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2.
J Surg Oncol ; 2020 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-31970787

RESUMO

BACKGROUND AND OBJECTIVES: Recent studies demonstrating decreased survival following minimally invasive surgery (MIS) for cervical cancer have generated concern regarding oncologic efficacy of MIS. Our objective was to evaluate the association between surgical approach and 5-year survival following resection of abdominopelvic malignancies. METHODS: Patients with stage I or II adenocarcinoma of the prostate, colon, rectum, and stage IA2 or IB1 cervical cancer from 2010-2015 were identified from the National Cancer Data Base. The association between surgical approach and 5-year survival was assessed using propensity-score-matched cohorts. Distributions were compared using logistic regression. Hazard ratio for death was estimated using Cox proportional-hazard models. RESULTS: The rate of deaths at 5 years was 3.4% following radical prostatectomy, 22.9% following colectomy, 18.6% following proctectomy, and 6.8% following radical hysterectomy. Open surgery was associated with worse survival following radical prostatectomy (HR, 1.18; 95% CI, 1.05-1.33; P = .005), colectomy (HR, 1.45; 95% CI, 1.39-1.51; P < .001), and proctectomy (HR, 1.28; 95% CI, 1.10-1.50; P = .002); however, open surgery was associated with improved survival following radical hysterectomy (HR, 0.61; 95% CI, 0.44-0.82; P = .003). CONCLUSIONS: These results suggest that MIS is an acceptable approach in selected patients with prostate, colon, and rectal cancers, while concerns regarding MIS resection of cervical cancer appear warranted.

3.
Ann Surg Oncol ; 27(1): 214-221, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31187369

RESUMO

INTRODUCTION: Cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) is an effective treatment option for selected patients with peritoneal metastases (PM), but national utilization patterns are poorly understood. The objectives of this study were to (1) describe population-based trends in national utilization of CRS/IPC; (2) define the most common indications for the procedure; and (3) characterize the types of hospitals performing the procedure. METHODS: The National Inpatient Sample (NIS) was used to identify patients from 2006 to 2015 who underwent CRS/IPC, and to calculate national estimates of procedural frequency and oncologic indication. Hospitals performing CRS/IPC were classified based on size and teaching status. RESULTS: The estimated annual number of CRS/IPC cases increased significantly from 189 to 1540 (p < 0.001). Overall, appendiceal cancer was the most common indication (25.7%), followed by ovarian cancer (23.3%), colorectal cancer (22.5%), and unspecified PM (15.0%). Remaining cases (13.5%) were performed for other indications. Most cases were performed in large teaching hospitals (65.9%), compared with smaller teaching hospitals (25.1%), large non-teaching hospitals (5.3%), or small non-teaching hospitals (3.2%). Patients were more likely to undergo CRS/IPC without a diagnosis based on level I evidence (appendiceal, ovarian, or colorectal) at large non-academic hospitals (odds ratio 2.00, 95% confidence interval 1.18-3.38, p = 0.010) compared with large academic hospitals. CONCLUSIONS: Utilization of CRS/IPC is increasing steadily in the US, is performed at many types of facilities, and often for a variety of indications that are not supported by high-level evidence. Given associated morbidity of CRS/IPC, a national registry dedicated to cases of IPC is necessary to further evaluate use and outcomes.

5.
J Gastrointest Surg ; 24(1): 144-154, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31420856

RESUMO

BACKGROUND: Venous thromboembolism (VTE) is the most common preventable cause of 30-day post-operative mortality, with many events occurring after hospital discharge. High-level evidence supports post-discharge VTE chemoprophylaxis following abdominal/pelvic cancer resection; however, some studies support a more tailored approach. Our objectives were to (1) identify risk factors associated with post-discharge VTE in a large cohort of patients undergoing colorectal cancer resection and (2) develop a post-discharge VTE risk calculator. METHODS: Patients who underwent colorectal cancer resection from 2012 to 2016 were identified from ACS NSQIP colectomy and proctectomy procedure-targeted modules. Multivariable logistic regression was used to identify factors associated with post-discharge VTE. Incorporating pre-operative, intra-operative, and post-operative variables, a post-discharge VTE risk calculator was constructed and validated. RESULTS: Of 51,139 patients, 387 (0.76%) developed post-discharge VTE. Pre-operative factors associated with post-discharge VTE included BMI (e.g., morbidly obese OR 2.27, 95% CI 1.65-3.12 vs. normal BMI), and thrombocytosis (OR 1.41, 95% CI 1.03-1.92). Intra-operative factors included operative time (4-6 h OR 1.56, 95% CI 1.12-2.17; > 6 h, OR 1.85, 95% CI 1.21-2.84, vs. < 2 h), and type of operation (e.g., open partial colectomy OR 1.67, 95% CI 1.30-2.16 vs. laparoscopic partial colectomy). Post-operative factors included anastomotic leak (OR 2.05, 95% CI 1.31-3.21) and post-operative ileus (OR 1.39, 95% CI 1.07-1.79). Using the risk calculator, the predicted probability of post-discharge VTE ranged from 0.04 to 10.29%. On a 10-fold cross validation, the calculator's mean C-Statistic was 0.65. CONCLUSIONS: Patient-specific factors are associated with varying rates of post-discharge VTE. We present the first post-discharge VTE risk calculator designed for use at the time of discharge following colorectal cancer resection.

6.
J Gastrointest Surg ; 2019 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-31848871

RESUMO

BACKGROUND: The link between smoking and poor postoperative outcomes is well established. Despite this, current smokers are still offered bariatric surgery. We describe the risk of postoperative 30-day complications and readmission following laparoscopic sleeve gastrectomy and laparoscopic Roux-En-Y gastric bypass in smokers. METHODS: The National Surgical Quality Improvement Program database was queried to identify patients who underwent laparoscopic sleeve gastrectomy and Roux-En-Y gastric bypass from 2012 to 2017. Patient outcomes were compared based on smoking status. Primary outcomes included 30-day readmission and death or serious morbidity. Secondary outcomes included wound and respiratory complications. Multivariable logistic regression was used to determine the association between smoking status and measured outcomes. RESULTS: Of the 133,417 patients who underwent bariatric surgery, 12,424 (9.3%) were smokers. Smokers more frequently experienced readmission (4.9% v 4.1%, p < 0.001), death or serious morbidity (3.8% v 3.4%, p = 0.019), wound complications (2% v 1.4%, p < 0.001), and respiratory complications (0.8% v 0.5%, p < 0.001). The likelihood of death or serious morbidity (OR 1.13, 95% CI 1.01-1.26), readmission (OR 1.21, 95% CI 1.10-1.33), wound (OR 1.44, 95% CI 1.24-1.68), and respiratory complications (OR 1.69, 95% CI 1.34-2.14) were greater in smokers. The adjusted ORs remained significant on subgroup analysis of laparoscopic sleeve gastrectomy and Roux-En-Y gastric bypass patients, with the exception of death or serious morbidity in laparoscopic Roux-En-Y gastric bypass (OR 1.04, 95% CI 0.89-1.24). CONCLUSIONS: Smokers undergoing bariatric surgery experience significantly worse 30-day outcomes when compared with non-smokers. There should be a continued emphasis on perioperative smoking cessation for patients being evaluated for bariatric surgery.

7.
J Gastrointest Surg ; 2019 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-31768832

RESUMO

BACKGROUND: Minimally invasive distal pancreatectomy (MIDP) for localized neoplasms has been demonstrated to be feasible and safe. However, national adoption of the technique is poorly understood. Objectives of this study were to identify factors associated with use of minimally invasive distal pancreatectomy for localized neoplasms and assess hospital variation in MIDP utilization. METHODS: Retrospective cohort study of patients with pancreatic cysts, stage I pancreatic ductal adenocarcinoma, and stage I pancreatic neuroendocrine tumors undergoing distal pancreatectomy from the ACS NSQIP Pancreas Targeted Dataset. Factors associated with use of MIDP were identified using multivariable logistic regression and hospital-level variation was assessed. RESULTS: Analysis included 3,059 patients at 139 hospitals. Overall, 64.5% of patients underwent minimally invasive distal pancreatectomy. Patients were more likely to undergo MIDP if they had lower ASA classification (P = 0.004) or BMI ≥ 30 (P < 0.001) and less likely if they had pancreatic adenocarcinoma (P < 0.001). There was notable hospital variability in utilization (range 0 to 100% of cases). Hospital-level utilization of minimally invasive distal pancreatectomy did not appear to be driven by patient selection, as hierarchical analysis demonstrated that only 1.8% of observed hospital variation was attributable to measured patient selection factors. CONCLUSION: Utilization of MIDP for localized pancreatic neoplasms is highly variable. While some patient-level factors are associated with MIDP use, hospital adoption of MIDP appears to be the primary driver of utilization. Monitoring hospital-level use of MIDP may be a useful quality measure to monitor uptake of emerging techniques in pancreatic surgery.

8.
Am J Surg ; 2019 Oct 25.
Artigo em Inglês | MEDLINE | ID: mdl-31679652

RESUMO

BACKGROUND: General surgery residencies continue to experience high levels of attrition. METHODS: Survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination. Outcomes were consideration of leaving residency, potential alternative career paths, and reasons for staying in residency. RESULTS: Among 7,409 residents, 930 (12.6%) reported considering leaving residency over the last year. Residents were more likely to consider other general surgery programs (46.2%) if PGY 2/3 (OR: 1.93, 95%CI 1.34-2.77) or reporting frequent duty hour violations (OR: 1.58, 95%CI 1.12-2.24). Consideration of other specialties (47.0%) was more likely if dissatisfied with being a surgeon (OR 2.86, 95%CI 1.92-4.26). Residents were more likely to consider leaving medicine (49.7%) if female (OR: 1.54, 95%CI 1.16-2.06) or dissatisfied with a surgical career (OR: 2.81, 95%CI 1.85-4.27). Common reasons for remaining in residency included a sense of too much invested to leave (65.3%) and career satisfaction (55.5%). CONCLUSION: Profiles of trainees considering leaving residency exist based on factors associated with alternative careers. This may be a target for future interventions to reduce attrition.

9.
Ann Surg Oncol ; 2019 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-31691112

RESUMO

INTRODUCTION: Chemotherapy is increasingly administered prior to resection in patients with early-stage pancreatic adenocarcinoma, but the national prevalence of this practice is poorly understood. Our objectives were to (1) describe the utilization of upfront chemotherapy management of stage I pancreatic cancer; (2) define factors associated with the use of upfront chemotherapy and subsequent resection; and (3) assess hospital-level variability in upfront chemotherapy and subsequent resection. METHODS: The National Cancer Database was used to identify patients treated for clinical stage I pancreatic adenocarcinoma. Outcomes were receipt of upfront chemotherapy and surgical resection after upfront chemotherapy. Associations between patient/hospital factors and both initial management and subsequent resection were assessed by multivariable logistic regression. RESULTS: A total of 17,495 patients were included, with 26.6% receiving upfront chemotherapy. Upfront chemotherapy was more likely in patients who were ≥ 80 years of age (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.39-1.93), had T2 tumors (OR 2.56, 95% CI 2.36-2.78), or were treated at a low-volume center (OR 2.10, 95% CI 1.63-2.71). Among patients receiving upfront chemotherapy, only 33.5% underwent subsequent resection. Resection was more likely in patients with T1 tumors (OR 1.22, 95% CI 1.04-1.43) and in those treated at high-volume centers (OR 4.03, 95% CI 2.90-5.60). Only 20.4% of hospitals performed resection in > 50% of patients after upfront chemotherapy. CONCLUSION: Rates of surgical resection after upfront chemotherapy are relatively low, and the proportion of patients who eventually undergo resection varies considerably between hospitals. The use of surgery after upfront chemotherapy in resectable pancreatic cancer should be considered as an internal quality-of-cancer-care measure.

10.
Ann Surg ; 2019 Apr 04.
Artigo em Inglês | MEDLINE | ID: mdl-31724974

RESUMO

MINI: Duty hour reform resulted in substantial changes in surgical education. In this difference-in-differences study, we examine the outcomes of patients treated by new surgeons who trained before and after duty reform. New surgeons trained after the duty hour reform achieved similar clinical results to those trained before the reform when compared with experienced surgeons practicing in the same time period in the same hospitals. OBJECTIVE: The aim of the study was to address the controversy surrounding the effects of duty hour reform on new surgeon performance, we analyzed patients treated by new surgeons following the transition to independent practice. SUMMARY BACKGROUND DATA: In 2003, duty hour reform affected all US surgical training programs. Its impact on the performance of new surgeons remains unstudied. METHODS: We studied 30-day mortality among 1,483,074 Medicare beneficiaries undergoing general and orthopedic operations between 1999 and 2003 ("traditional" era) and 2009 and 2013 ("modern" era). The operations were performed by 2762 new surgeons trained before the reform, 2119 new surgeons trained following reform and 15,041 experienced surgeons. We used a difference-in-differences analysis comparing outcomes in matched patients treated by new versus experienced surgeons within each era, controlling for the hospital, operation, and patient risk factors. RESULTS: Traditional era odds of 30-day mortality among matched patients treated by new versus experienced surgeons were significantly elevated [odds ratio (OR) 1.13; 95% confidence interval (CI) (1.05, 1.22), P < 0.001). The modern era elevated odds of mortality were not significant [OR 1.06; 95% CI (0.97-1.16), P = 0.239]. Relative performance of new and experienced surgeons with respect to 30-day mortality did not appear to change from the traditional era to the modern era [OR 0.93; 95% CI (0.83-1.05), P = 0.233]. There were statistically significant adverse changes over time in relative performance to experienced surgeons in prolonged length of stay [OR 1.08; 95% CI (1.02-1.15), P = 0.015], anesthesia time [9 min; 95% CI (8-10), P < 0.001], and costs [255USD; 95% CI (2-508), P = 0.049]. CONCLUSIONS: Duty hour reform showed no significant effect on 30-day mortality achieved by new surgeons compared to their more experienced colleagues. Patients of new surgeons, however, trained after duty hour reform displayed some increases in the resources needed for their care.

11.
N Engl J Med ; 381(18): 1741-1752, 2019 10 31.
Artigo em Inglês | MEDLINE | ID: mdl-31657887

RESUMO

BACKGROUND: Physicians, particularly trainees and those in surgical subspecialties, are at risk for burnout. Mistreatment (i.e., discrimination, verbal or physical abuse, and sexual harassment) may contribute to burnout and suicidal thoughts. METHODS: A cross-sectional national survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination assessed mistreatment, burnout (evaluated with the use of the modified Maslach Burnout Inventory), and suicidal thoughts during the past year. We used multivariable logistic-regression models to assess the association of mistreatment with burnout and suicidal thoughts. The survey asked residents to report their gender. RESULTS: Among 7409 residents (99.3% of the eligible residents) from all 262 surgical residency programs, 31.9% reported discrimination based on their self-identified gender, 16.6% reported racial discrimination, 30.3% reported verbal or physical abuse (or both), and 10.3% reported sexual harassment. Rates of all mistreatment measures were higher among women; 65.1% of the women reported gender discrimination and 19.9% reported sexual harassment. Patients and patients' families were the most frequent sources of gender discrimination (as reported by 43.6% of residents) and racial discrimination (47.4%), whereas attending surgeons were the most frequent sources of sexual harassment (27.2%) and abuse (51.9%). Proportion of residents reporting mistreatment varied considerably among residency programs (e.g., ranging from 0 to 66.7% for verbal abuse). Weekly burnout symptoms were reported by 38.5% of residents, and 4.5% reported having had suicidal thoughts during the past year. Residents who reported exposure to discrimination, abuse, or harassment at least a few times per month were more likely than residents with no reported mistreatment exposures to have symptoms of burnout (odds ratio, 2.94; 95% confidence interval [CI], 2.58 to 3.36) and suicidal thoughts (odds ratio, 3.07; 95% CI, 2.25 to 4.19). Although models that were not adjusted for mistreatment showed that women were more likely than men to report burnout symptoms (42.4% vs. 35.9%; odds ratio, 1.33; 95% CI, 1.20 to 1.48), the difference was no longer evident after the models were adjusted for mistreatment (odds ratio, 0.90; 95% CI, 0.80 to 1.00). CONCLUSIONS: Mistreatment occurs frequently among general surgery residents, especially women, and is associated with burnout and suicidal thoughts.


Assuntos
Esgotamento Profissional/epidemiologia , Cirurgia Geral/educação , Internato e Residência , Abuso Físico/estatística & dados numéricos , Assédio Sexual/estatística & dados numéricos , Discriminação Social/estatística & dados numéricos , Esgotamento Profissional/psicologia , Feminino , Humanos , Masculino , Estado Civil , Corpo Clínico Hospitalar , Recursos Humanos em Hospital , Abuso Físico/psicologia , Relações Médico-Paciente , Relações Profissional-Família , Fatores Sexuais , Assédio Sexual/psicologia , Discriminação Social/psicologia , Ideação Suicida , Inquéritos e Questionários , Estados Unidos/epidemiologia
12.
Artigo em Inglês | MEDLINE | ID: mdl-31596745

RESUMO

INTRODUCTION: A growing number of online hospital rating systems for orthopaedic surgery are found. Although the accuracy and consistency of these systems have been questioned in other fields of medicine, no formal analysis of these systems in orthopaedics has been found. METHODS: Five hospital rating systems (US News, HealthGrades, CareChex, Women's Choice, and Hospital Compare) were examined which designate "high-performing" and "low-performing" hospitals for orthopaedic surgery. Descriptive analysis was conducted for all hospitals defined as high- or low-performing in any of the five rating systems, and assessment for agreement/disagreement between ratings was done. A subsample of hospitals ranked by all systems was then created, and agreement between rating systems was investigated using a Cohen's kappa. Each hospital was included in a multinomial logistic regression model investigating which hospital characteristics increased the odds of being favorably/unfavorably rated by each system. RESULTS: One thousand six hundred forty hospitals were evaluated by every rating system. Six hundred thirty-eight unique hospitals were identified as high-performing by at least 1 rating system; however, no hospital was ranked as high-performing by all five rating systems. Four hundred fifty-two unique hospitals were identified as low-performing; however, no hospital was ranked as low-performing by all the three rating systems which define low-performing hospitals. Within the study subsample of hospitals evaluated by each system, little agreement between any combination of rating systems (κ < 0.10) regarding top-tier or bottom-tier performance was found. It was more likely for a hospital to be considered high-performing by one system and low-performing by another (10.66%) than for the majority of the five rating systems to consider a hospital high-performing (3.76%). CONCLUSION: Little agreement between hospital quality rating systems for orthopaedic surgery is found. Publicly available hospital ratings for performance in orthopaedic surgery offer conflicting results and provide little guidance to patients, providers, or payers when selecting a hospital for orthopaedic surgery. LEVEL OF EVIDENCE: Level 1 economic study.

13.
J Am Coll Surg ; 229(6): 609-620, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31541698

RESUMO

BACKGROUND: Needlestick injuries pose significant health hazards; however, the nationwide frequency of needlesticks and reporting practices among surgical residents are unknown. The objectives of this study were to examine the rate and circumstances of self-reported needlestick events in US surgery residents, assess factors associated with needlestick injuries, evaluate reporting practices, and identify reporting barriers. STUDY DESIGN: A survey administered after the American Board of Surgery In-Training Examination (January 2017) asked surgical residents how many times they experienced a needlestick during the last 6 months, circumstances of the most recent event, and reporting practices and barriers. Factors associated with needlestick events were examined using multivariable hierarchical regression models. RESULTS: Among 7,395 resident survey respondents from all 260 US general surgery residency programs (99.3% response rate), 27.7% (n = 2,051) noted experiencing a needlestick event in the last 6 months. Most events occurred in the operating room (77.5%) and involved residents sticking themselves (76.2%), mostly with solid needles (84.7%). Self-reported factors underlying needlestick events included residents' own carelessness (48.8%) and feeling rushed (31.3%). Resident-level factors associated with self-reported needlestick events included senior residents (PGY5 29.9% vs PGY1 22.4%; odds ratio 1.66; 95% CI 1.41 to 1.96), female sex (31.9% vs male 25.2%; odds ratio 1.31; 95% CI 1.18 to 1.46), or frequently working more than 80 hours per week (odds ratio 1.42; 95% CI 1.20 to 1.68). More than one-fourth (28.7%) of residents did not report the needlestick event to employee health. CONCLUSIONS: In this comprehensive national survey of surgical residents, needlesticks occurred frequently. Many needlestick events were not reported and numerous reporting barriers exist. These findings offer guidance in identifying opportunities to reduce needlesticks and encourage reporting of these potentially preventable injuries among trainees.

14.
Health Aff (Millwood) ; 38(9): 1523-1529, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31479370

RESUMO

The star rating system for hospitals of the Centers for Medicare and Medicaid Services (CMS) pools all hospitals together and awards each institution one to five stars for quality, despite variation across hospitals in the numbers and types of measures they report. Thus, hospitals essentially are being evaluated differently, which affects the validity of quality comparisons. We considered the number and types of measures reported and the size of measure denominators to represent different forms of a "test," and we used data from the December 2017 star ratings to show that hospitals took one of three general "test forms." Hospitals taking the most extensive test form reported an average of forty-three measures, while those taking the least extensive test reported an average of twenty-two measures. These test forms were differentially associated with star ratings and hospital characteristics. Our results caution against pooling all hospitals together when assigning star ratings, and they demonstrate a feasible approach to segmenting hospitals into peer groups for evaluation by stakeholders such as CMS.

15.
Ann Surg ; 270(4): 701-711, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31503066

RESUMO

OBJECTIVES: Our objective was to examine the implementation and associated clinical outcomes of a comprehensive surgical site infection (SSI) reduction bundle in a large statewide surgical quality improvement collaborative leveraging a multifaceted implementation strategy. SUMMARY BACKGROUND DATA: Bundled perioperative interventions reduce colorectal SSI rates when enacted at individual hospitals, but the ability to implement comprehensive SSI bundles and to examine the resultant clinical effectiveness within a larger, diverse population of hospitals is unknown. METHODS: A multifaceted SSI reduction bundle was developed and implemented in a large statewide surgical quality improvement collaborative through a novel implementation program consisting of guided implementation, data feedback, mentorship, process improvement training/coaching, and targeted-implementation toolkits. Bundle adherence and ACS NSQIP outcomes were examined preimplementation versus postimplementation. RESULTS: Among 32 hospitals, there was a 2.5-fold relative increase in the proportion of patients completing at least 75% of bundle elements (preimplementation = 19.5% vs. postimplementation = 49.8%, P = 0.001). Largest adherence gains were seen in wound closure re-gowning/re-gloving (24.0% vs. 62.0%, P < 0.001), use of clean closing instruments (32.1% vs. 66.2%, P = 0.003), and preoperative chlorhexidine bathing (46.1% vs. 77.6%, P < 0.001). Multivariable analyses showed a trend toward lower risk of superficial incisional SSI in the postimplementation period compared to baseline (OR 0.70, 95% CI 0.49-10.2, P = 0.06). As the adherence in the number of bundle elements increased, there was a significant decrease in superficial SSI rates (lowest adherence quintile, 4.6% vs. highest, 1.5%, P < 0.001). CONCLUSIONS: A comprehensive multifaceted SSI reduction bundle can be successfully implemented throughout a large quality improvement learning collaborative when coordinated quality improvement activities are leveraged, resulting in a 30% decline in SSI rates. Lower superficial SSI rates are associated with the number of adherent bundle elements a patient receives, rendering considerable benefits to institutions capable of implementing more components of the bundle.

16.
Ann Surg ; 270(4): 585-592, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31425291

RESUMO

OBJECTIVES: To empirically describe surgical residency program culture and assess program characteristics associated with program culture. SUMMARY BACKGROUND DATA: Despite concerns about the impact of the learning environment on trainees, empirical data have not been available to examine and compare program-level differences in residency culture. METHODS: Following the 2018 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. Survey items were analyzed using principal component analysis to derive composite measures of program culture. Associations between program characteristics and composite measures of culture were assessed. RESULTS: Analysis included 7387 residents at 260 training programs (99.3% response rate). Principal component analysis suggested that program culture may be described by 2 components: Wellness and Negative Exposures. Twenty-six programs (10.0%) were in the worst quartile for both Wellness and Negative Exposure components. These programs had significantly higher rates of duty hour violations (23.3% vs 11.1%), verbal/physical abuse (41.6% vs 28.6%), gender discrimination (78.7% vs 64.5%), sexual harassment (30.8% vs 16.7%), burnout (54.9% vs 35.0%), and thoughts of attrition (21.6% vs 10.8%; all P < 0.001). Being in the worst quartile of both components was associated with percentage of female residents in the program (P = 0.011), but not program location, academic affiliation, size, or faculty demographics. CONCLUSIONS: Residency culture was characterized by poor resident wellness and frequent negative exposures and was generally not associated with structural program characteristics. Additional qualitative and quantitative studies are needed to explore unmeasured local social dynamics that may underlie measured differences in program culture.

17.
Ann Surg ; 2019 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-31425331

RESUMO

OBJECTIVES: Our objective was to examine the implementation and associated clinical outcomes of a comprehensive surgical site infection (SSI) reduction bundle in a large statewide surgical quality improvement collaborative leveraging a multifaceted implementation strategy. SUMMARY BACKGROUND DATA: Bundled perioperative interventions reduce colorectal SSI rates when enacted at individual hospitals, but the ability to implement comprehensive SSI bundles and to examine the resultant clinical effectiveness within a larger, diverse population of hospitals is unknown. METHODS: A multifaceted SSI reduction bundle was developed and implemented in a large statewide surgical quality improvement collaborative through a novel implementation program consisting of guided implementation, data feedback, mentorship, process improvement training/coaching, and targeted-implementation toolkits. Bundle adherence and ACS NSQIP outcomes were examined preimplementation versus postimplementation. RESULTS: Among 32 hospitals, there was a 2.5-fold relative increase in the proportion of patients completing at least 75% of bundle elements (preimplementation = 19.5% vs. postimplementation = 49.8%, P = 0.001). Largest adherence gains were seen in wound closure re-gowning/re-gloving (24.0% vs. 62.0%, P < 0.001), use of clean closing instruments (32.1% vs. 66.2%, P = 0.003), and preoperative chlorhexidine bathing (46.1% vs. 77.6%, P < 0.001). Multivariable analyses showed a trend toward lower risk of superficial incisional SSI in the postimplementation period compared to baseline (OR 0.70, 95% CI 0.49-10.2, P = 0.06). As the adherence in the number of bundle elements increased, there was a significant decrease in superficial SSI rates (lowest adherence quintile, 4.6% vs. highest, 1.5%, P < 0.001). CONCLUSIONS: A comprehensive multifaceted SSI reduction bundle can be successfully implemented throughout a large quality improvement learning collaborative when coordinated quality improvement activities are leveraged, resulting in a 30% decline in SSI rates. Lower superficial SSI rates are associated with the number of adherent bundle elements a patient receives, rendering considerable benefits to institutions capable of implementing more components of the bundle.

18.
J Hosp Med ; 14(10): 668-672, 2019 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-31433769

RESUMO

BACKGROUND: Venous thromboembolism (VTE) is a serious medical condition that results in preventable morbidity and mortality. OBJECTIVES: The objective of this study was to identify nursing-related barriers to administration of VTE chemoprophylaxis to hospitalized patients. DESIGN: This was a qualitative study including nurses from five inpatient units at one hospital. METHODS: Observations were conducted on five units to gain insight into the process for administering chemoprophylaxis. Focus group interviews were conducted with nurses and were audio-recorded, transcribed verbatim, and analyzed using the Theoretical Domains Framework to identify barriers to providing VTE chemoprophylaxis. RESULTS: We conducted 14 focus group interviews with nurses from five inpatient units to assess nurses' perceptions of barriers to administration of VTE chemoprophylaxis. The barriers identified included nurses' misconceptions that ambulating patients did not require chemoprophylaxis, nurses' uncertainty when counseling patients on the importance of chemoprophylaxis, and a lack of comparative data for nurses regarding their specific refusal rates. CONCLUSIONS: Multiple factors act as barriers to patients receiving VTE chemoprophylaxis. These barriers are often modifiable targets for quality improvement. There is a need to focus on behavior changes that will remove or minimize barriers and equip nurses to ensure administration of VTE chemoprophylaxis by engaging patients in their care.

19.
Surg Endosc ; 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31388808

RESUMO

INTRODUCTION: Traditionally, laparoscopic Nissen fundoplication (LNF) has been considered an inpatient procedure. Advances in surgical and anesthetic techniques have led to a shift towards outpatient LNF procedures. However, differences in surgical outcomes between outpatient and inpatient LNF are poorly understood. The objectives of this study were (1) to describe the frequency of outpatient LNF in a national cohort and (2) to identify any differences in complications or readmission rates between outpatient and inpatient LNF. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify elective LNF cases from 2012 to 2016. Patients discharged on the day of surgery were compared to those discharged 24-48 h post-operatively. Outcomes included 30-day readmission and death or serious morbidity (DSM). Bivariate analyses were completed with Chi squared testing for categorical variables and two sided t tests for continuous variables. Associations between outpatient surgery and outcomes were assessed using multivariable logistic regression. Differences in readmission were analyzed using Kaplan-Meier failure estimates and log-rank tests. RESULTS: Of 7734 patients who underwent elective LNF, 568 (7.3%) were discharged on the day of surgery. The overall 30-day readmission rate was 4.1% (n = 316) and the overall rate of DSM was 1.0% (n = 79). The most common 30-day readmission diagnoses overall were infectious complications (16.1%), dysphagia (12.9%), and abdominal pain (11.7%). On multivariable analysis, there was no association between outpatient surgery and 30-day readmission (3.9% vs. 4.1%; aOR 0.97, 95% CI 0.62-1.52, p = 0.908) or DSM (1.1% vs. 1.0%; aOR 0.91, 95%CI 0.36-2.29, p = 0.848). Kaplan-Meier analysis showed no difference in rates of hospital readmission between groups at 30-days from discharge (3.9% vs. 4.1%, p = 0.325). CONCLUSIONS: Among patients undergoing elective LNF, there were no significant differences in post-operative complications and 30-day readmission when compared to traditional inpatient postoperative care. Further consideration should be given to transitioning LNF to an outpatient procedure.

20.
J Thorac Cardiovasc Surg ; 157(3): 1219-1235, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31343410

RESUMO

OBJECTIVE: In this study we present historic data on adherence to and survival outcomes associated with recently introduced quality measures for the management of non-small-cell lung cancer. METHODS: The National Cancer Data Base was queried to identify all patients with non-small-cell lung cancer from 1998 to 2011. Adherence to guidelines was assessed for each of 3 Commission on Cancer-defined quality measures: (1) sampling 10 regional lymph nodes at surgery; (2a) surgery within 120 days of neoadjuvant chemotherapy or, (2b) 180 days of adjuvant chemotherapy; and (3) nonsurgical primary therapy in cN2 disease. The likelihood of measure adherence and the association of measure adherence with all-cause mortality were analyzed controlling for patient, hospital, and time period characteristics. RESULTS: Regional lymph node sampling was inadequate in 72.7% of cases. Only 28.7% began adjuvant chemotherapy within 180 days of surgery. However, 96.5% of patients who received neoadjuvant chemotherapy proceeded to surgery within 120 days and surgery was first-line treatment for cN2 disease in only 3.7% of patients. Uninsured or Medicaid status was an independent risk factor for a prolonged delay between neoadjuvant chemotherapy and surgery (odds ratio, 1.36; 95% confidence interval, 1.08-1.72) and surgery and adjuvant treatment (odds ratio, 1.92; 95% confidence interval, 1.69-2.19). Overall survival was significantly better in patients whose care conformed to quality standards for nodal sampling (measure 1), and timing of chemotherapy. CONCLUSIONS: Adherence rates for nodal sampling at the time of surgery and receipt of adjuvant chemotherapy were low. These findings highlight opportunities for improvement efforts, but more measures are needed to more broadly assess the quality of lung cancer care.

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