services. As screening and therapy continues to improve, providers must continue to screen and to provide services that address the physical and psychosocial needs of rectal cancer survivors.

Association of Health Professional Shortage Area Hospital Designation With Surgical Outcomes and Expenditures Among Medicare Beneficiaries.

OBJECTIVE: To compare surgical outcomes and expenditures at hospitals located in Health Professional Shortage Areas to nonshortage area designated hospitals among Medicare beneficiaries. BACKGROUND: More than a quarter of Americans live in federally designated Health Professional Shortage Areas. Although there is growing concern that medical outcomes may be worse, far less is known about hospitals providing surgical care in these areas. METHODS: Cross-sectional retrospective study from 2014 to 2018 of 842,787 Medicare beneficiary patient admissions to hospitals with and without Health Professional Shortage Area designations for common operations including appendectomy, cholecystectomy, colectomy, and hernia repair. We assessed risk-adjusted outcomes using multivariable logistic regression accounting for patient factors, admission type, and year were compared for each of the 4 operations. Hospital expenditures were price-standardized, risk-adjusted 30-day surgical episode payments. Primary outcome measures included 30-day mortality, hospital readmissions, and 30-day surgical episode payments. RESULTS: Patients (mean age=75.6 years, males=44.4%) undergoing common surgical procedures in shortage area hospitals were less likely to be White (84.6% vs 88.4%, P <0.001) and less likely to have≥2 Elixhauser comorbidities (75.5% vs 78.2%, P <0.001). Patients undergoing surgery at Health Professional Shortage Area hospitals had lower risk-adjusted rates of 30-day mortality (6.05% vs 6.69%, odds ratio=0.90, CI, 0.90-0.91, P <0.001) and readmission (14.99% vs 15.74%, odds ratio=0.94, CI, 0.94-0.95, P <0.001). Medicare expenditures at Health Professional Shortage Area hospitals were also lower than nonshortage designated hospitals ($28,517 vs $29,685, difference= -$1168, P <0.001). CONCLUSIONS: Patients presenting to Health Professional Shortage Area hospitals obtain safe care for common surgical procedures without evidence of higher expenditures among Medicare beneficiaries. These findings should be taken into account as current legislative proposals to increase funding for care in these underserved communities are considered.

Barriers to Colorectal Cancer Screening in US Immigrants: A Scoping Review.

INTRODUCTION: Timely colorectal cancer (CRC) screening has been shown to improve CRC-related morbidity and mortality rates. However, even with this preventative care tool, CRC screening rates remain below 70% among eligible United States (US) adults, with even lower rates among US immigrants. The aim of this scoping review is to describe the barriers to CRC screening faced by this unique and growing immigrant population and discuss possible interventions to improve screening. METHODS: Four electronic databases were systematically searched for all original research articles related to CRC screening in US immigrants published after 2010. Following a full-text review of articles for inclusion in the final analysis, data extraction was conducted while coding descriptive themes. Thematic analysis led to the organization of this data into five themes. RESULTS: Of the 4637 articles initially identified, 55 met inclusion criteria. Thematic analysis of the barriers to CRC screening identified five unique themes: access, knowledge, culture, trust, health perception, and beliefs. The most cited barriers were in access (financial burden and limited primary care access) and knowledge (CRC/screening knowledge). CONCLUSIONS: US immigrants face several barriers to the receipt of CRC screening. When designing interventions to increase screening uptake among immigrants, gaps in physician and screening education, access to care, and trust need to be addressed through culturally sensitive supports. These interventions should be tailored to the specific immigrant group, since a one-size-fits approach fails to consider the heterogeneity within this population.

Management and Outcomes of Pathologic Upstaging of Clinical Stage I Rectal Cancers: An Exploratory Analysis.

BACKGROUND: Preoperative staging of clinical stage I rectal cancer can fail to diagnose T3 or nodal disease. Adjuvant treatment of these upstaged patients remains controversial. OBJECTIVE: The objective was to identify predictors of clinical stage I rectal cancer upstaging and quantify rates of local and systemic recurrence. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted using data from the United States Rectal Cancer Consortium, a registry of 1881 rectal cancer resections performed at 6 academic medical centers. PATIENTS: There were a total of 94 clinical stage I rectal cancer patients who underwent proctectomy without preoperative therapy. MAIN OUTCOME MEASURES: The primary measures were incidence of pathologic upstaging, recurrence (local and systemic), and overall survival. RESULTS: Among 94 clinical stage I patients who underwent proctectomy without preoperative therapy, 23 (24.5%) were upstaged by surgical pathology. There were 6 pT3N0 patients, 8 pT1-2N+ patients, and 9 pT3N+ patients. There were no significant differences in demographic or clinical characteristics between upstaged and nonupstaged patients. Of the 6 patients who were upstaged to T3N0 disease, none received adjuvant therapy and none developed recurrence. Of the 17 patients who were upstaged to N+ disease, 14 (82%) received adjuvant chemotherapy and 6 (35%) received adjuvant chemoradiation. None developed a local recurrence, but 4 (24%) developed systemic recurrence, and 2 (12%) died of disease over a mean of 36 months of follow-up. Among the 9 pT3N+ patients, the systemic recurrence rate was 33%, despite 8 of 9 patients receiving adjuvant fluorouracil, leucovorin, and oxaliplatin. LIMITATIONS: Small sample size hinders the ability to draw significant conclusions. CONCLUSIONS: One in 4 patients with stage I rectal cancer had unrecognized T3 or nodal disease found on operative pathology. Occult nodal disease was associated with worse outcomes, despite receiving adjuvant therapy. Systemic recurrence was more common than local recurrence. See Video Abstract at http://links.lww.com/DCR/B885 . MANEJO Y RESULTADOS DEL AUMENTO DEL ESTADIO PATOLGICO DE LOS CNCERES DE RECTO EN ESTADIO CLNICO I UN ANLISIS EXPLORATORIO: ANTECEDENTES:El estadiaje pre-operatorio del cáncer de recto en fase clínica I puede ser erróneo en el diagnóstico T3 o en la diseminación ganglionar. El tratamiento adyuvante de estos pacientes sobre-estadificados ​​sigue siendo controvertido.OBJETIVO:El identificar los factores predictivos en fase clínica I del cáncer de recto y cuantificar las tasas de recurrencia local y sistémica.DISEÑO:Estudio de cohortes retrospectivo.AJUSTE:El estudio se realizó utilizando los datos del Consorcio del Cáncer de Recto de los Estados Unidos, con un registro de 1.881 resecciones oncológicas rectales realizadas en seis centros médicos académicos.PACIENTES:Un total de 94 pacientes con cáncer de recto en fase clínica I fueron sometidos a proctectomía sin terapia preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas primarias fueron la incidencia del sobre-estadiaje histopatológico, la recurrencia (local y sistémica) y la sobrevida general.RESULTADOS:De 94 pacientes en fase clínica I que se sometieron a una proctectomía sin terapia preoperatoria, 23 (24,5%) fueron sobre-estadiados ​​por la histopatología quirúrgica. Hubieron 6 pacientes pT3N0, 8 pT1-2N + y 9 pT3N +. No hubo diferencias significativas en las características demográficas o clínicas entre los pacientes sobre-estadiados ​​y los no sobre-estadiados. De los 6 pacientes que fueron sobre-estadiados en la enfermedad T3N0, ninguno de ellos recibió terapia adyuvante y ninguno recidivó. De los 17 pacientes que fueron sobre-estadiados a la enfermedad N +, 14 (82%) recibieron quimioterapia adyuvante y 6 (35%) recibieron quimio-radioterapia adyuvante. Ninguno desarrolló recidiva local, pero 4 (24%) desarrollaron recidiva sistémica y 2 (12%) murieron a causa de la enfermedad durante el seguimiento medio de 36 meses. Entre los 9 pacientes con pT3N +, la tasa de recidiva sistémica fue del 33%, a pesar de que 8 de 9 pacientes recibieron fluorouracilo, leucovorina y oxaliplatino como quimio-adyuvantes.LIMITACIONES:El tamaño pequeño de la muestra dificulta la capacidad de obtener conclusiones significativas.CONCLUSIONES:Uno de cada cuatro pacientes con cáncer de recto en estadío I presentaba enfermedad ganglionar o T3 no descrita en la histopatología operatoria. La enfermedad ganglionar oculta se asoció con peores resultados, a pesar de recibir terapia adyuvante. La recidiva sistémica fue más común que la recidiva local. Consulte Video Resumen en http://links.lww.com/DCR/B885 . (Traducción-Dr. Xavier Delgadillo ).

Heterogeneity in Surgical Quality Improvement in Michigan.

OBJECTIVE: The aim of this study was to evaluate changes in 30-day postoperative outcomes and individual hospital variation in outcomes from 2012 to 2019 in a collaborative quality improvement network. SUMMARY BACKGROUND DATA: Collaborative quality improvement efforts have been shown to improve postoperative outcomes overall; however, heterogeneity in improvement between participating hospitals remains unclear. Understanding the distribution of individual hospital-level changes is necessary to inform resource allocation and policy design. METHODS: We performed a retrospective cohort study of 51 hospitals in the Michigan Surgical Quality Collaborative (MSQC) from 2012 to 2019. Risk-and reliability-adjusted hospital rates of 30-day mortality, complications, serious complications, emergency department (ED) visits, readmissions, and reoperations were calculated for each year and compared between the last 2 years and the first 2 years of the study period. RESULTS: There was a significant decrease in the rates of all 5 adverse outcomes across MSQC hospitals from 2012 to 2019. Of the 51 individual hospitals, 31 (61%) hospitals achieved a decrease in mortality (range -1.3 percentage points to +0.6 percentage points), 40 (78%) achieved a decrease in complications (range -8.5 percentage points to +2.9 percentage points), 26 (51%) achieved a decrease in serious complications (range -3.2 percentage points to +3.0 percentage points), 29 (57%) achieved a decrease in ED visits (range 5.0 percentage points to +2.2 percentage points), 46 (90%) achieved a decrease in readmissions (range -3.1 percentage points to +0.4 percentage points) and 39 (76%) achieved a decrease in reoperations (range 3.3 percentage points to +1.0 percentage points). CONCLUSIONS: Despite overall improvement in surgical outcomes across hospitals participating in a quality improvement collaborative, there was substantial variation in improvement between hospitals, highlighting opportunities to better understand hospital-level barriers and facilitators to surgical quality improvement.

Evaluation of an Intervention to Address Smoking and Food Insecurity at Preoperative Surgical Clinic Appointments.

Importance: The health of the US population is decreasing, and novel strategies are needed to reverse the trajectory. The surgical episode may be an opportune time to screen for poor health behaviors and social needs, yet little is known about the feasibility or acceptability of such efforts. Objective: To assess the feasibility and acceptability of a pilot program that engages patients in health behavior change and addresses unmet social needs at the time of surgery. Design, Setting, and, Participants: This quality improvement study was conducted among 10 338 patients seen in a preoperative clinic for elective surgery between February 8 and August 31, 2021. Patients who received a referral for institutional resources were contacted via telephone to complete follow-up surveys 30 to 90 days after surgery and between July 1, 2021, and March 31, 2022. Interventions: Implementation of a tool to screen patients for smoking and food insecurity in a preoperative clinic. Those who screened positive were offered referrals for institutional resources. Telephone surveys were conducted with patients who accepted referrals to understand attitudes toward addressing health behaviors and social needs. Main Outcomes and Measures: Screening and referral rates, patient-perceived acceptability of addressing health behaviors and social needs at the time of surgery, smoking cessation rates, and resolution of food insecurity. Results: A total of 10 338 patients (6052 women [58.5%]; mean [SD] age, 56.5 [17.9] years) were evaluated in the preoperative clinic. Of the 10 338 patients, 7825 (75.7%) were successfully screened. Of the 641 identified smokers, 152 (23.7%) accepted a referral for smoking cessation counseling. Of the 181 identified patients with food insecurity, 121 (66.9%) accepted a referral for nonmedical needs assistance. On follow-up surveys, 64 of 78 smokers (82.1%) agreed that the preoperative appointment was an appropriate time to discuss smoking cessation, and 34 of 78 smokers (43.6%) reported quitting smoking. Similarly, 69 of 84 patients with food insecurity (82.1%) agreed it was a good or very good idea for health systems to address nonmedical needs at the time of surgery, and 27 patients (32.1%) reported no longer being insecure about food since their preoperative visit. Conclusions and Relevance: This study suggests that it is feasible to address patients' foundational health at the time of surgery. Most patients agreed that these interventions were appropriate during the perioperative period. These results support using the surgical episode as an opportunity to address foundational health.

Rectovaginal Fistula Management in Low-Resource Settings.

Rectovaginal fistula (RVF) is an abnormal connection between the rectum and vagina that affects women globally. In low- and middle-income countries (LMIC), RVF is most commonly due to obstetric complications such as prolonged labor or perineal tears, female genital mutilation and trauma such as sexual violence or iatrogenic surgical injuries. Women affected by this condition suffer from debilitating physical symptoms, social isolation, economic disempowerment, psychological trauma, low self-esteem, and loss of role fulfillment. Lack of accessible, high-quality, and effective healthcare is a major barrier to timely and safe obstetric care and to care for subsequent complications such as RVF. Additionally, social, cultural, financial, and systemic barriers put women at risk of acquiring fistula and contribute to delays in seeking and receiving care. Literature evaluating RVF repair in those able to access care offers limited information about management and outcomes. It is difficult to ascertain which surgical techniques are used. To reduce the burden of this often-preventable disease, appropriate investment in healthcare infrastructure to strengthen maternal care in LMICs is paramount. Furthermore, more standardized reporting of severity and treatment approach along with outcome data are critical to improving the quality of care for patients impacted by RVF.

Decisional Regret Among Patients Undergoing Colectomy.

BACKGROUND: Patients undergoing colectomy may be at risk for postoperative regret, which is associated with worse quality of life, higher rates of depression, and poorer health outcomes. A better understanding of factors associated with decisional regret may allow surgeons to better tailor preoperative discussions to mitigate the risk of regret. OBJECTIVE: This study aimed to identify factors associated with regret in patients undergoing elective and urgent/emergent colectomy. DESIGN: A retrospective cohort study. SETTING: The Michigan Surgical Quality Collaborative, a 73-hospital collaborative, which collects clinical data on general surgery operations. PATIENTS: Patients aged >18 years who underwent elective or urgent/emergent colectomy between January 2017 and March 2020 and who completed a decision regret survey. MAIN OUTCOME MEASURES: Any degree of postoperative regret. RESULTS: Of 3638 patients, 2,530 (70%) underwent elective and 1108 (30%) underwent urgent/emergent colectomy. Overall, 381 (10.5%) patients reported regret, with higher rates among the urgent/emergent setting compared with the elective cohort (13.0% vs 9.4%; p < 0.001). In the elective cohort, regret was associated with length of stay >7 days (OR, 2.32; 95% CI, 1.06-5.07), postoperative complication (OR, 1.95; 95% CI, 1.36-2.79), and readmission (OR, 1.90; 95% CI, 1.22-2.95). Elective colectomies for cancer/adenoma/polyp were associated with lower odds of regret (OR, 0.68; 95% CI, 0.50-0.91). In the urgent/emergent cohort, regret was associated with female sex (OR, 1.69; 95% CI, 1.15-2.50) and nonhome discharge destination (OR, 1.61; 95% CI, 0.04-1.03). LIMITATIONS: Hospitals used different sampling strategies, limiting our ability to calculate a true response rate and characterize nonresponders. CONCLUSIONS: One in 10 patients reported regret after colectomy with higher rates in those undergoing urgent/emergent colectomy. Factors associated with regret were different between surgical settings. Efforts are needed to mitigate patients' risk of regret with individualized discussions contingent on surgical settings to better align expectations and outcomes. See Video Abstract at http://links.lww.com/DCR/C3 . ARREPENTIMIENTO DEL PACIENTE EN LA DECISIN DE SOMETIMIENTO A COLECTOMA: ANTECEDENTES:Los pacientes que se someten a una colectomía pueden estar en riesgo de arrepentimiento post operatorio, la cual está asociada con una peor calidad de vida, mayores tasas de depresión y peores resultados de salud. Una mejor comprensión de los factores asociados con el arrepentimiento de dicha decisión, puede permitir a los cirujanos adaptar de una mejor manera las discusiones preoperatorias y así mitigar el riesgo de arrepentimiento.OBJETIVO:Identificar factores asociados al arrepentimiento en pacientes sometidos a colectomía electiva y urgente/emergente.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:The Michigan Surgical Quality Collaborative, una colaboración de 73 hospitales.PACIENTES:Pacientes ≥18 años sometidos a colectomía electiva o urgente/emergente entre enero de 2017 y marzo de 2020, y que hayan completado una encuesta de arrepentimiento en cuanto a la decisión.PRINCIPALES MEDIDAS DE RESULTADO:Reporte de cualquier grado de arrepentimiento postoperatorio.RESULTADOS:De 3.638 pacientes, 2.530 (70%) fueron sometidos a colectomía electiva y 1.108 (30%) a colectomía urgente/emergente. En general, 381 (10,5%) pacientes informaron arrepentimiento, con tasas más altas en el grupo relacionado con el escenario urgente/emergente en comparación con la cohorte electiva (13,0% frente a 9,4%, p < 0,001). En la cohorte electiva, el arrepentimiento se asoció con una estancia hospitalaria >7 días (OR 2,32, IC 95% 1,06-5,07), complicación posoperatoria (OR 1,95, IC 95% 1,36-2,79) y reingreso (OR 1,90, IC 95% 1,22-2,95). Las colectomías electivas por cáncer/adenoma/pólipo se asociaron con una menor probabilidad de arrepentimiento (OR 0,68, IC 95%: 0,50-0,91). En la cohorte urgente/emergente, el arrepentimiento se asoció con el sexo femenino (OR 1,69, IC 95% 1,15-2,50) y el destino del alta no domiciliario (OR 1,61, IC 95% 0,04-1,03).LIMITACIONES:Los hospitales utilizaron diferentes estrategias de muestreo, lo que limita nuestra capacidad para calcular una tasa de respuesta real y caracterizar a los que no respondieron.CONCLUSIONES:Uno de cada diez pacientes reportó arrepentimiento después de la colectomía con tasas más altas en aquellos sometidos a colectomía urgente/emergente. Los factores asociados con el arrepentimiento fueron diferentes entre los entornos quirúrgicos. Se necesitan esfuerzos para mitigar el riesgo de arrepentimiento de los pacientes con discusiones individualizadas supeditadas al entorno quirúrgico para caracterizar de una mejor las expectativas y los resultados. Consulte Video Resumen en http://links.lww.com/DCR/C3 . (Traducción-Dr. Osvaldo Gauto).

How Program Directors Understand General Surgery Resident Wellness.

OBJECTIVE: Burnout among general surgery residents is prevalent. Guidance on how program directors (PDs) can effectively intervene on general surgery resident wellness is lacking. In this study, we explore how PDs learn about burnout among their residents and support their well-being. DESIGN: Semi-structured interviews were conducted with PDs. Interviews were transcribed and coded by study team dyads who utilized an inductive coding approach, and then reconciled via consensus. Interpretive description was the qualitative analytical method. SETTING: Program tours to 15 general surgery programs during the exploratory phase of the SECOND Trial. PARTICIPANTS: Fifteen general surgery PDs. RESULTS: PDs identified the utility of contextual information in understanding resident wellness and implementing program-specific resident wellness initiatives. Three themes relating to PD awareness of resident burnout and well-being were identified: (1) PDs used conventional and novel methods to collect data from multiple information sources, including residents, faculty, staff, institutional representatives, and anonymous parties. (2) These contextualized data inspired the development of responsive strategies to effect programmatic changes that improved education and wellness. (3) Barriers to acquiring and utilizing information exist, requiring careful analysis, creative problem solving, as well as persistence and dedication to resident wellness. CONCLUSIONS: Qualitative analysis of general surgery residency PDs yielded insightful knowledge about gathering and responding to information to support resident wellness, including successful strategies and areas of caution. The experience of these PDs can guide others in evaluating their wellness goals and initiatives for their own residents.

Application of power analysis to determine the optimal reporting time frame for use in statewide trauma system quality reporting.

BACKGROUND: Meaningful reporting of quality metrics relies on detecting a statistical difference when a true difference in performance exists. Larger cohorts and longer time frames can produce higher rates of statistical differences. However, older data are less relevant when attempting to enact change in the clinical setting. The selection of time frames must reflect a balance between being too small (type II errors) and too long (stale data). We explored the use of power analysis to optimize time frame selection for trauma quality reporting. METHODS: Using data from 22 Level III trauma centers, we tested for differences in 4 outcomes within 4 cohorts of patients. With bootstrapping, we calculated the power for rejecting the null hypothesis that no difference exists amongst the centers for different time frames. From the entire sample for each site, we simulated randomly generated datasets. Each simulated dataset was tested for whether a difference was observed from the average. Power was calculated as the percentage of simulated datasets where a difference was observed. This process was repeated for each outcome. RESULTS: The power calculations for the 4 cohorts revealed that the optimal time frame for Level III trauma centers to assess whether a single site's outcomes are different from the overall average was 2 years based on an 80% cutoff. CONCLUSION: Power analysis with simulated datasets allows testing of different time frames to assess outcome differences. This type of analysis allows selection of an optimal time frame for benchmarking of Level III trauma center data.

A multi-modal study examining long-term bowel, urinary, and sexual function after rectal cancer surgery.

BACKGROUND: Many rectal cancer survivors experience persistent bowel, urinary, and sexual dysfunction. A better understanding of their lived experience can help guide survivorship care. METHODS: Multi-modal study of patients who underwent rectal cancer surgery from 2015 to 2019 at a single institution. Surveys and qualitative interviews were used to describe patients' postoperative symptom burden and its impact on their quality of life. RESULTS: The total number of survey respondents was 188 (response rate = 63.5%). Among participants, 41.5% reported their bowel habits, bladder habits (7.8%) and sexual function (36.2%) to be a "moderate" or "big problem" in the past four weeks. The lived experiences varied widely even among patients who report similar symptom burden. CONCLUSIONS: Rectal cancer survivors commonly face lasting symptoms that negatively impact their quality of life for years after surgery. Additional support extending beyond the perioperative period is needed for patients with persistent dysfunction.

Patient, Surgeon, or Hospital: Explaining Variation in Outcomes after Colectomy.

BACKGROUND: Complication rates after colectomy remain high. Previous work has failed to establish the relative contribution of patient comorbidities, surgeon performance, and hospital systems in the development of complications after elective colectomy. STUDY DESIGN: We identified all patients undergoing elective colectomy between 2012 and 2018 at hospitals participating in the Michigan Surgical Quality Collaborative. The primary outcome was development of a postoperative complication. We used risk- and reliability-adjusted generalized linear mixed models to estimate the degree to which variance in patient-, surgeon-, and hospital-level factors contribute to complications. RESULTS: A total of 15,755 patients were included in the study. The mean hospital-level complication rate was 15.8% (range, 8.7% to 30.2%). The proportion of variance attributable to the patient level was 35.0%, 2.4% was attributable to the surgeon level, and 1.8% was attributable to the hospital level. The predicted probability of complication for the least comorbid patient was 1.5% (CI 0.7-3.1%) at the highest performing hospital with the highest performing surgeon, and 6.6% (CI 3.2-12.2%) at the lowest performing hospital with the lowest performing surgeon. By contrast, the most comorbid patient in the cohort had a 66.3% (CI 39.5-85.6%) or 89.4% (CI 73.7-96.2%) risk of complication. CONCLUSIONS: This study demonstrated that variance from measured factors at the patient level contributed more than 8-fold more to the development of complications after colectomy compared with variance at the surgeon and hospital level, highlighting the impact of patient comorbidities on postoperative outcomes. These results underscore the importance of initiatives that optimize patient foundational health to improve surgical care.

Identifying Strategies for Struggling Surgery Residents.

BACKGROUND: Struggling residents are not uncommon in general surgery. Early identification of these residents and effective remediation remain imperfect. MATERIALS AND METHODS: We performed a survey of program directors (PD) across all general surgery residencies. Survey questions included the following: demographic information about the program and PD, 10 vignettes about hypothetical residents struggling in various ACGME milestones to assess how PDs would address these deficiencies, and self-reported PD preparedness and availability of resources to support struggling residents. RESULTS: In total, we received 82 responses to our survey. All PDs who participated in our study reported having struggling residents in their program. The three most common ways struggling residents are identified were faculty word-of-mouth, formal evaluations such as milestones and ABSITE performance, and resident word-of-mouth. Over 18% of PDs reported having little to no relevant training in addressing the needs of a struggling resident, and 65.9% of PDs did not feel that their program had 'completely adequate' resources to address these needs. In the majority of cases, PDs offer mentorship with themselves or other faculty as a remediation strategy with infrequent use of other resources. CONCLUSIONS: Strategies to identify struggling residents and remediation strategies varied widely across programs. Diversifying remediation approaches should be considered for more effective remediation.

Surgical outcomes and travel burden among medicare beneficiaries living in Health Professional Shortage Areas.

BACKGROUND: Americans living in Health Professional Shortage Areas (HPSA) only have 44% of the required physician workforce to service their residents. We sought to determine whether residents living in HPSA have worse surgical outcomes than those living in non-HPSA. METHODS: We performed a retrospective review of 1,507,834 Medicare beneficiaries undergoing appendectomy, cholecystectomy, colectomy or hernia repair between 2014 and 2018. Multivariable logistical regression was used to determine the association of living in HPSA with rates of 30-day mortality. RESULTS: Compared with patients living in non-HPSA, patients living in HPSA traveled farther (median distance 35.3 miles vs. 11.7 miles, p < 0.001) and longer (median 45 min vs. 20 min, p < 0.001) for surgical care. Differences in rates of mortality between patients living in HPSA and non-HPSA (6.0% vs. 6.1%, OR = 0.97, 95% CI 0.97-0.97, p < 0.001) were small. CONCLUSION: Medicare beneficiaries living in HPSA experience more than double the travel time and triple the travel distance to undergo common surgical procedures compared to those living in non-HPSA. For those able to overcome the travel burden, the differences in surgical outcomes were small.

It's not fine: A photo-elicitation study of rectal cancer survivors' emotions and coping strategies.

BACKGROUND: Comprehensive cancer care includes supporting the psychological health of survivors who are at high risk of distress. However, little is known about the emotional experiences of rectal cancer survivors specifically. We sought to explore psychological well-being and coping strategies utilized by rectal cancer survivors. METHODS: Twenty rectal cancer survivors shared photographs of their post-treatment experiences. In follow-up interviews, participants discussed photographs' meanings and emotional experiences during their cancer journey. Transcribed interviews were analyzed using iterative steps of inductive thematic analysis. RESULTS: Emotions ranged from sadness to anxiety and fear of cancer recurrence. Coping mechanisms were grouped into 3 categories: (1) seeking support and information; (2) focus on attitudes and perspectives; and (3) distancing strategies. CONCLUSION: Our results highlight the persistent psychological impact of rectal cancer and need for additional support for survivors. Providers may help temper patients' fear of recurrence by explicitly discussing prognosis and risk of recurrence. Although multidisciplinary survivorship clinics are ideal, all cancer care providers and primary care physicians should feel empowered to screen for psychological distress and refer patients to appropriate resources when needed.

The Best Gift You Could Give a Resident: A Qualitative Study of Well-Being Resources and Use Following Unwanted Outcomes.

In recent years, there has been increasing focus on the well-being of resident physicians. Considering the persistent problem of burnout and attrition particularly among surgical trainees, this is a well-warranted and laudable area of focus. However, despite the widespread adoption of resources available to residents through individual institutions, there is little understanding of how and why these resources are engaged or not during particularly vulnerable moments, such as following an unwanted patient event including postoperative complications and deaths. Methods: This qualitative study explored access to and usage of resources to promote well-being following an unwanted patient outcome through semi-structured interviews of 28 general surgery residents from 14 residency programs across the United States, including community, academic, and hybrid programs. A qualitative descriptive approach was used to analyze transcripts. Results: Residents described 3 main types of institutional resources available to them to promote well-being, including counseling services, support from program leadership, and wellness committees. Residents also described important barriers to use for each of these resources, which limited their access and value of these resources. Finally, residents shared their recommendations for future initiatives, including additional protected time off during weekdays and regular usage of structured debrief sessions following adverse patient outcomes. Conclusions: While institutional resources are commonly available to surgery residents, there remain important limitations and barriers to use, which may limit their effectiveness in supporting resident well-being in times of need. These barriers should be addressed at the program level to improve services and accessibility for residents.