The Use and Impact of a Decision Support Tool for Appendicitis Treatment.

OBJECTIVE: Since introducing new and alternative treatment options may increase decisional conflict, we aimed to describe the use of the decision support tool (DST) and its impact on treatment preference and decisional conflict. SUMMARY BACKGROUND DATA: For the treatment of appendicitis, antibiotics are an effective alternative to appendectomy, with both approaches associated with a different set of risks (e.g., recurrence vs surgical complications) and benefits (e.g., more rapid return to work vs decreased chance of readmission). Patients often have limited knowledge of these treatment options and decision support tools that include video-based educational materials and questions to elicit patient preferences about outcomes may be helpful. Concurrent to the Comparing Outcomes of Drugs and Appendectomy (CODA) trial, our group developed a DST for appendicitis treatment (www.appyornot.org). METHODS: A retrospective cohort including people who self-reported current appendicitis and used the AppyOrNot DST between 2021-2023. Treatment preferences before- and after- use of the DST, demographic information, and Ottawa Decisional Conflict Scale (DCS) were reported after completing the DST. RESULTS: 8,243 people from 66 countries and all 50 US states accessed the DST. Before the DST, 14% had a strong preference for antibiotics and 31% for appendectomy, with 55% undecided. After using the DST, the proportion in the undecided category decreased to 49% (P<0.0001). 52% of those who completed the Ottawa Decisional Conflict Score (DCS) (n=356) reported the lowest level of decisional conflict (<25) after using the DST; 43% had a DCS score of 25-50, 5.1% had a DCS score of >50 and 2.5% had and DCS score of >75. CONCLUSION: The publicly available DST appyornot.org reduced the proportion that was undecided about which treatment they favored and had a modest influence on those with strong treatment preferences. Decisional conflict was not common after use. The use of this DST is now a component of a nationwide implementation program aimed at improving the way surgeons share information about appendicitis treatment options. If its use can be successfully implemented, this may be a model for improving communication about treatment for patients experiencing emergency health conditions.

Development and preliminary validation of a new task-based objective procedure-specific assessment of inguinal hernia repair procedural safety.

BACKGROUND: Surgical videos coupled with structured assessments enable surgical training programs to provide independent competency evaluations and align with the American Board of Surgery's entrustable professional activities initiative. Existing assessment instruments for minimally invasive inguinal hernia repair (IHR) have limitations with regards to reliability, validity, and usability. A cross-sectional study of six surgeons using a novel objective, procedure-specific, 8-item competency assessment for minimally invasive inguinal hernia repair (IHR-OPSA) was performed to assess inter-rater reliability using a "safe" vs. "unsafe" scoring rubric. METHODS: The IHR-OPSA was developed by three expert IHR surgeons, field tested with five IHR surgeons, and revised based upon feedback. The final instrument included: (1) incision/port placement; (2) dissection of peritoneal flap (TAPP) or dissection of peritoneal flap (TEP); (3) exposure; (4) reducing the sac; (5) full dissection of the myopectineal orifice; (6) mesh insertion; (7) mesh fixation; and (8) operation flow. The IHR-OPSA was applied by six expert IHR surgeons to 20 IHR surgical videos selected to include a spectrum of hernia procedures (15 laparoscopic, 5 robotic), anatomy (14 indirect, 5 direct, 1 femoral), and Global Case Difficulty (easy, average, hard). Inter-rater reliability was assessed against Gwet's AC2. RESULTS: The IHR-OPSA inter-rater reliability was good to excellent, ranging from 0.65 to 0.97 across the eight items. Assessments of robotic procedures had higher reliability with near perfect agreement for 7 of 8 items. In general, assessments of easier cases had higher levels of agreement than harder cases. CONCLUSIONS: A novel 8-item minimally invasive IHR assessment tool was developed and tested for inter-rater reliability using a "safe" vs. "unsafe" rating system with promising results. To promote instrument validity the IHR-OPSA was designed and evaluated within the context of intended use with iterative engagement with experts and testing of constructs against real-world operative videos.

Measuring Quality at the Surgeon Level.

Patients expect high-quality surgical care and increasingly are looking for ways to assess the quality of the surgeon they are seeing, but quality measurement is often more complicated than one might expect. Measurement of individual surgeon quality in a manner that allows for comparison among surgeons is particularly difficult. While the concept of measuring individual surgeon quality has a long history, technology now allows for new and innovative ways to measure and achieve surgical excellence. However, some recent efforts to make surgeon-level quality data publicly available have highlighted the challenges of this work. Through this chapter, the reader will be introduced to a brief history of surgical quality measurement, learn about the current state of quality measurement, and get a glimpse into what the future holds.

Formative Evaluation of a Peer Video-Based Coaching Initiative.

BACKGROUND: Few opportunities exist for surgeons to receive technical skills feedback after training. Surgeons at hospitals within the Illinois Surgical Quality Improvement Collaborative were invited to participate in a peer-to-peer video-based coaching initiative focused on improving technical skills in laparoscopic right colectomy. We present a formative qualitative evaluation of a video-based coaching initiative. METHODS: Concurrent with the implementation of our video-based coaching initiative, we conducted two focus groups and 15 individual semistructured interviews with participants; all interviews were audio-recorded and transcribed. A subset of surgeons participated in a group video-review session, which was observed by qualitative researchers. Transcripts and notes were analyzed using an organizational behavior framework adapted from executive coaching. RESULTS: Participation in the initiative was primarily motivated by the opportunity to learn from others and improve skills. Surgeons highlighted the value of self-video and peer-video assessment not only to learn new techniques but also for self-reflection and benchmarking. Barriers to participation included logistics (e.g. using the laparoscopic recording devices, coordinating schedules for peer coaching), time commitment, and a surgical culture that assumes the intent of coaching is to address deficiencies. CONCLUSIONS: Video-based peer-coaching provides a platform for surgeons to reflect, benchmark against peers, and receive personalized feedback; however, more work is needed to increase participation and sustain involvement over time. There is an opportunity to decrease logistical barriers and increase acceptability of coaching by integrating video-based coaching into existing surgical conferences and established continuous professional development efforts.

A Mixed-Methods Evaluation of Clinician Education Modules on Reducing Surgical Opioid Prescribing.

BACKGROUND: In this study, we developed online interactive clinician education modules highlighting best practices to minimize opioid prescribing at discharge after surgery. The modules were implemented as part of a multicomponent quality improvement initiative across a six-hospital health system. This article describes the development and evaluation of this educational intervention. MATERIALS AND METHODS: Clinician education modules targeting surgical prescribers, nurses, and pharmacists were developed and implemented by an interdisciplinary team. Clinicians were invited to participate in an evaluation survey after completing the modules. Survey items assessed clinicians' rating of the module and intention to change clinical practice because of the module. Quantitative and qualitative survey responses were analyzed by the study team. RESULTS: A total of 2119 clinicians completed the module and 1831 of these clinicians (86.4%) completed the survey. Of clinicians completing the survey, 65.6% reported that they intend to change clinical practice after completing the module. Intended changes were related to increased knowledge and awareness, provider empowerment, opioid prescribing practices, nonopioid prescribing practices, and patient education. Many clinicians who indicated they do not intend to change practice reported that their clinical practices were already in line with module recommendations. Some clinicians did not perceive the module to be relevant to their role. CONCLUSIONS: Module completion was associated with the intention to improve clinical practice in areas related to provider empowerment, opioid prescribing, nonopioid prescribing, and patient education. Evaluation data will inform future module improvements. There is an opportunity to ensure that all clinicians, including those who are not prescribers, recognize their role in opioid stewardship.

High-Dose Opioid Use Among Veterans with Unexplained Gastrointestinal Symptoms Versus Structural Gastrointestinal Diagnoses.

BACKGROUND: In a cohort of Veterans dually enrolled in the Department of Veterans Affairs (VA) and Medicare Part D, we sought to describe high-dose daily opioid use among Veterans with unexplained gastrointestinal (GI) symptoms and structural GI diagnoses and examine factors associated with high-dose use. METHODS: We used linked national patient-level data from the VA and Centers for Medicare and Medicaid Services (CMS). We grouped patients into 3 subsets: those with unexplained GI symptoms (e.g., chronic abdominal pain); structural GI diagnoses (e.g., chronic pancreatitis); and those with a concurrent unexplained GI symptom and structural GI diagnosis. High-dose daily opioid use levels were examined as a binary variable [≥ 100 morphine milligram equivalents (MME)/day] and as an ordinal variable (50-99 MME/day, 100-119 MME/day, or ≥ 120 MME/day). RESULTS: We identified 141,805 chronic GI patients dually enrolled in VA and Part D. High-dose opioid use was present in 11% of Veterans with unexplained GI symptoms, 10% of Veterans with structural GI diagnoses, and 15% of Veterans in the concurrent GI group. Compared to Veterans with only an unexplained GI symptom or structural diagnosis, concurrent GI patients were more likely to have higher daily opioid doses, more opioid days ≥ 100 MME, and higher risk of chronic use. Factors associated with high-dose use included opioid receipt from both VA and Part D, younger age, and benzodiazepine use. CONCLUSIONS: A significant subset of chronic GI patients in the VA are high-dose opioid users. Efforts are needed to reduce high-dose use among Veterans with concurrent GI symptoms and diagnoses.

Shift from androgen to estrogen action causes abdominal muscle fibrosis, atrophy, and inguinal hernia in a transgenic male mouse model.

Inguinal hernia develops primarily in elderly men, and more than one in four men will undergo inguinal hernia repair during their lifetime. However, the underlying mechanisms behind hernia formation remain unknown. It is known that testosterone and estradiol can regulate skeletal muscle mass. We herein demonstrate that the conversion of testosterone to estradiol by the aromatase enzyme in lower abdominal muscle (LAM) tissue causes intense fibrosis, leading to muscle atrophy and inguinal hernia; an aromatase inhibitor entirely prevents this phenotype. LAM tissue is uniquely sensitive to estradiol because it expresses very high levels of estrogen receptor-α. Estradiol acts via estrogen receptor-α in LAM fibroblasts to activate pathways for proliferation and fibrosis that replaces atrophied myocytes, resulting in hernia formation. This is accompanied by decreased serum testosterone and decreased expression of the androgen receptor target genes in LAM tissue. These findings provide a mechanism for LAM tissue fibrosis and atrophy and suggest potential roles of future nonsurgical and preventive approaches in a subset of elderly men with a predisposition for hernia development.

Primary prevention of prescription opioid diversion: a systematic review of medication disposal interventions.

Background: In the U.S., 50-75% of nonmedical users of prescription opioids obtain their pills through diversion by friends or relatives. Increasing disposal of unused opioid prescriptions is a fundamental primary prevention strategy in combatting the opioid epidemic.Objectives: To identify interventions for disposal of unused opioid pills and assess the evidence of their effectiveness on disposal-related outcomes.Methods: A search of four electronic databases was conducted (October 2019). We included all empirical studies, systematic literature reviews, and meta-analyses about study medication disposal interventions in the U.S. Studies of disposal interventions that did not include opioids were excluded. We abstracted data for the selected articles to describe the study design, and outcomes. Further, we assessed the quality of each study using the NIH Study Quality Assessment Tools.Results: We identified 25 articles that met our inclusion criteria. None of the 13 studies on drug take-back events or the two studies on donation boxes could draw conclusions about their effectiveness. Although studies on educational interventions found positive effects on knowledge acquisition, they did not find differences in disposal rates. Two randomized controlled trials on drug disposal bags found higher opioid disposal rates in their intervention arms compared to the control arms (57.1% vs 28.6% and 33.3%, p = .01; and 85.7% vs 64.9%, p = .03).Conclusions: Peer-reviewed publications on opioid disposal interventions are limited and either do not address effectiveness or have conflicting findings. Future research should address these limitations and further evaluate implementation and cost-effectiveness.

National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training.

BACKGROUND: Concerns persist regarding the effect of current surgical resident duty-hour policies on patient outcomes, resident education, and resident well-being. METHODS: We conducted a national, cluster-randomized, pragmatic, noninferiority trial involving 117 general surgery residency programs in the United States (2014-2015 academic year). Programs were randomly assigned to current Accreditation Council for Graduate Medical Education (ACGME) duty-hour policies (standard-policy group) or more flexible policies that waived rules on maximum shift lengths and time off between shifts (flexible-policy group). Outcomes included the 30-day rate of postoperative death or serious complications (primary outcome), other postoperative complications, and resident perceptions and satisfaction regarding their well-being, education, and patient care. RESULTS: In an analysis of data from 138,691 patients, flexible, less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P=0.92; unadjusted odds ratio for the flexible-policy group, 0.96; 92% confidence interval, 0.87 to 1.06; P=0.44; noninferiority criteria satisfied) or of any secondary postoperative outcomes studied. Among 4330 residents, those in programs assigned to flexible policies did not report significantly greater dissatisfaction with overall education quality (11.0% in the flexible-policy group and 10.7% in the standard-policy group, P=0.86) or well-being (14.9% and 12.0%, respectively; P=0.10). Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education but were more likely to perceive negative effects on personal activities. There were no significant differences between study groups in resident-reported perception of the effect of fatigue on personal or patient safety. Residents in the flexible-policy group were less likely than those in the standard-policy group to report leaving during an operation (7.0% vs. 13.2%, P<0.001) or handing off active patient issues (32.0% vs. 46.3%, P<0.001). CONCLUSIONS: As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality. (FIRST ClinicalTrials.gov number, NCT02050789.).

Minimizing Opioid Prescribing in Surgery (MOPiS) Initiative: An Analysis of Implementation Barriers.

BACKGROUND: The United States is in the midst of an opioid epidemic. In response, our institution developed the Minimizing Opioid Prescribing in Surgery (MOPiS) initiative. MOPiS is a multicomponent intervention including: (1) patient education on opioid safety and pain management expectations; (2) clinician education on safe opioid prescribing; (3) prescribing data feedback; (4) patient risk screening to assess for addictive behavior; and (5) optimizations to the electronic health record (EHR). We conducted a preintervention formative evaluation to identify barriers and facilitators to implementation. MATERIALS AND METHODS: We conducted 22 semistructured interviews with key stakeholders (surgeons, nurses, pharmacists, and administrators) at six hospitals within a single health care system. Interviewees were asked about perceived barriers and facilitators to the components of the intervention. Responses were analyzed to identify common themes using the Consolidated Framework for Implementation Research. RESULTS: We identified common themes of potential implementation barriers and classified them under 12 Consolidated Framework for Implementation Research domains and three intervention domains. Time and resource constraints (needs and resources), the modality of educational material (design quality and packaging), and prescribers' concern for patient satisfaction scores (external policy and incentives) were identified as the most significant structural barriers. Resident physicians, pharmacists, and pain specialists were identified as potential key facilitating actors to the intervention. CONCLUSIONS: We identified specific barriers to successful implementation of an opioid reduction initiative in a surgical setting. In our MOPiS initiative, a preintervention formative evaluation enabled the design of strategies that will overcome implementation barriers specific to the components of our initiative.

Public reporting and transparency: a primer on public outcomes reporting.

INTRODUCTION: Healthcare consumers seeking accurate information about where to find quality surgical care face a confusing constellation of rating systems that lack transparency or consistency of opinion. For example, a 2016 report in Health Affairs demonstrated that no hospital was rated as a high performer by all four prominent national ratings systems: Consumer Reports, Leapfrog, Healthgrades and U.S. News & World Report (Austin et al. Health Aff 34:423-430, 2015). Surgeons should have an understanding of the current state of public reporting of quality; hospital ratings and data sources; physician ratings and data sources; and transparency of reporting. METHODS: We conducted a non-systematic review of the literature. RESULTS: Hospital quality ratings remain nebulous and there is not universal opinion on the utility of voluntary participation in ranking systems, leaving the current systems largely opinion-based. Early attempts at physician ranking systems are rudimentary at best and suffer from methodological concerns. Publicly reported metrics should be easily understandable, accessible, clinically relevant, reliable, non-punitive, and shielded from legal discovery. Transparency is increasing within institutions to help align staff to institutional objectives, while specialty specific registries are helping to standardize care pathways and outcomes measures across organizations. Measuring surgical outcomes beyond 30-day morbidity and mortality has been plagued by a lack of understanding on how to create metrics that matter; the four attributes of relevance, scientific soundness, feasibility and comprehensiveness set a high bar for the development of effective and efficient quality measures in surgery. DISCUSSION: SAGES, via the Quality, Outcomes, and Safety Committee, is committed to learning how to develop meaningful quality metrics in general surgery and will continue to work in other areas that impact quality, such as opioid prescribing, and surgeon wellness.

Evaluation of the ProPublica Surgeon Scorecard "Adjusted Complication Rate" Measure Specifications.

OBJECTIVES: The ProPublica Surgeon Scorecard is the first nationwide, multispecialty public reporting of individual surgeon outcomes. However, ProPublica's use of a previously undescribed outcome measure (composite of in-hospital mortality or 30-day related readmission) and inclusion of only inpatients have been questioned. Our objectives were to (1) determine the proportion of cases excluded by ProPublica's specifications, (2) assess the proportion of inpatient complications excluded from ProPublica's measure, and (3) examine the validity of ProPublica's outcome measure by comparing performance on the measure to well-established postoperative outcome measures. METHODS: Using ACS-NSQIP data (2012-2014) for 8 ProPublica procedures and for All Operations, the proportion of cases meeting all ProPublica inclusion criteria was determined. We assessed the proportion of complications occurring inpatient, and thus not considered by ProPublica's measure. Finally, we compared risk-adjusted performance based on ProPublica's measure specifications to established ACS-NSQIP outcome measure performance (eg, death/serious morbidity, mortality). RESULTS: ProPublica's inclusion criteria resulted in elimination of 82% of all operations from assessment (range: 42% for total knee arthroplasty to 96% for laparoscopic cholecystectomy). For all ProPublica operations combined, 84% of complications occur during inpatient hospitalization (range: 61% for TURP to 88% for total hip arthroplasty), and are thus missed by the ProPublica measure. Hospital-level performance on the ProPublica measure correlated weakly with established complication measures, but correlated strongly with readmission (R = 0.834, P < 0.001). CONCLUSIONS: ProPublica's outcome measure specifications exclude 82% of cases, miss 84% of postoperative complications, and correlate poorly with well-established postoperative outcomes. Thus, the validity of the ProPublica Surgeon Scorecard is questionable.

Initiating statistical process control to improve quality outcomes in colorectal surgery.

BACKGROUND: Unexpected variations in postoperative length of stay (LOS) negatively impact resources and patient outcomes. Statistical process control (SPC) measures performance, evaluates productivity, and modifies processes for optimal performance. The goal of this study was to initiate SPC to identify LOS outliers and evaluate its feasibility to improve outcomes in colorectal surgery. METHODS: Review of a prospective database identified colorectal procedures performed by a single surgeon. Patients were grouped into elective and emergent categories and then stratified by laparoscopic and open approaches. All followed a standardized enhanced recovery protocol. SPC was applied to identify outliers and evaluate causes within each group. RESULTS: A total of 1294 cases were analyzed--83% elective (n = 1074) and 17% emergent (n = 220). Emergent cases were 70.5% open and 29.5% laparoscopic; elective cases were 36.8% open and 63.2% laparoscopic. All groups had a wide range in LOS. LOS outliers ranged from 8.6% (elective laparoscopic) to 10.8% (emergent laparoscopic). Evaluation of outliers demonstrated patient characteristics of higher ASA scores, longer operating times, ICU requirement, and temporary nursing at discharge. Outliers had higher postoperative complication rates in elective open (57.1 vs. 20.0%) and elective lap groups (77.6 vs. 26.1%). Outliers also had higher readmission rates for emergent open (11.4 vs. 5.4%), emergent lap (14.3 vs. 9.2%), and elective lap (32.8 vs. 6.9%). Elective open outliers did not follow trends of longer LOS or higher reoperation rates. CONCLUSIONS: SPC is feasible and promising for improving colorectal surgery outcomes. SPC identified patient and process characteristics associated with increased LOS. SPC may allow real-time outlier identification, during quality improvement efforts, and reevaluation of outcomes after introducing process change. SPC has clinical implications for improving patient outcomes and resource utilization.

Process control to measure process improvement in colorectal surgery: modifications to an established enhanced recovery pathway.

BACKGROUND: After more than a decade of improvement, our enhanced recovery pathway had patients who had undergone laparoscopic colectomy going home a mean 3.7 days postoperatively. We wondered if adding a transverse abdominus plane block and intravenous acetaminophen to an established pathway would improve outcomes and resource use. OBJECTIVE: The aim of this study was to evaluate the impact of modification of an enhanced recovery pathway on patient outcomes. DESIGN: This was a case-matched study. METHODS: After the addition of transverse abdominus plane blocks and acetaminophen to the enhanced recovery pathway 12 months ago, review of a prospective database was performed. Patients were matched by procedure type, age, and sex. SETTINGS: This study was performed at a tertiary referral center. PATIENTS: Patients undergoing elective major laparoscopic colorectal surgery from 2010 to 2012 were included. MAIN OUTCOME MEASURES: The primary outcome measures were hospital length of stay, readmission rate, postoperative complications, and the cost of the hospital episode before and after the amendment of our enhanced recovery pathway. RESULTS: Two hundred eight elective major laparoscopic cases were evaluated. Both groups were similar in demographics and comorbidities. Length of stay was significantly shorter once transverse abdominus plane blocks and acetaminophen were introduced (p < 0.01), dropping from 3.7 to 2.6 days. There were significantly more complications in the prechange group (p = 0.02), but no significant differences in readmissions or mortality. Direct costs were similar, but there was a $500 increase in total margin per case (p = 0.004) with the pathway changes. With the use of statistical process control to examine the effect on outliers, there was significantly less variation in the mean length of stay (2.29 vs 1.90 days, p < 0.01) after the addition of transverse abdominus plane blocks and intravenous acetaminophen. LIMITATIONS: The single-surgeon, single-institution design was a limitation of this study. CONCLUSIONS: The addition of a transverse abdominus plane block and acetaminophen significantly reduced length of stay more than that seen with a previously established pathway. Statistical process control demonstrated that our pathway changes significantly reduced the spread of outliers around our mean length of stay.

Surgeons' knowledge regarding perioperative pain management in patients with opioid use disorder: a survey among 260 members of the American College of Surgeons.

BACKGROUND: Patients with opioid use disorder (OUD) are increasing, challenging surgeons to adjust post-operative pain management guidelines. A literature review identified limited information on how to best care for these patients. The purpose of this study was to determine surgical perioperative management of OUD, challenges, and support needed for optimal care. METHODS: This study utilized an anonymous voluntary survey that was distributed to members of the American College of Surgeons through the association's electronic weekly newsletter. The survey was advertised weekly for three consecutive weeks. The survey included questions regarding surgeons' management of perioperative pain in patients with opioid use disorder and perceived barriers in treatment. RESULTS: A total of 260 surgeons responded representing all specialties except ophthalmology. General surgery (66.5%) and plastic and reconstructive surgery (7.5%) represented the majority of responders. Ninety-five percent of surgeons reported treating a patient who used opioids in the past month and 86% encountered a patient with OUD. Nearly half (46%) reported being uncomfortable managing postoperative pain in patients with OUD. Most (67%) were not aware of any guidelines or standards pertaining to perioperative management of patients with OUD. While consultation was sought by 86% of surgeons, analyses identified lack of timely response and a lack of care coordination among specialists. Lack of knowledge and fear of harm (contributing further to addiction) were the most common themes. CONCLUSION: Nearly half of surgeons report discomfort caring for patients with OUD with the vast majority involving a consulting service to assist with their care. Most surgeons believe that it would be helpful to have guidelines regarding the care of these patients. This provides an opportunity for increased education and training on the perioperative management of patients with OUD and further collaboration with addiction medicine, psychiatry and pain management colleagues.

Learning from the implementation of a surgical opioid reduction initiative in an integrated health system: a qualitative study among providers and patients.

BACKGROUND: Surgical opioid overprescribing can result in long-term use or misuse. Between July 2018 and March 2019, the multicomponent intervention, Minimizing Opioid Prescribing in Surgery (MOPiS) was implemented in the general surgery clinics of five hospitals and successfully reduced opioid prescribing. To date, various studies have shown a positive outcome of similar reduction initiatives. However, in addition to evaluating the impact on clinical outcomes, it is important to understand the implementation process of an intervention to extend sustainability of interventions and allow for dissemination of the intervention into other contexts. This study aims to evaluate the contextual factors impacting intervention implementation. METHODS: We conducted a qualitative study with semi-structured interviews held with providers and patients of the general surgery clinics of five hospitals of a single health system between March and November of 2019. Interview questions focused on how contextual factors affected implementation of the intervention. We coded interview transcripts deductively, using the Consolidated Framework for Implementation Research (CFIR) to identify the relevant contextual factors. Content analyses were conducted using a constant comparative approach to identify overarching themes. RESULTS: We interviewed 15 clinicians (e.g., surgeons, nurses), 1 quality representative, 1 scheduler, and 28 adult patients and identified 3 key themes. First, we found high variability in the responses of clinicians and patients to the intervention. There was a strong need for intervention components to be locally adaptable, particularly for the format and content of the patient and clinician education materials. Second, surgical pain management should be recognized as a team effort. We identified specific gaps in the engagement of team members, including nurses. We also found that the hierarchical relationships between surgical residents and attendings impacted implementation. Finally, we found that established patient and clinician views on opioid prescribing were an important facilitator to effective implementation. CONCLUSION: Successful implementation of a complex set of opioid reduction interventions in surgery requires locally adaptable elements of the intervention, a team-centric approach, and an understanding of patient and clinician views regarding changes being proposed.

Association between Surgical Technical Skills and Clinical Outcomes: A Systematic Literature Review and Meta-Analysis.

Background: A systematic literature review and meta-analysis was conducted to assess the association between intraoperative surgical skill and clinical outcomes. Methods: Peer-reviewed, original research articles published through August 31, 2021 were identified from PubMed and Embase. From the 1,513 potential articles, seven met eligibility requirements, reporting on 151 surgeons and 17,932 procedures. All included retrospective assessment of operative videos. Associations between surgical skill and outcomes were assessed by pooling odds ratios (OR) using random-effects models with the inverse variance method. Eligible studies included pancreaticoduodenectomy, gastric bypass, laparoscopic gastrectomy, prostatectomy, colorectal, and hemicolectomy procedures. Results: Meta-analytic pooling identified significant associations between the highest vs. lowest quartile of surgical skill and reoperation (OR: 0.44; 95% confidence interval [CI]: 0.23, 0.83), hemorrhage (OR: 0.66; 95% CI, 0.65, 0.68), obstruction (OR: 0.33; 95% CI, 0.30, 0.35), and any medical complication (OR: 0.23, 95% CI, 0.19, 0.27). Nonsignificant inverse associations were noted between skill and readmission, emergency department visit, mortality, leak, infection, venous thromboembolism, and cardiac and pulmonary complications. Conclusions: Overall, surgeon technical skill appears to predict clinical outcomes. However, there are surprisingly few articles that evaluate this association. The authors recommend a thoughtful approach for the development of a comprehensive surgical quality infrastructure that could significantly reduce the challenges identified by this study.

The development of a safe opioid use agreement for surgical care using a modified Delphi method.

BACKGROUND: Opioids prescribed to treat postsurgical pain have contributed to the ongoing opioid epidemic. While opioid prescribing practices have improved, most patients do not use all their pills and do not safely dispose of leftovers, which creates a risk for unsafe use and diversion. We aimed to generate consensus on the content of a "safe opioid use agreement" for the perioperative settings to improve patients' safe use, storage, and disposal of opioids. METHODS: We conducted a modified three-round Delphi study with clinicians across surgical specialties, quality improvement (QI) experts, and patients. In Round 1, participants completed a survey rating the importance and comprehensibility of 10 items on a 5-point Likert scale and provided comments. In Round 2, a sub-sample of participants attended a focus group to discuss items with the lowest agreement. In Round 3, the survey was repeated with the updated items. Quantitative values from the Likert scale and qualitative responses were summarized. RESULTS: Thirty-six experts (26 clinicians, seven patients/patient advocates, and three QI experts) participated in the study. In Round 1, >75% of respondents rated at least four out of five on the importance of nine items and on the comprehensibility of six items. In Round 2, participants provided feedback on the comprehensibility, formatting, importance, and purpose of the agreement, including a desire for more specificity and patient education. In Round 3, >75% of respondents rated at least four out of five for comprehensibility and importance of all 10 updated item. The final agreement included seven items on safe use, two items on safe storage, and one item on safe disposal. CONCLUSION: The expert panel reached consensus on the importance and comprehensibility of the content for an opioid use agreement and identified additional patient education needs. The agreement should be used as a tool to supplement rather than replace existing, tailored education.

Development of the Illinois Surgical Quality Improvement Collaborative (ISQIC): Implementing 21 Components to Catalyze Statewide Improvement in Surgical Care.

INTRODUCTION: In 2014, 56 Illinois hospitals came together to form a unique learning collaborative, the Illinois Surgical Quality Improvement Collaborative (ISQIC). Our objectives are to provide an overview of the first three years of ISQIC focused on (1) how the collaborative was formed and funded, (2) the 21 strategies implemented to support quality improvement (QI), (3) collaborative sustainment, and (4) how the collaborative acts as a platform for innovative QI research. METHODS: ISQIC includes 21 components to facilitate QI that target the hospital, the surgical QI team, and the peri-operative microsystem. The components were developed from available evidence, a detailed needs assessment of the hospitals, reviewing experiences from prior surgical and non-surgical QI Collaboratives, and interviews with QI experts. The components comprise 5 domains: guided implementation (e.g., mentors, coaches, statewide QI projects), education (e.g., process improvement (PI) curriculum), hospital- and surgeon-level comparative performance reports (e.g., process, outcomes, costs), networking (e.g., forums to share QI experiences and best practices), and funding (e.g., for the overall program, pilot grants, and bonus payments for improvement). RESULTS: Through implementation of the 21 novel ISQIC components, hospitals were equipped to use their data to successfully implement QI initiatives and improve care. Formal (QI/PI) training, mentoring, and coaching were undertaken by the hospitals as they worked to implement solutions. Hospitals received funding for the program and were able to work together on statewide quality initiatives. Lessons learned at one hospital were shared with all participating hospitals through conferences, webinars, and toolkits to facilitate learning from each other with a common goal of making care better and safer for the surgical patient in Illinois. Over the first three years, surgical outcomes improved in Illinois. DISCUSSION: The first three years of ISQIC improved care for surgical patients across Illinois and allowed hospitals to see the value of participating in a surgical QI learning collaborative without having to make the initial financial investment themselves. Given the strong support and buy-in from the hospitals, ISQIC has continued beyond the initial three years and continues to support QI across Illinois hospitals.