Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA.

OBJECTIVE: Over 15 million colonoscopies and 7 million osophagogastroduodenoscopies (OGDs) are performed annually in the USA. We aimed to estimate the rates of infections after colonoscopy and OGD performed in ambulatory surgery centres (ASCs). DESIGN: We identified colonoscopy and OGD procedures performed at ASCs in 2014 all-payer claims data from six states in the USA. Screening mammography, prostate cancer screening, bronchoscopy and cystoscopy procedures were comparators. We tracked infection-related emergency department visits and unplanned in-patient admissions within 7 and 30 days after the procedures, examined infection sites and organisms and analysed predictors of infections. We investigated case-mix adjusted variation in infection rates by ASC. RESULTS: The rates of postendoscopic infection per 1000 procedures within 7 days were 1.1 for screening colonoscopy, 1.6 for non-screening colonoscopy and 3.0 for OGD; all higher than screening mammography (0.6) but lower than bronchoscopy (15.6) and cystoscopy (4.4) (p<0.0001). Predictors of postendoscopic infection included recent history of hospitalisation or endoscopic procedure; concurrence with another endoscopic procedure; low procedure volume or non-freestanding ASC; younger or older age; black or Native American race and male sex. Rates of 7-day postendoscopic infections varied widely by ASC, ranging from 0 to 115 per 1000 procedures for screening colonoscopy, 0 to 132 for non-screening colonoscopy and 0 to 62 for OGD. CONCLUSION: We found that postendoscopic infections are more common than previously thought and vary widely by facility. Although screening colonoscopy is not without risk, the risk is lower than diagnostic endoscopic procedures.

Emergency Department Utilization Among the Uninsured During Insurance Expansion in Maryland.

STUDY OBJECTIVE: We analyzed the effect of insurance expansion on emergency department (ED) utilization among the uninsured in Maryland, which expanded Medicaid eligibility and created health insurance exchanges in 2014. METHODS: This was a retrospective analysis of statewide administrative claims for July 2012 to December 2015. We used coarsened exact matching to pair uninsured and insured (Medicaid, Medicare, commercial, and other) adult Maryland residents who visited an ED or were hospitalized at baseline (July 2012 to December 2013). We compared ED utilization between these groups after insurance expansion (January 2014 to December 2015), using a difference-in-differences quasi-experimental design. Nonreturning patients from the baseline period were included in the post-insurance expansion rates as having zero visits. RESULTS: Matching yielded 178,381 pairs. In the 12 months before insurance expansion, the baseline uninsured group visited the ED at a rate of 26.1 per 100 patient-quarters versus 28.2 among the insured group (relative rate=0.93). In the 24 months after insurance expansion, 45% of the baseline uninsured returned to an ED, of whom 33% returned uninsured, 40% returned with Medicaid, and 21% returned with commercial insurance. After insurance expansion, with 55% of patients in each group not returning, the ED visit rate for both the baseline uninsured and insured groups was 15.9 per 100 patient-quarters (relative rate=1.00). This 8% relative increase from baseline in ED visits among the uninsured group was driven primarily by increases in higher-acuity visits. Uninsured patients from high-poverty zip codes (N=34,964 pairs) increased their ED utilization by 15% after insurance expansion, whereas baseline uninsured patients with no comorbidities (N=94,330 pairs) showed a 3% decrease. CONCLUSION: Insurance expansion in Maryland was associated with a modest relative increase in ED visits among the uninsured, driven by increases in higher-acuity visits. It remains unclear whether insurance coverage helped the uninsured address their unmet medical needs.

Patient, surgeon, and hospital disparities associated with benign hysterectomy approach and perioperative complications.

BACKGROUND: Hysterectomy is among the most common major surgical procedures performed in women. Approximately 450,000 hysterectomy procedures are performed each year in the United States for benign indications. However, little is known regarding contemporary US hysterectomy trends for women with benign disease with respect to operative technique and perioperative complications, and the association between these 2 factors with patient, surgeon, and hospital characteristics. OBJECTIVE: We sought to describe contemporary hysterectomy trends and explore associations between patient, surgeon, and hospital characteristics with surgical approach and perioperative complications. STUDY DESIGN: Hysterectomies performed for benign indications by general gynecologists from July 2012 through September 2014 were analyzed in the all-payer Maryland Health Services Cost Review Commission database. We excluded hysterectomies performed by gynecologic oncologists, reproductive endocrinologists, and female pelvic medicine and reconstructive surgeons. We included both open hysterectomies and those performed by minimally invasive surgery, which included vaginal hysterectomies. Perioperative complications were defined using the Agency for Healthcare Research and Quality patient safety indicators. Surgeon hysterectomy volume during the 2-year study period was analyzed (0-5 cases annually = very low, 6-10 = low, 11-20 = medium, and ≥21 = high). We utilized logistic regression and negative binomial regression to identify patient, surgeon, and hospital characteristics associated with minimally invasive surgery utilization and perioperative complications, respectively. RESULTS: A total of 5660 hospitalizations were identified during the study period. Most patients (61.5%) had an open hysterectomy; 38.5% underwent a minimally invasive surgery procedure (25.1% robotic, 46.6% laparoscopic, 28.3% vaginal). Most surgeons (68.2%) were very low- or low-volume surgeons. Factors associated with a lower likelihood of undergoing minimally invasive surgery included older patient age (reference 45-64 years; 20-44 years: adjusted odds ratio, 1.16; 95% confidence interval, 1.05-1.28), black race (reference white; adjusted odds ratio, 0.70; 95% confidence interval, 0.63-0.78), Hispanic ethnicity (adjusted odds ratio, 0.62; 95% confidence interval, 0.48-0.80), smaller hospital (reference large; small: adjusted odds ratio, 0.26; 95% confidence interval, 0.15-0.45; medium: adjusted odds ratio, 0.87; 95% confidence interval, 0.79-0.96), medium hospital hysterectomy volume (reference ≥200 hysterectomies; 100-200: adjusted odds ratio, 0.78; 95% confidence interval, 0.71-0.87), and medium vs high surgeon volume (reference high; medium: adjusted odds ratio, 0.87; 95% confidence interval, 0.78-0.97). Complications occurred in 25.8% of open and 8.2% of minimally invasive hysterectomies (P < .0001). Minimally invasive hysterectomy (adjusted odds ratio, 0.22; 95% confidence interval, 0.17-0.27) and large hysterectomy volume hospitals (reference ≥200 hysterectomies; 1-100: adjusted odds ratio, 2.26; 95% confidence interval, 1.60-3.20; 101-200: adjusted odds ratio, 1.63; 95% confidence interval, 1.23-2.16) were associated with fewer complications, while patient payer, including Medicare (reference private; adjusted odds ratio, 1.86; 95% confidence interval, 1.33-2.61), Medicaid (adjusted odds ratio, 1.63; 95% confidence interval, 1.30-2.04), and self-pay status (adjusted odds ratio, 2.41; 95% confidence interval, 1.40-4.12), and very-low and low surgeon hysterectomy volume (reference ≥21 cases; 1-5 cases: adjusted odds ratio, 1.73; 95% confidence interval, 1.22-2.47; 6-10 cases: adjusted odds ratio, 1.60; 95% confidence interval, 1.11-2.23) were associated with perioperative complications. CONCLUSION: Use of minimally invasive hysterectomy for benign indications remains variable, with most patients undergoing open, more morbid procedures. Older and black patients and smaller hospitals are associated with open hysterectomy. Patient race and payer status, hysterectomy approach, and surgeon volume were associated with perioperative complications. Hysterectomies performed for benign indications by high-volume surgeons or by minimally invasive techniques may represent an opportunity to reduce preventable harm.

The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments.

STUDY OBJECTIVE: A proposed benefit of expanding Medicaid eligibility under the Patient Protection and Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for primary care needs. Pre-ACA studies found that new Medicaid enrollees increased their ED utilization rates, but the effect on system-level ED visits was less clear. Our objective was to estimate the effect of Medicaid expansion on aggregate and individual-based ED utilization patterns within Maryland. METHODS: We performed a retrospective cross-sectional study of ED utilization patterns across Maryland, using data from Maryland's Health Services Cost Review Commission. We also analyzed utilization differences between pre-ACA (July 2012 to December 2013) uninsured patients who returned post-ACA (July 2014 to December 2015). RESULTS: The total number of ED visits in Maryland decreased by 36,531 (-1.2%) between the 6 quarters pre-ACA and the 6 quarters post-ACA. Medicaid-covered ED visits increased from 23.3% to 28.9% (159,004 additional visits), whereas uninsured patient visits decreased from 16.3% to 10.4% (181,607 fewer visits). Coverage by other insurance types remained largely stable between periods. We found no significant relationship between Medicaid expansion and changes in ED volume by hospital. For patients uninsured pre-ACA who returned post-ACA, the adjusted visits per person during 6 quarters was 2.38 (95% confidence interval 2.35 to 2.40) for those newly enrolled in Medicaid post-ACA compared with 1.66 (95% confidence interval 1.64 to 1.68) for those remaining uninsured. CONCLUSION: There was a substantial increase in patients covered by Medicaid in the post-ACA period, but this did not significantly affect total ED volume. Returning patients newly enrolled in Medicaid visited the ED more than their uninsured counterparts; however, this cohort accounted for only a small percentage of total ED visits in Maryland.

Evaluation of Noninvasive Hemoglobin Monitoring in Surgical Critical Care Patients.

OBJECTIVE: To assess the clinical utility of noninvasive hemoglobin monitoring based on pulse cooximetry in the ICU setting. DESIGN AND SETTING: A total of 358 surgical patients from a large urban, academic hospital had the noninvasive hemoglobin monitoring pulse cooximeter placed at admission to the ICU. Core and stat laboratory hemoglobin measurements were taken at the discretion of the clinicians, who were blinded to noninvasive hemoglobin monitoring values. MEASUREMENT AND MAIN RESULTS: There was a poor correlation between the 2,465 time-matched noninvasive hemoglobin monitoring and laboratory hemoglobin measurements (r = 0.29). Bland-Altman analysis showed a positive bias of 1.0 g/dL and limits of agreement of -2.5 to 4.6 g/dL. Accuracy was best at laboratory values of 10.5-14.5 g/dL and least at laboratory values of 6.5-8 g/dL. At hemoglobin values that would ordinarily identify a patient as requiring a transfusion (< 8 g/dL), noninvasive hemoglobin monitoring consistently overestimated the patient's true hemoglobin. When sequential laboratory values declined below 8 g/dL (n = 102) and 7 g/dL (n = 13), the sensitivity and specificity of noninvasive hemoglobin monitoring at identifying these events were 27% and 7%, respectively. At a threshold of 8 g/dL, continuous noninvasive hemoglobin monitoring values reached the threshold before the labs in 45 of 102 instances (44%) and at 7 g/dL, noninvasive hemoglobin monitoring did so in three of 13 instances (23%). Noninvasive hemoglobin monitoring minus laboratory hemoglobin differences showed an intraclass correlation coefficient of 0.47 within individual patients. Longer length of stay and higher All Patient Refined Diagnostic-Related Groups severity of illness were associated with poor noninvasive hemoglobin monitoring accuracy. CONCLUSIONS: Although noninvasive hemoglobin monitoring technology holds promise, it is not yet an acceptable substitute for laboratory hemoglobin measurements. Noninvasive hemoglobin monitoring performs most poorly in the lower hemoglobin ranges that include commonly used transfusion trigger thresholds and is not consistent within individual patients. Further refinement of the signal acquisition and analysis algorithms and clinical reevaluation are needed.

A perverse quality incentive in surgery: implications of reimbursing surgeons less for doing laparoscopic surgery.

BACKGROUND: Surgery is one of the highest priced services in health care, and complications from surgery can be serious and costly. Recently, advances in surgical techniques have allowed surgeons to perform many common operations using minimally invasive methods that result in fewer complications. Despite this, the rates of open surgery remain high across multiple surgical disciplines. METHODS: This is an expert commentary and review of the contemporary literature regarding minimally invasive surgery practices nationwide, the benefits of less invasive approaches, and how minimally invasive compared with open procedures are differentially reimbursed in the United States. We explore the incentive of the current surgeon reimbursement fee schedule and its potential implications. RESULTS: A surgeon's preference to perform minimally invasive compared with open surgery remains highly variable in the U.S., even after adjustment for patient comorbidities and surgical complexity. Nationwide administrative claims data across several surgical disciplines demonstrates that minimally invasive surgery utilization in place of open surgery is associated with reduced adverse events and cost savings. Reducing surgical complications by increasing adoption of minimally invasive operations has significant cost implications for health care. However, current U.S. payment structures may perversely incentivize open surgery and financially reward physicians who do not necessarily embrace newer or best minimally invasive surgery practices. CONCLUSIONS: Utilization of minimally invasive surgery varies considerably in the U.S., representing one of the greatest disparities in health care. Existing physician payment models must translate the growing body of research in surgical care into physician-level rewards for quality, including choice of operation. Promoting safe surgery should be an important component of a strong, value-based healthcare system. Resolving the potentially perverse incentives in paying for surgical approaches may help address disparities in surgical care, reduce the prevalent problem of variation, and help contain health care costs.

Predicting Which Patients will Likely Benefit from Subglottic Secretion Drainage Endotracheal Tubes: A Retrospective Study.

BACKGROUND: Subglottic secretion drainage endotracheal tubes (SSD ETTs) have been shown to decrease ventilator-associated pneumonia and are recommended for patients intubated > 48 h or 72 h. However, it is difficult to determine which patients will be intubated > 48 h or 72 h at the time of intubation. OBJECTIVE: We attempted to determine which patient characteristics were associated with intubations ≥ 48 h or 72 h in order to guide proper placement of SSD ETTs. METHODS: The medical records of 2,159 ventilated patients at a single institution were retrospectively reviewed for intubation duration, age, sex, race, body mass index, weight, intubation reason, whether the intubation was emergent, operative status, intensive care unit (ICU) diagnosis, intubation location, ICU location, comorbidities (e.g., congestive heart failure, chronic obstructive pulmonary disorder, coronary artery disease, dementia, and liver disease), acute kidney injury (AKI), and chronic renal injury. A multivariate regression analysis was then performed with all reliable data. RESULTS: The following were associated with intubation ≥ 48 h: neuroscience critical care unit (NCCU) admission (risk ratio [RR] = 1.85; 95% confidence interval [CI] 1.34-2.56), emergent intubation (RR = 1.97; 95% 1.28-3.03), comorbid dementia (RR = 2.31; 95% 1.28-4.18), nonoperative intubation (RR = 1.77; 95% 1.28-4.18), and AKI (RR = 3.32; 95% 2.56-4.3). The following were independently associated with intubation ≥ 72 h: NCCU admission (RR = 2.2; 95 CI 1.57-3.08), nonoperative intubation (RR = 3.38; 95% CI 2.63-4.35), comorbid dementia (RR = 3.03; 95% CI 1.67-5.48), and AKI (RR = 3.11; 95% CI 2.38-4.07). CONCLUSION: Nonoperative intubation, emergent intubation, history of dementia, admission to NCCU and AKI all appear to be independently associated with increased RRs for either ≥ 48 h or 72 h of ventilation.

The Student Curriculum Review Team: How we catalyze curricular changes through a student-centered approach.

Student feedback is a valuable asset in curriculum evaluation and improvement, but many institutions have faced challenges implementing it in a meaningful way. In this article, we report the rationale, process and impact of the Student Curriculum Review Team (SCRT), a student-led and faculty-supported organization at the Johns Hopkins University School of Medicine. SCRT's evaluation of each pre-clinical course is composed of a comprehensive three-step process: a review of course evaluation data, a Town Hall Meeting and online survey to generate and assess potential solutions, and a thoughtful discussion with course directors. Over the past two years, SCRT has demonstrated the strength of its approach by playing a substantial role in improving medical education, as reported by students and faculty. Furthermore, SCRT's uniquely student-centered, collaborative model has strengthened relationships between students and faculty and is one that could be readily adapted to other medical schools or academic institutions.

The effects of global budget payments on hospital utilization in rural Maryland.

OBJECTIVE: To assess the effect of Maryland's 2010 Total Patient Revenue (TPR) global budget reform in eight rural hospitals on population-level hospital rates of utilization three years after implementation. DATA SOURCES/STUDY SETTING: Data on all inpatient discharges and outpatient department visits from the Health Services Cost Review Commission, population data from Claritas Demographic Reports, and county-level data from the Area Health Resource File. STUDY DESIGN: We use a difference-in-differences approach to compare changes in utilization rates over time in the reform areas comprising 125 Zip Code Tabulation Areas (ZCTAs) and in two control hospital areas (66 ZCTAs and 327 ZCTAs, respectively). We examine several inpatient and outpatient measures and distinguish between relatively discretionary and nondiscretionary utilization. DATA COLLECTION: Admissions data are hospital-reported discharge abstracts of all encounters in Maryland during 2008-2013. Population data are derived from the US Census. PRINCIPAL FINDINGS: We find no statistically significant changes in admissions, either overall or discretionary. We find a statistically significant 8.9 percent (95%CI = [1.8, 16.0]) reduction in outpatient visits, with a statistically significant reduction of 14.8 percent (95%CI = [5.3, 24.3]) visits not to the Emergency Department. CONCLUSIONS: We find that the TPR reform decreased outpatient utilization but did not affect inpatient utilization.

Association Between Board Certification, Maintenance of Certification, and Surgical Complications in the United States.

Physician credentialing processes aim to improve patient safety and quality, but little research has examined their direct relationship with surgical outcomes. Using national Medicare claims for 2009 to 2013, the authors studied the association between board certification and completion of Maintenance of Certification (MOC) requirements and surgeon rates of complications for 8 elective procedures. Exemplar surgeons were defined as those in the lowest decile of complication rates, and outlier surgeons were those in the highest decile. The analysis included 1.9 million procedures performed by 14 598 surgeons (64% orthopedics, 17% general surgery, 11% urology, 7% neurosurgery). Board-certified surgeons were less likely to be outliers (odds ratio 0.79 [0.66-0.94]). However, completion of MOC was not associated with differences in complication rates in orthopedic surgery or urology. Incorporating additional assessment methods into MOC, such as video evaluation of technical skills, retraining on state-of-the-art care, and peer review, may facilitate further improvements in surgical quality.

Evaluation of a Peer-to-Peer Data Transparency Intervention for Mohs Micrographic Surgery Overuse.

IMPORTANCE: Mohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions based on margin status. Wide surgeon-level variation exists in the mean number of staged resections used to treat a tumor, resulting in a cost disparity and question of appropriateness. OBJECTIVE: To evaluate the effectiveness of a behavioral intervention aimed at reducing extreme overuse in MMS, as defined by the specialty society, by confidentially sharing stages-per-case performance data with individual surgeons benchmarked to their peers nationally. DESIGN, SETTING, AND PARTICIPANTS: This nonrandomized controlled intervention study included 2329 US surgeons who performed MMS procedures from January 1, 2016, to March 31, 2018. Physicians were identified using a 100% capture of Medicare Part B claims. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery. INTERVENTIONS: Individualized performance reports were delivered to all outlier surgeons, defined by the specialty society as those with mean stages per case 2 SDs above the mean, and inlier surgeons in the intervention group. MAIN OUTCOMES AND MEASURES: The primary outcome was surgeon-level change in mean stages per case between the prenotification (January 2016 to January 2017) and postnotification (March 2017 to March 2018) periods. A multivariable linear regression model was used to evaluate the association of notification with this surgeon-level outcome. The surgeon-level metric of mean stages per case was not risk adjusted. The mean Medicare cost savings associated with changes in practice patterns were calculated. RESULTS: Of the 2329 included surgeons, 1643 (70.5%) were male and 2120 (91.0%) practiced in metropolitan areas. In the intervention group (n = 1045), 53 surgeons (5.1%) were outliers; in the control group (n = 1284), 87 surgeons (6.8%) were outliers. Among the outliers in the intervention group, 44 (83%) demonstrated a reduction in mean stages per case compared with 60 outliers in the control group (69%; difference, 14%; 95% CI of difference, -1 to 27; P = .07). There was a mean stages-per-case reduction of 12.6% among outliers in the intervention group compared with 9.0% among outliers in the control group, and outliers in the intervention group had an adjusted postintervention differential decrease of 0.14 stages per case (95% CI, -0.19 to -0.09; P = .002). The total administrative cost of the intervention program was $150 000, and the estimated reduction in Medicare spending was $11.1 million. CONCLUSIONS AND RELEVANCE: Sharing personalized practice pattern data with physicians benchmarked to their peers can reduce overuse of MMS among outlier physicians.

Variation in markups on outpatient oncology services in the United States.

OBJECTIVES: Price markups are a major cause of healthcare inflation and financial harm to patients, especially those who are self-paying or covered by commercial insurance. STUDY DESIGN: Retrospective analysis of publicly-available information on Medicare physician payments, representing 100% of Part B services provided to fee-for-service beneficiaries during calendar year 2014. METHODS: Outcomes were markup ratios for oncology services, defined as the ratio of submitted charges to the amount reimbursed by Medicare. For example, the overall cost-to-charge ratio for all Medicare-reimbursed services in 2013 was 3.4, or a 240% charge markup. RESULTS: Our analysis included oncology services provided by 3248 hospitals in all 50 states. There was significant variation in markup ratios by hospital across oncology specialty: radiology (median = 3.7; interquartile range [IQR], 3.1-4.5), hematology/oncology (median = 2.3; IQR, 1.8-2.9), medical oncology (median = 2.4; IQR, 1.8-3.0), pathology (median = 4.1; IQR 3.1-5.1), and radiation oncology (median = 3.6; IQR, 2.9-4.5). Higher markups were associated with for-profit status for medical oncology services (coefficient, 0.29; 95% CI, 0.12-0.45) and prestige status for radiology (0.53; 95% CI, 0.15-0.92) and pathology (0.65; 95% CI, 0.20-1.09) services. CONCLUSIONS: High markups exist for oncology services, and further legislation is needed to protect patients from highly variable pricing and to address disparities in access to high-quality cancer care.

The Impact of Price Transparency for Surgical Services.

Increasing insurance deductibles have prompted some medical centers to initiate transparent pricing. However, the impact of price transparency (PT) on surgical volume, revenue, and patient satisfaction is unknown, along with the barriers to achieving PT. We identified ambulatory surgical centers in the Free Market Medical Association database that publicly list prices for surgical services online. Six of eight centers (75%) responded to our data collection inquiry. Among five centers that reported their patient volume and revenue after adopting PT, patient volume increased by a median of 50 per cent (range 10-200%) at one year. Four centers (80%) reported an increase in revenue by a median of 30 per cent (range 4-75%), whereas three centers (60%) experienced an increase in third-party administrator contracts with the average increase being seven new third-party administrator contracts (range = 2-12 contracts). Three centers (50%) reported a reduction in their administrative burden and five centers (83%) reported an increase in patient satisfaction and patient engagement after PT. The leading barrier reported to making prices transparent was discouragement from another practice, hospital, or insurance company. The findings of this preliminary study may help guide medical practices in designing and implementing PT strategies.

Comparison of upper gastrointestinal fluoroscopy versus computed tomography for evaluation of post-operative leak in a bariatric surgery patient.

Bariatric surgery patients commonly undergo post-operative fluoroscopic evaluation for complications, including leaks, in order to progress with oral intake and recovery. As one of the most severe and potentially life-threatening complications, leaks occur in as many as 5% of bariatric surgery patients. Several characteristics of these patients complicate the detection of leaks, including large body habitus and limited mobility. The early detection of leaks can lead to significant reductions in morbidity and mortality in bariatric surgery patients. In a retrospective case series of 619 patients, of whom 20 had experienced a leak, CT scan had a sensitivity of 95% and specificity of 100%, while upper gastrointestinal (UGI) evaluation had an inferior sensitivity of 79% and specificity of 95%. In addition to greater sensitivity and specificity, CT scan can identify other complications, such as abscesses and bowel obstructions. Also, UGI evaluation is notably more dependent on patient and technologist compliance, resulting in suboptimal examinations. UGI, on the other hand, may help further define the size and more precise location of the leak, but typically cannot be performed until the following day if the patient becomes symptomatic at night. We propose that CT evaluation, used in combination with UGI, may increase the overall sensitivity of detecting a leak, thereby improving patient outcomes and decreasing hospital utilization.

Medical Student Perceptions of Global Surgery at an Academic Institution: Identifying Gaps in Global Health Education.

PURPOSE: Robust global health demands access to safe, affordable, timely surgical care for all. The long-term success of global surgery requires medical students to understand and engage with this emerging field. The authors characterized medical students' perceptions of surgical care relative to other fields within global health. METHOD: An optional, anonymous survey was given to all Johns Hopkins medical students from February to March 2016 to assess perceptions of surgical care and its role in global health. RESULTS: Of 480 students, 365 (76%) completed the survey, with 150 (41%) reporting global health interests. One-third (34%) of responding students felt that surgical care is one of two fields with the greatest potential global health impact in the future, second to infectious disease (49%). A minority (28%) correctly identified that trauma results in more deaths worldwide than obstetric complications or HIV/AIDS, tuberculosis, and malaria combined. Relative to other examined fields, students perceived surgical care as the least preventive and cost-effective, and few students (3%) considered adequate surgical care the best indicator of a robust health care system. Students believed that practicing in a surgical field was least amenable to pursuing a global health career, citing several barriers. CONCLUSIONS: Medical students have several perceptions of global surgery that contradict current evidence and literature, which may have implications for their career choices. Opportunities to improve students' global health knowledge and awareness of global surgery career paths include updating curricula, fostering meaningful international academic opportunities, and creating centers of global surgery and global health consortia.

Rodent models of obsessive compulsive disorder: Evaluating validity to interpret emerging neurobiology.

Obsessive Compulsive Disorder (OCD) is a common neuropsychiatric disorder with unknown molecular underpinnings. Identification of genetic and non-genetic risk factors has largely been elusive, primarily because of a lack of power. In contrast, neuroimaging has consistently implicated the cortico-striatal-thalamo-cortical circuits in OCD. Pharmacological treatment studies also show specificity, with consistent response of OCD symptoms to chronic treatment with serotonin reuptake inhibitors; although most patients are left with residual impairment. In theory, animal models could provide a bridge from the neuroimaging and pharmacology data to an understanding of pathophysiology at the cellular and molecular level. Several mouse models have been proposed using genetic, immunological, pharmacological, and optogenetic tools. These experimental model systems allow testing of hypotheses about the origins of compulsive behavior. Several models have generated behavior that appears compulsive-like, particularly excessive grooming, and some have demonstrated response to chronic serotonin reuptake inhibitors, establishing both face validity and predictive validity. Construct validity is more difficult to establish in the context of a limited understanding of OCD risk factors. Our current models may help us to dissect the circuits and molecular pathways that can elicit OCD-relevant behavior in rodents. We can hope that this growing understanding, coupled with developing technology, will prepare us when robust OCD risk factors are better understood.

Effect of Surgeon and Hospital Volume on Emergency General Surgery Outcomes.

BACKGROUND: Emergency general surgery (EGS) contributes to half of all surgical mortality nationwide, is associated with a 50% complication rate, and has a 15% readmission rate within 30 days. We assessed associations between surgeon and hospital EGS volume with these outcomes. STUDY DESIGN: Using Maryland's Health Services Cost Review Commission database, we identified nontrauma EGS procedures performed by general surgeons among patients 20 years or older, who were admitted urgently or emergently, from July 2012 to September 2014. We created surgeon and hospital volume categories, stratified EGS procedures into simple (mortality ≤ 0.5%) and complex (>0.5%) procedures, and assessed postoperative mortality, complications, and 30-day readmissions. Multivariable logistic regressions both adjusted for clinical factors and accounted for clustering by individual surgeons. RESULTS: We identified 14,753 procedures (61.5% simple EGS, 38.5% complex EGS) by 252 (73.3%) low-volume surgeons (≤25 total EGS procedures/year), 63 (18.3%) medium-volume surgeons (26 to 50/year), and 29 (8.4%) high-volume surgeons (>50/year). Low-volume surgeons operated on one-third (33.1%) of all patients. For simple procedures, the very low rate of death (0.2%) prevented a meaningful regression with mortality; however, there were no associations between low-volume surgeons and complications (adjusted odds ratio [aOR] 1.07; 95% CI 0.81 to 1.41) or 30-day readmissions (aOR 0.80; 95% CI 0.64 to 1.01) relative to high-volume surgeons. Among complex procedures, low-volume surgeons were associated with greater mortality (aOR 1.64; 95% CI 1.12 to 2.41) relative to high-volume surgeons, but not complications (aOR 1.06; 95% CI 0.85 to 1.32) or 30-day readmission (aOR 0.99; 95% CI 0.80 to 1.22). Low-volume hospitals (≤125 total EGS procedures/year) relative to high-volume hospitals (>250/year) were not associated with mortality, complications, or 30-day readmissions for simple or complex procedures. CONCLUSIONS: We found evidence that surgeon EGS volume was associated with outcomes. Developing EGS-specific services, mentorship opportunities, and clinical pathways for less-experienced surgeons may improve outcomes.

Overtreatment in the United States.

BACKGROUND: Overtreatment is a cause of preventable harm and waste in health care. Little is known about clinician perspectives on the problem. In this study, physicians were surveyed on the prevalence, causes, and implications of overtreatment. METHODS: 2,106 physicians from an online community composed of doctors from the American Medical Association (AMA) masterfile participated in a survey. The survey inquired about the extent of overutilization, as well as causes, solutions, and implications for health care. Main outcome measures included: percentage of unnecessary medical care, most commonly cited reasons of overtreatment, potential solutions, and responses regarding association of profit and overtreatment. FINDINGS: The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures. The most common cited reasons for overtreatment were fear of malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing medical records (38.2%). Potential solutions identified were training residents on appropriateness criteria (55.2%), easy access to outside health records (52.0%), and more practice guidelines (51.5%). Most respondents (70.8%) believed that physicians are more likely to perform unnecessary procedures when they profit from them. Most respondents believed that de-emphasizing fee-for-service physician compensation would reduce health care utilization and costs. CONCLUSION: From the physician perspective, overtreatment is common. Efforts to address the problem should consider the causes and solutions offered by physicians.