Characteristics and Practice Patterns of Non-certified Surgeons Treating Medicare Patients.

OBJECTIVE: The objective of this study is to explore the patient characteristics and practice patterns of non-certified surgeons who treat Medicare patients in the United States. SUMMARY BACKGROUND DATA: While most surgeons in the United States are board-certified, non-certified surgeons are permitted to practice in many locations. At the same time, surgical workforce shortages threaten access to surgical care for many patients. It is possible that non-certified surgeons may be able to help fill these access gaps. However, little is known about the practice patterns of non-certified surgeons. METHODS: A 100% sample of Medicare claims data from 2014-2019 were used to identify practicing general surgeons. Surgeons were categorized as certified or non-certified in general surgery​​ based on data from the American Board of Surgery. Surgeon practice patterns and patient characteristics were analyzed. RESULTS: A total of 2,097,206 patient cases were included in the study. These patients were treated by 16,076 surgeons, of which 6% were identified as non-certified surgeons. Compared to certified surgeons, non-certified surgeons were less frequently fellowship-trained (20.5% vs. 24.2%, P=0.008) and more likely to be a foreign medical graduate (14.5% vs. 9.2%, P<0.001). Non-certified surgeons were more frequently practicing in for-profit hospitals (21.2% vs. 14.2%, P<0.001) and critical access hospitals (2.2% vs. 1.3%, P<0.001), and were less likely to practice in a teaching hospital (63.2% vs. 72.4%, P<0.001). Compared to certified surgeons, non-certified surgeons treated more non-White patients (19.6% vs. 14%, P<0.001) as well as a higher percentage of patients in the two lowest socioeconomic status (SES) quintiles (36.2% vs. 29.2%, P<0.001). Operations related to emergency admissions were more common amongst non-certified surgeons (68.8% vs. 55.7%, P<0.001). There were no differences in gender or age of the patients treated by certified and non-certified surgeons. CONCLUSION: For Medicare patients, non-certified surgeons treated more patients who are non-White, of lower SES, and in more rural, critical-access hospitals.

The Emergence of Rural Emergency Hospitals: Safely Implementing New Models of Care.

This Viewpoint discusses the potential benefits of the rural emergency hospital model, which exclusively provides outpatient and emergency services, in rural communities faced with possible hospital closures, as well as safeguards to monitor and minimize unintended consequences.

The impact of frailty on ventral hernia repair outcomes in a statewide database.

INTRODUCTION: Preoperative frailty is a strong predictor of postoperative morbidity in the general surgery population. Despite this, there are a paucity of research examining the effect of frailty on outcomes after ventral hernia repair (VHR), one of the most common abdominal operations in the USA. We examined the association of frailty with short-term postoperative outcomes while accounting for differences in preoperative, operative, and hernia characteristics. METHODS: We retrospectively reviewed the Michigan Surgery Quality Collaborative Hernia Registry (MSQC-HR) for adult patients who underwent VHR between January 2020 and January 2022. Patient frailty was assessed using the validated 5-factor modified frailty index (mFI5) and categorized as follows: no (mFI5 = 0), moderate (mFI5 = 1), and severe frailty (mFI5 ≥ 2). Our primary outcome was any 30-day complication. Multivariable logistic regression was used to evaluate the association of frailty with outcomes while controlling for patient, operative, and hernia variables. RESULTS: A total of 4406 patients underwent VHR with a mean age (SD) of 55 (15) years, 2015 (46%) females, and 3591 (82%) white patients. The mean (SD) BMI of the cohort was 33 (8) kg/m2. A total of 2077 (47%) patients had no frailty, 1604 (36%) were moderately frail, and 725 (17%) were severely frail. The median hernia size (interquartile range) was 2.5 cm (1.5-4.0 cm). Severe frailty was associated with increased odds of any complication (adjusted Odds Ratio (aOR) 3.12, 95% CI 1.78-5.47), serious complication (aOR 5.25, 95% CI 2.17-13.19), SSI (aOR 3.41, 95% CI 1.58-7.34), and post-discharge adverse events (aOR 1.70, 95% CI 1.24-2.33). CONCLUSION: After controlling for patient, operative, and hernia characteristics, frailty was independently associated with increased odds of postoperative complications. These findings highlight the importance of preoperative frailty assessment for risk stratification and to inform patient counseling.

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.

Surgical Procedures at Critical Access Hospitals Within Hospital Networks.

OBJECTIVE: To compare surgical outcomes and expenditures at critical access hospitals that do versus do not participate in a hospital network among Medicare beneficiaries. BACKGROUND: Critical access hospitals provide essential care to more than 80 million Americans. These hospitals, often rural, are located more than 35 miles away from another hospital and are required to maintain patient transfer agreements with other facilities capable of providing higher levels of care. Some critical access hospitals have gone further to formally participate in a hospital network. METHODS: This was a cross-sectional retrospective study from 2014 to 2018 comparing 16,128 Medicare beneficiary admissions for appendectomy, cholecystectomy, colectomy, or hernia repair at critical access hospitals that do versus do not participate in a hospital network. Thirty-day mortality and readmissions were risk adjusted using multivariable logistic regression accounting for patient and hospital factors. Price-standardized, risk-adjusted Medicare expenditures were compared for the 30-day total episode payments consisting of index hospitalization, physician services, readmissions, and postacute care payments. RESULTS: Beneficiaries (average age = 75.7 years, SD = 7.4) who obtained care at critical access hospitals in a hospital network were more likely to carry ≥2 Elixhauser comorbidities (68.7% vs. 62.8%, P < 0.001). Rates of 30-day mortality were higher at critical access hospitals in a hospital network (4.30% vs. 3.81%, OR = 1.11, P < 0.001). Similarly, readmission rates were higher at critical access hospitals that were in a hospital network (15.13% vs. 14.34%, OR = 1.06, P < 0.001). Additionally, total episode payments were found to be $960 higher per patient at critical access hospitals that were in a hospital network ($23,878 vs. $22,918, P < 0.001). CONCLUSIONS: Critical access hospitals within hospital networks provided care to more medically complex patients and were associated with worse clinical outcomes and higher costs among Medicare beneficiaries undergoing common general surgery operations.

US Public's Perceptions of Online Transformation Photos.

BACKGROUND: Although many plastic surgeons seek to optimize their online presence and reach a broader patient base, no studies to our knowledge have evaluated the general public's perceptions of one of the most valued informational tools: transformation photos. OBJECTIVES: The aim of this study was to evaluate the general public's preferences for viewing transformation photos online. METHODS: Respondents representative of the US public, crowdsourced through Amazon Mechanical Turk, answered a survey assessing perceptions of the posting of before-and-after photos. RESULTS: One thousand respondents completed the questionnaire. Ninety percent (905/1000) of respondents are willing to view online before-and-after photos. Sixty-three percent (634/1000) would consent to online posting of before-and-after photos of at least 1 body area, with comfort levels highest for facelift (36.4%), nonoperative facial rejuvenation (31.9%), liposuction (24.9%), and abdominoplasty (23.2%). Breast reduction (12.4%), breast reconstruction (10.9%), gluteal augmentation (14.0%), and vaginal rejuvenation (4.4%) are considered least acceptable for public posting. Respondents are significantly more opposed to online viewing of genitals than any other body area (P < 0.0001). Of those willing to have their own transformation photos posted online, 74.0% would allow posting on professional practice websites, 35.1% on Instagram, 26.6% on Facebook, 17.2% on Twitter, and 10.7% on Snapchat. Significantly more respondents prefer their transformation photos reside only on professional practice websites rather than on a social media platform (P < 0.0001). CONCLUSIONS: The public considers aesthetic facial procedures and body contouring most acceptable for showcasing transformation photos online. Although most respondents prefer viewing these photos on professional practice websites, Instagram is the favored social media platform. The majority of the public seek transformation photos when choosing a plastic surgeon for a cosmetic procedure.

Bilayer wound matrix dermal substitute allows survival of split-thickness skin graft in necrotizing fasciitis defects: A retrospective, uncontrolled case study.

BACKGROUND: Necrotizing fasciitis (NF) is a rapid infectious process involving the fascia and subcutaneous tissue. Current standards of care rely on surgical debridement, resulting in large defects, with limited reconstructive options. Wound management has evolved over the last decade, including use of bilayer wound matrices (BWM). The authors sought to assess the use of collagen-GAG bilayer wound matrices on STSG take for NF wounds. METHODS: A qualitative clinical evaluation (2016-2018) was performed to analyze the efficacy of BWM to aide in STSG take. Primary outcomes were 180-day bilayer matrix success, defined by progressing to split-thickness skin graft (STSG) and STSG take, determined by clinical evaluation. Wounds without a diagnosis of NF or reconstruction with BWM were excluded. RESULTS: Ten patients with 11 NF wounds were identified. Average BMI was 32 kg/m2. Comorbidities included hypertension (70%), diabetes (40%), and peripheral vascular disease (40%). Average wound size was 542cm2 (range: 49cm2 -1050cm2) and average wound age was 19 days at BWM placement. Matrices were applied to the lower extremity (64%), upper extremity (27%), and perineum (9%). One-hundred percent (n = 11) of wounds were deemed successful by receiving a STSG. Average time to STSG was 44 days (21d -108d). Complications consisted of delayed healing (n = 1, 8%) and partial necrosis (n = 1). No instances of infection or STSG graft loss occurred. CONCLUSION: Complex defects caused by soft tissue necrotizing infections remain a reconstructive challenge. We highlight the benefit of a BWM as a treatment modality for reconstruction by priming the wound bed for a definitive STSG.

Assessing State Variation in Plastic Surgeons' Risk of Hepatitis C Exposure: Revisit in Methodology.

BACKGROUND: As the national opioid epidemic escalates, rates of the Hepatitis C (HCV) infection have similarly risen. Surgeons exposed intraoperatively secondary to sharp instrument or needle-sticks are affected both socioeconomically and physically. Current treatment strategies involve antiretroviral agents that have not been universally available. This study evaluates the current risk of surgeon exposure to HCV. METHODS: CDC data regarding state-by-state HCV diagnosis reporting were combined with the plastic surgery workforce data from the ASPS. Proxy variables for exposure risk to HCV were generated for each state and compared. RESULTS: West Virginia plastic surgeons were found to have a significantly elevated risk of exposure (60.0 versus 18.7, P < 0.0001). Their exposure risk is a notable outlier compared with the rest of the country (Risk >3 × IQR + 75th percentile). Similarly, states within the Ohio Valley were found to be at increased risk (34.8 versus 16.0, P = 0.05). States most heavily burdened by the opioid crisis were found to be at an increased risk for HCV exposure (40.8 versus 13.6, P = 0.0003). CONCLUSIONS: Plastic surgeons employed in states within the Ohio Valley were found to be at an increased risk of exposure to HCV. Plastic surgeons operating in states severely impacted by the opioid crisis were found to be at an increased risk of exposure. These findings underscore the importance of reducing the risk in the operating room and the need for better data collection to better understand this association and mitigate the risk to the operating surgeon.

Closing the Breast Cancer Loop: Barriers and Perceptions of Breast Reconstruction among Rural Women.

BACKGROUND: Despite policies such as the Women's Health and Cancer Rights Act (WHCRA) and Breast Cancer Patient Education Act, rates for breast reconstruction vary and are especially low for some subpopulations of patients, especially rural women. In order to better understand patient perceptions, qualitative analysis using focus groups is an underutilized tool for obtaining patient perspectives regarding health-related issues and access to care. Our aim was to better understand patient perceptions using qualitative analysis. METHODS: Three focus groups were held in rural counties within West Virginia in order to better understand patient perceptions, knowledge, and beliefs regarding breast health, breast cancer, access to breast reconstruction, and how to disseminate and educate this patient population regarding their right to accessing breast reconstruction. RESULTS: Major themes analyses revealed perceived barriers to care related to lacking care coordination, lack of insurance coverage and other resources, as well as issues related to transportation. Participants consistently discussed avoiding breast screening care due fear and denial in addition to pain. Few patients were aware of their right to accessing breast reconstruction per the WHCRA, and many were concerned about follow-up burden, complications, and general fear related to breast reconstruction. Themes related to dissemination of information to promote the option of breast reconstruction included social media, patient counseling by their referring physician, and other means of intervention in clinics and other points in the care coordination chain. CONCLUSIONS: Rural women have important, unique viewpoints regarding access to and perceived barriers from obtaining breast reconstruction. Plastic surgeons must work diligently to educate, disseminate, and improve care coordination among this population in order to improve access to breast reconstruction among rural breast cancer patients.

Analysis of Outcomes in Living Donor Liver Transplants Involving Reconstructive Microsurgeons.

BACKGROUND: Living donor transplantation is becoming increasingly popular as a modality for patients necessitating liver transplantation. Hepatic artery thrombosis (HAT) remains the most feared acute postoperative complication associated with living-donor liver transplantation. Preoperative planning, including scheduling reconstructive microsurgeons to perform the hepatic artery anastomosis using a surgical microscope or loupes, can decrease HAT rates. METHODS: A retrospective review of two reconstructive microsurgeons at a single institution was performed to analyze postoperative outcomes of adult and pediatric live donor liver transplants where reconstructive microsurgeons performed the hepatic artery anastomosis. One surgeon utilized the surgical microscope, while the other surgeon opted to use surgical loupes for the anastomosis. RESULTS: A total of 38 patients (30 adult and eight pediatric) met inclusion criteria for this study, and average patient age in the adult and pediatric population studied was 48.5 and 3.6 years, respectively. Etiologies of adult patients' liver failure were most commonly cholestatic (43%), followed by alcohol (23%), hepatitis C virus-related cirrhosis (17%), and nonalcoholic steatohepatitis (7%), while etiologies of pediatric liver failure were most commonly cholestatic (62.5%). None of the patients (0%) experienced acute postoperative HAT. On average, 22 and 25 months of postoperative follow-up was obtained for the adult and pediatric cohorts, respectively, and only one adult patient was found to have any liver-related complication. CONCLUSION: A collaborative relationship between reconstructive microsurgeons and transplant surgeons mitigates the risk of HAT and improves patient outcomes in living donor liver transplantation.

A Statewide Assessment of Rib Fixation Patterns Reveals Missed Opportunities.

BACKGROUND: Rib fractures are a common consequence of traumatic injury and can result in significant debilitation. Rib fixation offers fracture stabilization, resulting in improved outcomes and decreased pulmonary complications, especially in high-risk groups such as those with flail segments. However, commercial rib fixation has only recently become clinically prevalent, and we hypothesize that significant variability exists in its utilization based on injury pattern and trauma center. METHODS: The Pennsylvania Trauma System Foundation database was queried for all multiple rib fracture patients occurring statewide in 2016 and 2017. Demographics including the presence of flail and the occurrence of rib fixation was abstracted. Outcomes were compared between the fixation group and all other rib fracture patients. Deidentified treating trauma center was used to elicit center-level disparities. RESULTS: During the study period, there were 12,910 patients with multiple rib fractures, of which 135 had flail segments. 57 patients underwent rib fixation, and 10 of which had a flail segment. Compared with the nonoperative cohort, those who underwent rib fixation were younger (52.5 versus 61.5, P = 0.0009), similar in gender (68% versus 62% male, P = 0.373), and race (80% versus 86% White, P = 0.239). The rib fixation group had higher Injury Severity Scores (19.4 versus 15.4 P = 0.0011). The timing of rib fixation was most frequent within 1 wk of injury but extended out through 3 wk; the occurrence of pulmonary complications had a similar distribution. The frequency of rib fixation rates within trauma centers was not associated with rib fracture patient volume, and 37.1% of multiple rib fracture patients were cared for at centers that did not perform rib fixation. CONCLUSIONS: Rib fixation is infrequently used at trauma centers in Pennsylvania. It is used more frequently in nonflail injuries, and its use may be associated with the occurrence of pulmonary complications. Significant center-level variation exists in rib fixation rates among multiple fractured patients. A significant number of patients are cared for at centers that do not perform rib fixation. Further research is needed to illicit better-defined indications for operative fixation, and opportunities exist to further the penetrance of this practice to all trauma centers.

To Glue or Not to Glue? Analysis of Fibrin Glue for Split-thickness Skin Graft Fixation.

BACKGROUND: Split-thickness skin grafting (STSG) is a commonly used tool in the plastic surgeon's reconstructive armamentarium. Fibrin glue (FG) consists of a combination of clotting factors and thrombin whose key properties include adherence and hemostasis. This preliminary study aimed to assess clinical outcomes and cost of FG for STSG fixation in a general wound reconstruction. METHODS: A retrospective review was conducted in all patients undergoing STSG placement by a single surgeon (JPF) from January 2016 to March 2018. Twenty patients were identified and matched by wound location and wound size. Patients were then divided into 2 groups based on the method of STSG fixation: FG (n = 10) or suture only (SO) (n = 10). RESULTS: In patients with FG fixation, we observed trends of decreased adjusted operative times (34.9 versus 49.4 minutes, P = 0.612), a similar length of stay (2.8 versus 3.5 days, P = 0.306), and liberation from the use of negative pressure wound therapy (0 versus 10 wounds, P < 0.0001). There were no observed differences between the 2 groups in terms of graft-related complications at 180 days (1 complication FG versus 0 complications SO). Time to 100% graft take was also not different (20.2 versus 29.4 days, P = 0.405). Additionally, total direct cost ($16,542 FG versus $24,266 SO; P = 0.545) and total charges ($120,336 FG versus $183,750 SO; P = 0.496) were not statistically different between the FG and SO groups. CONCLUSIONS: In this preliminary comparative assessment, FG for STSG fixation has shown no difference in clinical outcomes to SO fixation, trends of decreased operative time, and afforded complete liberation from negative pressure wound therapy dressings.

Patient Advocacy in Plastic Surgery: An Underutilized Tool.

Healthcare advocacy is an important tool in the plastic surgeon's arsenal that stands the potential to improve both patient care and the profession. However, many physicians underestimate the importance and influence that healthcare advocacy has on the profession and feel that they lack the leverage and knowledge to advocate on behalf of themselves, their practices, their patients, and their profession, all of which are untrue. Plastic surgeons are uniquely positioned to advocate based on their clinical acumen, personal experiences with patient care, and their position in the healthcare ecosystem value chain. This article aims to equip plastic surgeons with a general framework of knowledge regarding policy and advocacy. Additionally, the article outlines and discusses recent advocacy efforts related to plastic surgery, and efforts that are on the horizon to provide some context to the relevance of advocacy related to plastic surgery. Finally, we aim to empower plastic surgeons to step into the policy advocacy arena for the betterment of our patients and the professional practice of plastic surgery.

Associations between Orofacial Clefting and Neonatal Abstinence Syndrome.

BACKGROUND: Orofacial clefting (OFC) is the most common developmental craniofacial malformation, and causal etiologies largely remain unknown. The opioid crisis has led to a large proportion of infants recovering from neonatal abstinence syndrome (NAS) due to in-utero narcotics exposure. We sought to characterize the prevalence of OFC in infants with NAS. METHODS: This cohort study analyzed live births at our institution from 2013 to 2017 to identify any association between OFC and NAS. RESULTS: Prevalence of OFC was 6.79 and 1.63 (per 1,000 live births) in the NAS and general population, respectively. Odds ratios for NAS patients having developed OFC, isolated cleft palate, isolated cleft lip, and combined cleft lip and palate compared with the general population were found to be 4.18 (P = 0.001), 5.92 (P = 0.001), 3.79 (P = 0.05), and 2.94 (P = 0.35), respectively. Analyses performed comparing the NAS and general populations to control for potential confounding variables influencing the NAS population yielded no significant differences with exception of in-utero exposure to physician prescribed opioids. CONCLUSIONS: Prevalence of OFC in infants with NAS was higher than the general live birth population. Isolated cleft palate and isolated cleft lip, specifically, were significantly more prevalent in NAS patients compared with the general population and were associated with in-utero opioid exposure.

Linea Arcuate Hernia Following Transversus Abdominis Release Incisional Hernia Repair.

Open abdominal surgery continues to be most commonly complicated by postoperative herniation at the incision line. In 2012, Novitsky et al described a novel hernia repair technique that utilized a transversus abdominis release coupled with a posterior (retrorectus) component separation (TAR-PCS) of the ventral abdominal wall. Early reports attest to the versatility and low recurrence rate of this technique, particularly when repairing large and complex defects. We present a rare case of herniation below the linea arcuate (LAH) following repair via TAR-PCS. Given its novelty compared with more widely utilized techniques, literature review revealed less discussion regarding potential pitfalls associated with this type of reconstruction, in particular the potential for LAH. To date, only 9 cases of symptomatic LAH have been described, although 2 previously described "suprapubic" herniations following TAR-PCS may represent previously mischaracterized cases of this type of complication. Nonetheless, none of these reports were in the setting of ventral hernia repair.

Historical review of Dakin's solution applications.

Dakin's solution and the Carrel-Dakin method were developed and integrated into clinical practice in the early 20th century, which were found to aid in effective wound healing and infection. This historical review briefly outlines highlights with regard to the history of infection management, wartime amputation, and wound treatment dating back to Galen through the early 20th century. This paper extensively reviews and discusses the historic use of Dakin's solution, which was developed almost a century ago, in both wartime settings and in the civilian sector as well. This review further elaborates on the use of Dakin's solution in the current treatment of wounds in the United States. Additionally, we discuss the history of wound care with the emphasis on the Carrel-Dakin method. Finally, this review discusses and presents contemporary application and utilization of Dakin's solution in two large tertiary care centers.