Health System Integration and Cancer Center Access for Rural Hospitals

BACKGROUND

Cancer centers provide superior care but are less accessible to rural populations. Health systems that integrate a cancer center may provide broader access to quality surgical care, but penetration to rural hospitals is unknown.

METHODS

Cancer center data were linked to health system data to describe health systems based on whether they included at least one accredited cancer center. Health systems with and without cancer centers were compared based on rural hospital presence. Bivariate tests and multivariable logistic regression were used with results reported as P-values and odds ratios (OR) with 95% confidence intervals (CIs).

RESULTS

Ninety percent of cancer centers are in a health system, and 72% of health systems (434/607) have a cancer center. Larger health systems (P = .03) with more trainees (P = .03) more often have cancer centers but are no more likely to include rural hospitals (11% vs 6%, P = .43; adjusted OR .69, 95% CI .28-1.70). The minority of cancer centers not in health systems (N = 95) more often serve low complexity patient populations (P = .02) in non-metropolitan areas (P = .03).

DISCUSSION

Health systems with rural hospitals are no more likely to have a cancer center. Ongoing health system integration will not necessarily expand rural patients' access to surgical care under existing health policy infrastructure and incentives.

Validity of Entrustable Professional Activities in a National Sample of General Surgery Residency Programs

BACKGROUND

The American Board of Surgery has endorsed competency-based education as vital to the assessment of surgical training. From 2018 to 2020, a national pilot study was conducted at 28 general surgery programs to evaluate feasibility of implementing entrustable professional activities (EPAs) for 5 common general surgical conditions. ACGME core competency Milestones were also rated for each resident by program clinical competency committees. This study aimed to evaluate the validity of general surgery EPAs compared with Milestones.

STUDY DESIGN

Prospectively collected, de-identified EPA Pilot Study data were analyzed. EPAs studied were EPA-1 (gallbladder), EPA-2 (inguinal hernia), EPA-3 (right lower quadrant pain), EPA-4 (trauma), and EPA-5 (consult). Variables abstracted included levels of EPA entrustment (1 to 5) and corresponding ACGME Milestone subcompetency ratings (1 to 5) for the same study cycle. Spearman's correlations were used to evaluate the relationship between summative EPA scores and corresponding Milestone ratings.

RESULTS

A total of 493 unique residents received a summative entrustment decision. EPA summative entrustment scores had moderate-to-strong positive correlation with mapped Milestone subcompetencies, with median rho value of 0.703. Among operation-focused EPAs, median rho values were similar between EPA-1 (0.688) and EPA-2 (0.661), but higher for EPA-3 (0.833). EPA-4 showed a strong positive correlation with diagnosis and communication competencies (0.724), whereas EPA-5, mapped to the most Milestone subcompetencies, had the lowest median rho value (0.455).

CONCLUSIONS

Moderate-to-strong positive correlation was noted between EPAs and patient care, medical knowledge, and communication Milestones. These findings support the validity of EPAs in general surgery and suggest that EPA assessments can be used to inform Milestone ratings by clinical competency committees.

Entrustable Professional Activities in Surgery: A Review

Importance

Entrustable professional activities (EPAs) compose a competency-based education (CBE) assessment framework that has been increasingly adopted across medical specialties as a workplace-based assessment tool. EPAs focus on directly observed behaviors to determine the level of entrustment a trainee has for a given activity of that specialty. In this narrative review, we highlight the rationale for EPAs in general surgery, describe current evidence supporting their use, and outline some of the practical considerations for EPAs among residency programs, faculty, and trainees.

Observations

An expanding evidence base for EPAs in general surgery has provided moderate validity evidence for their use as well as practical recommendations for implementation across residency programs. Challenges to EPA use include garnering buy-in from individual faculty and residents to complete EPA microassessments and engage in timely, specific feedback after a case or clinical encounter. When successfully integrated into a program's workflow, EPAs can provide a more accurate picture of residents' competence for a fundamental surgical task or activity compared with other assessment methods.

Conclusions and Relevance

EPAs represent the next significant shift in the evaluation of general surgery residents as part of the overarching progression toward CBE among all US residency programs. While pragmatic challenges to the implementation of EPAs remain, the best practices from EPA and other CBE assessment literature summarized in this review may assist individuals and programs in implementing EPAs. As EPAs become more widely used in general surgery resident training, further analysis of barriers and facilitators to successful and sustainable EPA implementation will be needed to continue to optimize and advance this new assessment framework.

Contemporary trends in extent of surgery for differentiated thyroid cancer with extrathyroidal extension

OBJECTIVE

Although lobectomy is acceptable for patients with small, low-risk differentiated thyroid cancer (DTC), gross extrathyroidal extension (ETE) remains an indication for total thyroidectomy (TT). Here we investigate evolving trends in extent of surgery for ​+ ​ETE DTC.

METHODS

Patients with +ETE DTC who underwent resection from 2010 to 2020 were identified using the National Cancer Database. The primary outcome was performance of TT versus lobectomy.

RESULTS

Among 5851 patients, most were female (79.7%), white (80.0%), and had minimal ETE (91.8%). Ninety-two percent of patients received TT. Year of treatment was influential (p ​< ​0.001), with increasing lobectomy rates in later years. On multivariable analyses, a decreased likelihood of TT was seen in years 2015 through 2020.

CONCLUSIONS

Most patients with +ETE DTC underwent guideline-concordant TT, but lobectomy rates doubled over the study period. These findings may reflect increased preference for lobectomy in low-risk DTC, but could undertreat patients with high-risk features.

Defining the Disparity: A Multi-Institutional Analysis of Factors Associated With Decreased Resident Operative Experience

INTRODUCTION

Technical learning in surgical training is multifaceted and existing literature suggests a positive relationship between case volume and proficiency. Little is known about factors associated with a decreased volume of operative experience. This study aimed to identify resident and program factors associated with general surgery residents (GSR) in the bottom quartile of logged case volume upon program completion.

METHODS

A post hoc analysis of a multicenter study was used to examine case logs for categorical GSR. Participants included graduates between 2010 and 2020 from 20 programs. Residents below and above the 25th percentile for total operative volume were compared.

RESULTS

The present study includes 1343 GSR who graduated over the 11-y period. In total, 336 residents were below the 25th percentile and 1007 residents were above the 25th percentile. Those below the 25th percentile were more likely to be female (41% versus 34%, P = 0.02), identify as underrepresented in medicine (22% versus 14%, P < 0.01), and pursue fellowship (86% versus 80%, P = 0.01) compared to those above the 25th percentile. Residents below the 25th percentile were more likely to have graduated from a low volume program (55% versus 25%, P < 0.01) and from top National Institutes of Health funded institutions (57% versus 52%, P = 0.01).

CONCLUSIONS

This study identified individual and program characteristics associated with lower operative volume of GSR. Understanding such characteristics will aid surgical educators to achieve better equity in training.

Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium

OBJECTIVE

To determine the relationship between race/ethnicity and case volume among graduating surgical residents.

BACKGROUND

Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed.

METHODS

A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups.

RESULTS

The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period.

CONCLUSIONS

In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.

Quality of breast surgery care at a comprehensive cancer center and its rural affiliate hospital

BACKGROUND

Cancer centers are increasingly affiliating with rural hospitals to perform surgery. Perioperative and oncologic outcomes for cancer center surgeons operating at rural hospitals are understudied.

METHODS

For patients with non-metastatic breast cancer from a rural catchment area who had oncologic surgery at an NCI-designated comprehensive cancer center (CC) or its rural affiliate (RA) from 2017 to 2022, we compared perioperative outcomes (composite of surgical site infection, seroma requiring drainage, and reoperation for margins) and receipt of guideline-concordant care (if patient received all applicable treatments) using descriptive statistics and chi-squared tests.

RESULTS

Among 168 patients, 99 had surgery at RA, 60 CC. RA patients were older, higher stage, and more often had lumpectomy. There were no differences in perioperative outcomes (CC 10%, RA 14%, p ​= ​0.445) or guideline concordant care (RA 76%, CC 78%, p ​= ​0.846).

CONCLUSIONS

Cancer center surgeons operating at a rural affiliate had comparable perioperative outcomes and guideline-concordant care.

Racial and ethnic variation in presentation and outcomes of high-grade soft tissue sarcoma at a Southeastern United States comprehensive cancer center

BACKGROUND

High-grade soft tissue sarcoma is rare and associated with poor prognosis. This study examines racial and ethnic variation in presentation and outcomes at a Southeastern US cancer center.

METHODS

Among an institutional cohort of patients seen between January 2016-December 2021, racial and ethnic differences were evaluated using chi-squared tests, Kaplan Meier curves, and Cox proportional hazards models.

RESULTS

There were 295 patients (71 ​% Non-Hispanic White, 24 ​% Black, 3 ​% Hispanic White, 2 ​% Other). Black representation was greater than national cohorts (24 ​% vs. 12 ​%). Histological subtype varied by race/ethnicity (p ​= ​0.007). Adjusting for histology and stage, survival was worse for Black vs. White patients (HR 1.71, 95 ​% CI 1.07-2.76) and those with metastatic disease (5.47, 3.54-8.44). In non-metastatic patients, survival differences for Black vs. White patients were attenuated by receipt of multi-modal treatment (1.53, 0.82-2.88).

CONCLUSION

Observed racial disparities in survival of high-grade sarcoma may be addressed by early, multidisciplinary management.

A multi-institutional study from the US ROPE consortium examining factors associated with endocrine surgery exposure for general surgery residents

BACKGROUND

Prior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not.

METHODS

We analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period.

RESULTS

Of the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8-12, P < .01), endocrine-trained faculty (+8, confidence interval 7-10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 -8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2-6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (-10, confidence interval -12 to -8, P < .01) and endocrine-focused otolaryngologists (-3, confidence interval -4 to -1, P < .01).

CONCLUSION

Several characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.

Evolving variation in the extent of surgery for low-risk papillary thyroid cancer in the United States

BACKGROUND

The continued debate over total thyroidectomy versus lobectomy and declining favor for prophylactic central neck dissection for patients with clinically node-negative papillary thyroid cancer ≤4 cm is ongoing after the 2015 guideline updates from the American Thyroid Association. This study aimed to evaluate contemporary trends in the extent of surgery in this low-risk cohort.

METHODS

Retrospective data from the National Cancer Database were used to identify adult patients with clinically node-negative papillary thyroid cancer ≤4 cm who underwent resection from 2012 to 2020. The primary outcome was the extent of surgery (lobectomy or total thyroidectomy, with or without prophylactic central neck dissection). Multivariable regression was performed to identify characteristics associated with variation in the extent of surgery.

RESULTS

Of 83,464 included patients, 79.3% were female patients with a median age of 51 years. The majority underwent total thyroidectomy either with prophylactic central neck dissection (39.1%) or without (37.5%) versus lobectomy with prophylactic central neck dissection (7.2%) or without (16.2%). Lobectomy rates increased from 18.3% in 2012 to 29.9% in 2020. Prophylactic central neck dissection rates also increased (42.9% to 52.1%). Patients who were male sex, Asian American, had smaller tumors or were treated at community cancer programs had a decreased likelihood of total thyroidectomy. Patients who were older, male sex, Black race, with smaller tumors, or were treated at community cancer programs or mid- or low-volume facilities had decreased likelihood of prophylactic central neck dissection.

CONCLUSION

Proportional use rates of operative approaches for low-risk, clinically node-negative papillary thyroid cancer have changed in recent years after the American Thyroid Association guideline changes, including increasing overall rates of lobectomy as well as prophylactic central neck dissection, with differences noted based on patient- and facility-level factors.

Using Graduating Surgical Resident Milestone Ratings to Predict Patient Outcomes: A Blunt Instrument for a Complex Problem

In 2013, U.S. general surgery residency programs implemented a milestones assessment framework in an effort to incorporate more competency-focused evaluation methods. Developed by a group of surgical education leaders and other stakeholders working with the Accreditation Council for Graduate Medical Education and recently updated in a version 2.0, the surgery milestones framework is centered around 6 "core competencies": patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. While prior work has focused on the validity of milestones as a measure of resident performance, associations between general surgery resident milestone ratings and their post-training patient outcomes have only recently been explored in an analysis in this issue of Academic Medicine by Kendrick et al. Despite their well-designed efforts to tackle this complex problem, no relationships were identified. This accompanying commentary discusses the broader implications for the use of milestone ratings beyond their intended application, alternative assessment methods, and the challenges of developing predictive assessments in the complex setting of surgical care. Although milestone ratings have not been shown to provide the specificity needed to predict clinical outcomes in the complex settings studied by Kendrick et al, hope remains that utilization of other outcomes, assessment frameworks, and data analytic tools could augment these models and further our progress toward a predictive assessment in surgical education. Evaluation of residents in general surgery residency programs has grown both more sophisticated and complicated in the setting of increasing patient and case complexity, constraints on time, and regulation of resident supervision in the operating room. Over the last decade, surgical education research efforts related to resident assessment have focused on measuring performance through accurate and reproducible methods with evidence for their validity, as well as on attempting to refine decision making about resident preparedness for unsupervised practice.

Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium

OBJECTIVE

To examine differences in resident operative experience between male and female general surgery residents.

BACKGROUND

Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level.

METHODS

Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents.

RESULTS

There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02).

CONCLUSIONS

Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.

Comparative utility of preoperative imaging in normocalcemic versus hypercalcemic primary hyperparathyroidism

BACKGROUND

Normocalcemic primary hyperparathyroidism (PHPT) has been shown to benefit from parathyroidectomy. PHPT may be localized preoperatively with various imaging modalities, but the utility of preoperative imaging in normocalcemic PHPT compared to hypercalcemic PHPT is not well defined.

METHODS

Retrospective review was performed on all PHPT patients who underwent parathyroidectomy from 2001 to 2019. Patients were stratified into normocalcemic and hypercalcemic groups. Patient and outcomes data were analyzed.

RESULTS

All 2218 patients in this database were included. 433 patients had normocalcemic PHPT (19.5%) and 1785 had hypercalcemic PHPT (80.5%). Among normocalcemic patients, equivalent cure rates were seen between patients with preoperative imaging versus those without (100% vs 99%). No differences in postoperative complications were demonstrated except for a slightly increase in transient hypocalcemia in patients without imaging.

CONCLUSIONS

Normocalcemic PHPT patients had equivalent cure and similar complication rates with or without preoperative imaging compared to hypercalcemic patients. Routine localization studies in normocalcemic PHPT may be safely omitted in favor of exploration with intraoperative adjuncts by experienced surgeons.

Real-World Adherence to Nodal Surveillance for Sentinel Lymph Node-Positive Melanoma

BACKGROUND

Patients with sentinel lymph node-positive (SLN+) melanoma are increasingly undergoing active nodal surveillance over completion lymph node dissection (CLND) since the Second Multicenter Selective Lymphadenectomy Trial (MSLT-II). Adherence to nodal surveillance in real-world practice remains unknown.

METHODS

In a retrospective cohort of SLN+ melanoma patients who underwent nodal surveillance at a single institution from July 2017 through April 2021, this study evaluated adherence to nodal surveillance ultrasound (US). Adherence to nodal US was compared with adherence to other surveillance methods based on receipt of adjuvant therapy. Early recurrence data were reported using descriptive statistics.

RESULTS

Among 109 SLN+ patients, 37 (34%) received US surveillance at recommended intervals. Of the 72 (66%) non-adherent patients, 16 were lost to follow-up, and 33 had planned follow-up at an outside institution without available records. More patients had a minimum of bi-annual clinic visits (83%) and cross-sectional imaging (53%) compared to those who were adherent with nodal US. The patients who received adjuvant therapy (60%) had fewer ultrasounds (p < 0.01) but more exams (p < 0.01) and a trend toward more cross-sectional imaging (p = 0.06). Of the overall cohort, 26 patients (24%) experienced recurrence at a median follow-up period of 15 months. Of these recurrences, 10 were limited to the SLN basin, and all of these isolated nodal recurrences were resectable.

CONCLUSIONS

Pragmatic challenges to real-world delivery of nodal surveillance remain after MSLT-II, and adjuvant therapy appears to be associated with a decreased likelihood of US adherence. Understanding US utility alongside cross-sectional imaging will be critical as increasingly more patients undergo nodal surveillance and adjuvant therapy.

An Internal Perspective: the Psychological Impact of Mistreatment

OBJECTIVES

Student mistreatment remains a prominent issue in medical education. Mistreatment has been linked to negative mental health outcomes, including depression, anxiety, and burnout. Continued challenges in this arena include difficulties in identifying mistreatment and underreporting. The objective of this study was to better understand the nuances of individual students' reactions to mistreatment.

METHODS

Medical students, who had experienced mistreatment, were invited to participate in this study. Individual, semi-structured, peer-to-peer interviews were conducted with 21 students. Interview transcriptions were coded using grounded theory and inductive analysis, and themes were extracted.

RESULTS

The interviews generated 34 unique mistreatment incidents. Four major themes arose in students' reactions to mistreatment. (1) Descriptions-the student described the incident as inappropriate, unusual, or unnecessary. (2) Recognition-most students did not immediately recognize the incident as mistreatment. (3) Emotions-the student described negative emotions (negative self-views, anger, powerlessness, shock, discomfort) associated with the mistreatment incident. (4) Coping mechanisms-the student utilized avoidance and rationalization to process their mistreatment.

CONCLUSIONS

Mistreatment generates complex emotions and coping mechanisms that impair the learning process. These complex emotions and coping mechanisms also make it difficult for trainees to identify mistreatment and to feel safe to report. Increasing understanding of the psychological impact of mistreatment can help peers and educators better screen for mistreatment in trainees and guide them in reporting decisions.

Tired of Being Ignored: Fatigue as a Presenting Symptom in Primary Hyperparathyroidism

BACKGROUND

Fatigue is a common presenting symptom in primary hyperparathyroidism (PHPT). Although fatigue alone is not currently an indication for parathyroidectomy, it can have a significant detrimental effect on quality of life. The purpose of this study was to determine if there are underlying differences in demographic or disease characteristics in patients with PHPT who present with fatigue compared with those who do not.

METHODS

We reviewed a prospective database of 2197 patients undergoing parathyroidectomy for PHPT by three endocrine surgeons from 2001 to 2019. Patients were divided into two groups based on the presence or absence of fatigue as a presenting symptom. Objective measures of disease severity were then compared between groups.

RESULTS

A total of 1379 (63%) patients presented with fatigue. Patients presenting with fatigue were more likely to be female and to have a prior fracture, lower preoperative serum calcium (Ca), and normocalcemic PHPT. There were no statistically significant differences between groups in age, body mass index, history of nephrolithiasis, or preoperative serum parathyroid hormone levels. Patients presenting with fatigue were also more likely to have smaller parathyroid glands and multiglandular disease. No statistically significant differences were detected in postoperative serum Ca and parathyroid hormone levels, or cure or recurrence rates.

CONCLUSIONS

Patients with PHPT who report fatigue as a presenting symptom present with more complex disease as manifested by a higher incidence of multiglandular disease and normocalcemic PHPT. Despite this, surgical cure is equivalent to other patients. Therefore, fatigue should be a discrete indication for parathyroidectomy in PHPT.

Valve-in-Valve Transcatheter Aortic Valve Implantation: A Novel Approach to Treat Paravalvular Leak

Enlarging or "cracking" a surgical stented bioprosthetic valve during valve-in-valve transcatheter aortic valve implantation (TAVI) increases orifice area, reducing transvalvular energy losses. We demonstrate that TAVI with valve cracking can be used to treat paravalvular leak (PVL) while providing optimal aortic valve physiology. A 61-year-old woman with a history of aortic valve replacement with a stented bioprosthesis presented with heart failure. Transthoracic echocardiography revealed severe prosthetic aortic valve stenosis with PVL and severe regurgitation. The patient underwent valve-in-valve TAVI with valve cracking. This successfully treated both the stenosis and the PVL with regurgitation.